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|Number COVID 20-02: Prior Myocarditis in Setting of COVID-19 Infection|
Prior Myocarditis in Setting of COVID-19 Infection
Chaitanya Madamanchi MD, Michael Steigner MD, Raymond Kwong MD, MPH
Clinical History: A 41-year-old man with nonischemic cardiomyopathy (Exercise Single Photon Emission Computed Tomography thirteen years prior revealed no perfusion abnormalities and LVEF 44%) presented with fever, myalgias, abdominal pain, and shortness of breath. CT Abdomen/Pelvis with Contrast was performed revealing no acute abnormalities in the abdomen but was notable for focal peripheral consolidation in the lungs (Image 1). The patient was treated for community-acquired pneumonia with ceftriaxone and prescribed a course of azithromycin upon discharge. He presented again one week later after having two syncopal episodes. Labs on admission were notable for leukopenia (WBC 3.56 K/uL, Ref 4.0-11.0 K/uL), elevated CRP 44.2 mg/L (Ref 0-8 mg/L), high sensitivity Troponin T 100 ng/L (Ref 0-14 ng/L). SARS-COV 2 PCR from nasopharyngeal swab was positive. ECG revealed normal sinus rhythm with occasional premature ventricular contractions with Q waves and T wave inversions in inferior leads (Image 2). An ischemic evaluation was pursued with coronary CTA which revealed no coronary plaque or stenosis but was notable for myocardial thinning involving the basal and mid inferior wall of the left ventricle (Image 3), which could represent sequelae from prior myocarditis.
Image 1: Chest CT scan showing bilateral pulmonary consolidations (red arrows)
Image 2: Electrocardiogram showing inverted T-waves in inferior leads and ventricular ectopy
Image 3: CT Coronary angiogram demonstrating inferolateral myocardial wall thinning (red arrows)
CMR Findings: Cardiac MRI was obtained to evaluate for acute myocarditis. Steady State Free Procession cine images revealed mildly dilated LV with moderately decreased global systolic function with LVEF 33% and dyskinesis of the inferolateral wall (Movie 1). T2 weighted imaging and T2 mapping did not reveal any edema (Image 4). There was extensive, epicardial late gadolinium enhancement (LGE) involving the entire anterior, inferior, and lateral walls, and mid anteroseptal wall (Image 5).
Movie 1: SSFP cine images showing dilated left ventricle, dyskinesis of inferolateral wall and decreased global systolic function
Image 4: T2 weighted image with semiquantitative analysis showing a mean global myocardial T2 signal of 40 msec.
Image 5: Late enhancement imaging with epicardial enhancement involving the anterior, inferior, lateral and mid septal walls
Conclusion: Overall, these CMR findings are consistent with fibrosis from a non-ischemic cause, possibly from prior myocarditis given pattern of LGE. There is no evidence of acute myocardial edema based on T2 weighted imaging or T2 mapping. This case illustrates a part of the spectrum of clinical scenarios for which CMR is requested during the COVID-19 pandemic. CMR can evaluate the acuteness and etiology of cardiomyopathy or suspected acute coronary syndromes in patients presenting with cardiac symptoms suspected to be related to COVID infection.
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