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

Abstract

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.