Myopericarditis, Rhabdomyolysis, and Acute Hepatic Injury
2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 7 Linguagem: Inglês
10.1161/circimaging.120.010907
ISSN1942-0080
AutoresFrédéric Legrand, C. Chong-Nguyen, Nachwan Ghanem,
Tópico(s)Pericarditis and Cardiac Tamponade
ResumoHomeCirculation: Cardiovascular ImagingVol. 13, No. 7Myopericarditis, Rhabdomyolysis, and Acute Hepatic Injury Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBMyopericarditis, Rhabdomyolysis, and Acute Hepatic InjurySole Expression of a SARS-CoV-2 Infection Frédéric Legrand, MSc, Caroline Chong-Nguyen, MD and Nachwan Ghanem, MD Frédéric LegrandFrédéric Legrand Frédéric Legrand, MSc, Service de cardiologie, Hôpital Simone Veil, 14 rue de St-Prix, 95600 Eaubonne, France. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0342-8670 Department of Cardiology, Simone Veil hospital, Eaubonne, France (F.L., N.G.). , Caroline Chong-NguyenCaroline Chong-Nguyen Department of Cardiology, Bichat Hospital, Paris, France (C.C.-N.). and Nachwan GhanemNachwan Ghanem Department of Cardiology, Simone Veil hospital, Eaubonne, France (F.L., N.G.). Originally published8 Jul 2020https://doi.org/10.1161/CIRCIMAGING.120.010907Circulation: Cardiovascular Imaging. 2020;13:e010907Novel severe acute respiratory syndrome-coronavirus-2 (SARS CoV-2) which emerged at the end of 2019 in Wuhan, China, has spread to multiple countries rapidly. We report a case of a patient with SARS-CoV-2 presenting with myopericarditis, rhabdomyolysis, and acute liver injury, but without respiratory symptoms.A 39-year old patient without any medical history presented chest pain and dyspnea for 2 days. He had no fever or cough. The ECG performed in the emergency room (Figure [A]) showed diffuse ST elevation associated with PQ depression. Initial laboratory testing showed CRP 22 mg/L, leucocytes 13.7×109/L, troponin 15.4 µg/L (N<0.05 µg/L), arterial lactate 6 mmol/L, sodium 126 mmol/L, and potassium 5.6 mmol/L. The chest computerized tomography-Scan (Figure [B]) showed both pleural and pericardial effusions, atelectasis but without any typical SARS-CoV-2 acute lung injury. Since his wife was diagnosed with SARS-CoV-2, reverse transcription polymerase chain reaction was performed and found to be positive. Echocardiography confirmed a moderate circumferential pericardial effusion, without any sign of tamponade. Cardiac magnetic resonance imaging (Figure [C] and [D]) was performed at day 5 confirming the diagnosis of myopericarditis with a subepicardial late gadolinium enhancement and T2 myocardial hyperintensity in the basal inferolateral segment.Download figureDownload PowerPointFigure. SARS-CoV-2 (Severe acute respiratory syndrome coronavirus-2) myopericarditis ECG chest computed tomography (CT) scan and cardiac magnetic resonance imaging (MRI) A, SARS-CoV-2 myopericarditis ECG: ST elevation with PQ depression on DI, DII, v2 to v6. B, Chest CT-Scan: pleural and pericardial effusion without typical SARS-CoV-2 acute lung injury. C, Parasternal short-axis MRI view: subepicardial delayed myocardial enhancement in the basal inferolateral segment. D, Parasternal 4 chambers MRI view: subepicardial delayed myocardial enhancement in the basal inferolateral segment.The patient was treated with colchicine 1 mg daily. The patient presented with mild evidence of heart failure, including dyspnea, pleural effusion, and an elevated NT-proBNP (N-terminal pro-B-type natriuretic peptide; 4473 pg/mL), controlled with low doses of diuretics for 4 days. Hyperkalemia was controlled with insulin but hyponatremia persisted despite a fluid restricted diet. Adrenal insufficiency had been excluded. The respiratory condition was stable with no more than 1 L/min of oxygen. The pleural fluid was an exudate with 28 g/L of protein and 376 IU/L of LDH. Troponin peak level was at 25 µg/L (N<0.05 µg/L) and CRP peak level at 141 mg/L. One episode of paroxysmal atrial fibrillation was treated successfully with amiodarone without any recurrence. Pericardial effusion completely disappeared at day 5 of the treatment with colchicine.The second complication was rhabdomyolysis, associated with severe foot and leg myalgias, with a peak CPK level of 17 070 IU/L (day 5) resulting in mild acute renal failure (creatinine 113 µmol/L on day 6). Immunologic tests (myositis specific and associated antibodies, antinuclear