SARS-CoV-2 Myocarditis in a High School Athlete after COVID-19 and Its Implications for Clearance for Sports

Abstract

This case report describes a high school athlete with palpitation, myalgia, fatigue, and dyspnea on exertion after SARS-CoV-2 infection with evidence of myocarditis by cardiac magnetic resonance (CMR), but echocardiography and troponin were normal. This case is unusual as the standard cardiac tests recommended by the American Heart Association for sports clearance, including ECG, echocardiography, and cardiac biomarkers, were normal. Still, she continued to be symptomatic after mild COVID-19. The CMR was performed to evaluate her unexplained palpitation and showed patchy myocardial edema two months after her initial SARS-CoV-2 infection. In this case, the diagnosis of myocardial involvement would be missed by normal echocardiograms and cardiac bio-markers without CMR. Because acute myocarditis is a risk factor for sudden death in competitive athletes, pediatric cardiologists should consider performing additional tests such as cardiac MRI in symptomatic COVID-19 patients, even if cardiac biomarkers and echocardiograms are normal.

Myocarditis and Pericarditis Following the SARS-CoV-2 Infection and COVID-19 Vaccination

“…Recently, SARS-CoV-2 infection has been a leading cause of myocarditis, resulting in growing numbers of acute cardiac injury cases worldwide. The pathophysiologic mechanism of myocarditis in the context of COVID-19 can result from either direct viral invasion of cardiomyocytes or indirect heart tissue damage as a result of cytokine storm, microvascular disease, hypoxia-induced excessive intracellular calcium leading to cardiac myocyte apoptosis, or angiotensin-converting enzyme 2 (ACE2)-mediated loss of protective cardiovascular effects on target organs [12,13], all leading to increased vascular permeability and the resultant myocardial edema (Figures 1 and 2). Like any other complications, myocarditis can occur alongside or following other typical COVID-19 manifestations [14,15] or may represent the infection's presenting or sole manifestations without fever, cough, or other respiratory involvements [16,17].…”

COVID-19 and myocarditis: a review of literature

“…However, clinical presentations of patients with COVID-19 myocarditis can vary from patient to patient. Some patients have relatively mild presentations such as cough, fever and dyspnea [ 9 , 10 , 22 , 66 , 67 ]. These symptoms may be due to COVID-19 itself and not the myocarditis.…”

“…In one report this chest pain was present without fatigue, cough or dyspnea [ 68 ]. Some patients may also present with palpitations alongside their other symptoms [ 67 , 71 ]. After initial presentation, patients may deteriorate to develop signs of heart failure and hemodynamic compromise if treatment is not initiated or is inadequate [ 9 – 11 ].…”

Parametric Mapping Cardiac Magnetic Resonance Imaging for the Diagnosis of Myocarditis in Children in the Era of COVID-19 and MIS-C

“…Out of 100 adults who recently recovered from COVID-19, Puntmann et al [ 69 ] identified cardiac involvement in CMR in 78%, but the case selection of this cohort (with many patients having new or persistent symptoms) influenced the high incidence. Many case reports and meta-analyses [ 70 , 71 , 72 , 73 , 74 , 75 ] describing the CMR findings in adolescents and young adult athletes aged 16 to 21 years who had positive for COVID-19 were published and summarized in Table 2 . An example of COVID-19 myocarditis in a 15-year-old soccer player with linear subepicardial LGE is shown in Figure 8 .…”