Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection

Sala, Simone; Peretto, Giovanni; Gramegna, Mario; Palmisano, Anna; Villatore, Andrea; Vignale, Davide; Cobelli, Francesco De; Tresoldi, Moreno; Cappelletti, Alberto; Basso, Cristina; Godino, Cosmo; Esposito, Antonio

doi:10.1093/eurheartj/ehaa286

Cited by 445 publications

(560 citation statements)

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“…So far, few cases of COVID-19 related acute myocarditis are described in literature. [31][32][33][36][37][38] Althought rare, their presentations might be severe with hypotension and low cardiac output requiring inotropic therapy. Cardiac magnetic resonance may show diffuse ventricular wall thickening and oedema.…”

Section: Acute Myocardial Injury During Covid-19mentioning

confidence: 99%

“…31,32,[36][37][38] Among two patients who underwent endomyocardial biopsy, criteria for acute myocarditis were met in only one case. 37 In the other case, SARS-CoV-2 was shown although within macrophages, but not in cardiomyocytes, and biopsy showed only low-grade interstitial myocardial inflammation and aspecific changes of cardiac myocytes with myofibrillar lysis and lipid droplets. 32 These data show that the virus can reside within the heart but do not prove that it has a direct pathogenetic role.…”

Section: Acute Myocardial Injury During Covid-19mentioning

confidence: 99%

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COVID‐19 and heart failure: from infection to inflammation and angiotensin II stimulation. Searching for evidence from a new disease

Tomasoni

Italia

Adamo

et al. 2020

European J of Heart Fail

232

245

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Patients with cardiovascular disease and, namely, heart failure are more susceptible to coronavirus disease 2019 (COVID‐19) and have a more severe clinical course once infected. Heart failure and myocardial damage, shown by increased troponin plasma levels, occur in at least 10% of patients hospitalized for COVID‐19 with higher percentages, 25% to 35% or more, when patients critically ill or with concomitant cardiac disease are considered. Myocardial injury may be elicited by multiple mechanisms, including those occurring with all severe infections, such as fever, tachycardia, adrenergic stimulation, as well as those caused by an exaggerated inflammatory response, endotheliitis and, in some cases, myocarditis that have been shown in patients with COVID‐19. A key role may be that of the renin–angiotensin–aldosterone system. Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infects human cells binding to angiotensin‐converting enzyme 2 (ACE2), an enzyme responsible for the cleavage of angiotensin II into angiotensin 1–7, which has vasodilating and anti‐inflammatory effects. Virus‐mediated down‐regulation of ACE2 may increase angiotensin II stimulation and contribute to the deleterious hyper‐inflammatory reaction of COVID‐19. On the other hand, ACE2 may be up‐regulated in patients with cardiac disease and treated with ACE inhibitors or angiotensin receptor blockers. ACE2 up‐regulation may increase the susceptibility to COVID‐19 but may be also protective vs. angiotensin II‐mediated vasoconstriction and inflammatory activation. Recent data show the lack of untoward effects of ACE inhibitors or angiotensin receptor blockers for COVID‐19 infection and severity. Prospective trials are needed to ascertain whether these drugs may have protective effects.

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Section: Acute Myocardial Injury During Covid-19mentioning

confidence: 99%

Section: Acute Myocardial Injury During Covid-19mentioning

confidence: 99%

COVID‐19 and heart failure: from infection to inflammation and angiotensin II stimulation. Searching for evidence from a new disease

Tomasoni

Italia

Adamo

et al. 2020

European J of Heart Fail

232

245

View full text Add to dashboard Cite

show abstract

“…Table 1 compares the clinical, laboratory and diagnostic features of all the cases published hereinbefore. (13)(14)(15)(16)(17)(18)(19)(20)(21) Secondly, in our patient, acute onset with progressive clinical deterioration and refractory cardiogenic shock met the diagnostic criteria for fulminant myocarditis (FM). (22,23) This is not unexpected in adulthood, as 4 out of the 9 published cases involving adult patients diagnosed with myocarditis met the criteria of COVID-19-related FM (Table 1).…”

