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|Number COVID 20-04: Subacute perimyocarditis caused by COVID-19 infection|
Subacute perimyocarditis caused by COVID-19 infection
Jose Vicente Monmeneu Menadas MD PhD, Pilar García-Gonzalez MD PhD, Alicia M. Maceira Gonzalez MD PhD
On admission, he had a heart rate of 77 bpm, blood pressure 135/80 mmHg, temperature 36.8ºC and SpO2 91%. Chest X-ray (Image 1) revealed a diffuse interstitial pattern with opacities in both lungs. ECG (Image 2) showed sinus rhythm with minimal ST segment elevation and extensive repolarization abnormalities.
Laboratory results were: high-sensitivity troponin T curve of 29-24-24-18-15 ng/L (<14 ng/L), NT-proBNP 456 pg/mL (<125 pg/mL), ferritin 1060 ng/mL (< 300 ng/mL), D-dimer 790 ng/mL (< 500 ng/mL), C-reactive protein 14 mg/L (<10 mg/L), leukocyte count 4.03 x 10˄3/μL (> 4.8 x 10˄3/μL), 83% neutrophils (< 70%) and lymphocytes 0.42 x 10˄3/μL (> 0.9 x 10˄3/μL), 10.4% (>19%).
Image 1: Chest x-ray with diffuse interstitial pattern with opacities in both lungs
Image 2: Twelve lead electrocardiogram with sinus rhythm with minimal ST segment elevation and extensive repolarization abnormalities.
Image 3: Axial and coronal single shot SSFP images with right pulmonary consolidation along with associated pleural effusion.
Movie 1: Cine SSFP left ventricle two chamber, four chamber, and three chamber showing mild concentric hypertrophy and mildly decreased systolic function.
Movie 2: Cine SSFP short axis stack showing mild concentric hypertrophy and mildly decreased systolic function.
Image 4: Two chamber and four chamber cine SSFP at end-diastole and end-systole with global longitudinal strain.
Image 5: Short tau inversion recovery (STIR) four chamber and two chamber images with hyperintensity of the subepicardial lateral, anterior, inferior and apical segments indicating myocardial edema.
Image 6: T2 mapping four chamber and two chamber sequences with an average of 60 ms, mid-septum of 53 ms, and lateral wall of 67 ms, reference value 50 ms.
Image 7: Short axis native T1 mapping and extracellular volume (ECV). Top: Native T1: average 1110 ms, mid-septum 1047 ms, lateral wall 1204 ms, reference value 950 ms. Bottom: ECV: average 33%, mid-septum 29%, lateral wall 39%, reference value 24%.
Image 8: Two chamber, four chamber, and three chamber myocardial late gadolinium enhancement images show extensive, patchy mid to epicardial late gadolinium enhancement affecting the basal to apical lateral, anterior, inferior walls and apical septal wall including the pericardium.
Image 9. Myocardial tissue characterization summary. A. Four chamber STIR. B. Four chamber T2 map. C. Four chamber late gadolinium enhancement. D. Short axis native T1 map. E. Short axis ECV map. F. Four chamber strain end-systole.
One month later a follow-up CMR was performed, showing less edema in T2 mapping sequences, lower values of native T1 and ECV, and late gadolinium enhancement was significantly diminished as shown in Image 10.
Image 10: Myocardial tissue characterization summary from the one month follow-up CMR. A-B. T2 mapping four chamber and short axis with average myocardial value of 47 ms, mid-septum of 44 ms, and lateral wall of 51 ms. C-D. Native T1 and ECV short axis with average myocardial native T1 value of 988 ms, mid-septum 972 ms, and lateral wall 1030 ms. Average myocardial ECV 28%, mid-septum 25%, and lateral wall 31%. E-F. Late gadolinium enhancement four chamber and short axis with improved lateral wall enhancement compared to the previous CMR.
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