A Hispanic gentleman in his thirties presented to the emergency department with chest pain and fever. The chest pain was 7/10 in intensity, sharp in nature, intermittent, retrosternal in location, worsening with breathing movements, and radiating to the back. Additionally, he complained of subjective fever associated with chills and an episode of vomiting. The review of the system was negative otherwise. There was no significant past medical or surgical history. He did not have any family history of major cardiovascular disease. There was no recent travel or contact with known COVID-19 patients. The patient was a former smoker and stopped approximately 4 years ago. Last, he used to drink 2 pints of vodka every day but denied use of any other illicit drugs.
Vital signs were within normal limits, and the physical examination was unremarkable except for bilateral basilar dry rales on auscultation of the lungs. Laboratory tests were significant for leukocytosis (16.4/μL) with neutrophilic predominance, elevated C-reactive protein (CRP; 242 mg/L), elevated erythrocyte sedimentation rate (ESR; 76 mm/hr), elevated D-dimer (823 ng/mL), elevated lactate dehydrogenase (LDH; 475 units/L), elevated ferritin (676 ng/mL), and elevated troponin T levels (55 ng/L, normal ≤12 ng/L). Urine drug screen was negative. The initial 12-lead electrocardiogram (ECG) showed diffuse PR segment depression (Figure 7-1), which was suggestive of pericarditis in the setting of chest pain and subjective fever. Chest radiography (CXR) demonstrated multifocal pneumonia and borderline enlarged cardiac silhouette likely secondary to cardiomegaly or pericardial fluid. A computed tomography (CT) scan of the chest with contrast excluded pulmonary embolism and showed normal heart and pericardium. Rapid influenza and COVID-19 real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) testing were negative. Repeat troponin was trending upward (63 ng/L), so the patient was admitted in the coronary care unit (CCU) for suspected myopericarditis.
Initial ECG showing normal sinus rhythm and diffuse PR segment depression.
Anti-inflammatory therapy with colchicine and ibuprofen was begun for myopericarditis. The patient was started on broad-spectrum antibiotics empirically. He was maintained on droplet and contact isolation for COVID-19 as suspicion was high despite one negative COVID-19 rRT-PCR test. However, he was found to have positive antibodies for COVID-19 (anti–SARS-CoV-2 IgG/IgM reactive antibodies). Therefore, a provisional diagnosis of COVID-19 myopericarditis was made. The repeat COVID-19 rRT-PCR test was negative again. Due to suggested evidence of worsening outcome in COVID-19 patients with use of nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen was discontinued. Instead, the patient was changed to oral prednisone and continued on colchicine for treatment. Transthoracic echocardiogram (TTE) revealed a left ventricular ejection fraction (LVEF) of 47%, eccentric left ventricular hypertrophy (LVH) with global LV wall motion abnormality, mild pulmonary hypertension, and no evidence of pericardial effusion. Based on these findings, low doses of angiotensin-converting enzyme inhibition (ACE-I) and β-adrenoceptor blockade (beta blocker) were begun for LV systolic dysfunction. During the hospital ...