Section: Resultsmentioning

confidence: 73%

Life-threatening cardiogenic shock in a pediatric patient with SARS-CoV-2-associated myocarditis treated with remdesivir: a case description and report of similar cases from the Literature

Molinari

Colasanto

Melzi

et al. 2020

Preprint

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BackgroundChildren are relatively spared from Coronavirus disease 2019 (COVID-19), but some severe cases have been reported. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children may affect the cardiovascular system. We hereby report about a case of myocarditis evolving to cardiogenic shock in a SARS-CoV-2 positive child.Case presentationAn otherwise healthy 12-year-old patient was admitted with fever, vomiting, diarrhoea and drowsiness, without any respiratory symptoms. He was diagnosed with COVID-19 on nasopharyngeal swab. He developed hypotension and cardiogenic shock. Bedside echocardiography revealed left ventricular impairment with an ejection fraction (LVEF) below 25%. Plasmatic markers of myocardial injury were remarkably raised, as well as inflammatory biomarkers, including procalcitonin (highest recorded value: 66 ng/mL) and interleukin-6 (8209 pg/mL). The child was transferred to Intensive Care Unit and he was treated with catecholamine support, mechanical ventilation and empiric anti-infectious therapy, including broad spectrum antibiotics and the antiviral agent remdesivir. All additional microbiological investigations yielded negative results. We observed a gradual improvement of LVEF within 5 days. A cardiac magnetic resonance confirmed the suspicion of myocarditis. After 21 days of hospitalisation, the child was discharged without sequelae.ConclusionsOur hypothesis is that the child suffered from SARS-CoV-2-induced fulminant myocarditis, probably in the setting of cytokine release syndrome (CRS). The peculiarity of this SARS-CoV-2 infection is the presence of cardiac failure in a previously healthy child without a respiratory illness. The positive outcome is in line with published Literature about the overall better prognosis of COVID-19 children compared to adults. Remdesivir, an investigational antiviral therapy, may have played a role on the clinical improvement of the child.

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“…Accordingly, current reports suggest that the majority of COVID‐19 patients with myocardial injury without evidence of epicardial coronary artery thrombosis, show imaging data supporting the diagnosis of acute myocarditis 21,22 ; also, cases of fulminant myocarditis and fatal arrhythmias have been described 23,24 . Even if a direct cardiotropic localization SARS‐CoV‐2 into myocytes has never been demonstrated, some authors showed autoptic findings (eg, lymphocyte infiltrates and macrophagic response) compatible with viral myocarditis 25‐27 …”

Section: Acute Myocarditis and Arrhythmiasmentioning

confidence: 99%

Usefulness of echocardiography to detect cardiac involvement in COVID‐19 patients

et al. 2020

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Coronavirus disease 2019 (COVID‐19) outbreak is a current global healthcare burden, leading to the life‐threatening severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). However, evidence showed that, even if the prevalence of COVID‐19 damage consists in pulmonary lesions and symptoms, it could also affect other organs, such as heart, liver, and spleen. Particularly, some infected patients refer to the emergency department for cardiovascular symptoms, and around 10% of COVID‐19 victims had finally developed heart injury. Therefore, the use of echocardiography, according to the safety local protocols and ensuring the use of personal protective equipment, could be useful firstly to discriminate between primary cardiac disease or COVID‐19–related myocardial damage, and then for assessing and monitoring COVID‐19 cardiovascular complications: acute myocarditis and arrhythmias, acute heart failure, sepsis‐induced myocardial impairment, and right ventricular failure derived from treatment with high‐pressure mechanical ventilation. The present review aims to enlighten the applications of transthoracic echocardiography for the diagnostic and therapeutic management of myocardial damage in COVID‐19 patients.

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Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection

Cited by 445 publications

References 0 publications

COVID‐19 and heart failure: from infection to inflammation and angiotensin II stimulation. Searching for evidence from a new disease

COVID‐19 and heart failure: from infection to inflammation and angiotensin II stimulation. Searching for evidence from a new disease

Life-threatening cardiogenic shock in a pediatric patient with SARS-CoV-2-associated myocarditis treated with remdesivir: a case description and report of similar cases from the Literature

Usefulness of echocardiography to detect cardiac involvement in COVID‐19 patients

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