antibodies, anti-cyclic citrullinated peptide antibodies, ANCA, CH50, C3-C4) were all negative.The third complication was severe acute hepatic injury with ASAT 556 IU/L (15× upper normal value), ALAT 557 IU/L (8×), cholestasis, and elevated total bilirubin at 36 µmol/L, but normal prothrombin time ratio at 96%. Viral hepatitis serologies were negative.The patient was discharged on day 10 with decreasing ASAT (416 IU/L, 11× normal value), still increasing ALAT (557 IU/L, 8× normal value), normalized bilirubin (11 μmol/L), resolving rhabdomyolysis (resolved myalgia, CPK 2093 IU/L), decreasing CRP (20 mg/L) and troponin (3.2 μg/L), resolved acute renal failure (creatinine 72 μmol/L), and resolved symptoms of heart failure (no dyspnea, NT-proBNP 804 pg/mL on day 8).We present the first case of SARS-CoV-2 infection without any respiratory symptoms, presenting only with cardiac, hepatic, and muscle complications. Respiratory symptoms are the most common presentation for SARS-CoV-2. Myocarditis is described as a potential complication of SARS-CoV-2 infection with prevalence still unknown. The overall incidence of acute cardiac injury has been variable but roughly 8% to 12% of the positive cases are known to develop significant elevation of troponin.1 General muscle pain and fatigue are common symptoms of SARS-CoV-2, and rhabdomyolysis can be misdiagnosed. Early detection and hydration is the key to avoid severe acute renal failure. The pathophysiology is still unknown.2The mechanisms of liver injury that occurred during SARS-CoV-2 infection remain largely unclear. Our current understanding suggests that infection of highly pathogenic human coronavirus may result in liver injury by direct virus-induced cytopathic effects and immunopathology induced by overshooting inflammatory responses.3 Whereas hepatic injury may be worsened by the use of drugs such as antibiotics, hepatic injury was present before our patient received 2 doses of ceftriaxone. No other cause for liver injury was identified aside from SARS-CoV-2.In conclusion, we present this case where the expression of SARS-CoV-2 infection involved only nonrespiratory systems to highlight the importance of surveillance for manifestations that may be overlooked. Additional studies are required to assess for any long-term sequela of the myopericarditis, rhabdomyolysis, and hepatic injury associated with SARS-CoV-2 infection.Sources of FundingNone.DisclosuresNone.FootnotesFrédéric Legrand, MSc, Service de cardiologie, Hôpital Simone Veil, 14 rue de St-Prix, 95600 Eaubonne, France. Email legrand.[email protected]comReferences1. Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, Jain SS, Burkhoff D, Kumaraiah D, Rabbani L, et alCOVID-19 and Cardiovascular Disease.Circulation. 2020; 141:1648–1655. doi: 10.1161/CIRCULATIONAHA.120.046941LinkGoogle Scholar2. Jin M, Tong Q. Rhabdomyolysis as Potential Late Complication Associated with COVID-19 [published online ahead of print, 2020 Mar 20].Emerg Infect Dis. 2020; 26(7):10.3201/eid2607.200445. doi: 10.3201/eid2607.200445Google Scholar3. Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections.Liver Int. 2020; 40:998–1004. doi: 10.1111/liv.14435CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Haussner W, DeRosa A, Haussner D, Tran J, Torres-Lavoro J, Kamler J and Shah K (2022) COVID-19 associated myocarditis: A systematic review, The American Journal of Emergency Medicine, 10.1016/j.ajem.2021.10.001, 51, (150-155), Online publication date: 1-Jan-2022. Freund O, Eviatar T and Bornstein G (2022) Concurrent myopathy and inflammatory cardiac disease in COVID-19 patients: a case series and literature review, Rheumatology International, 10.1007/s00296-022-05106-3, 42:5, (905-912), Online publication date: 1-May-2022. Diaz-Arocutipa C, Saucedo-Chinchay J and Imazio M (2021) Pericarditis in patients with COVID-19: a systematic review, Journal of Cardiovascular Medicine, 10.2459/JCM.0000000000001202, 22:9, (693-700), Online publication date: 1-Sep-2021. July 2020Vol 13, Issue 7 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.120.010907PMID: 32635747 Originally publishedJuly 8, 2020 KeywordscreatinineCOVID-19hyperkalemiadiureticspericardial effusionPDF download Advertisement SubjectsCardiomyopathyMagnetic Resonance Imaging (MRI)Pericardial Disease
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