Çınar, Tufan; Hayıroğlu, Mert İlker; Çiçek, Vedat; Uzun, Mehmet; Orhan, Ahmet Lütfullah

doi:10.1590/1806-9282.66.S2.48

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RAPID COMMUNICATIONS • Rev. Assoc. Med. Bras. 66 (Suppl 2) • 2020 • https://doi.org/10.1590/1806-9282.66.S2.48 copiar

COVID-19 and acute myocarditis: current literature review and diagnostic challenges

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

INTRODUÇÃO

Na literatura atual, houve um aumento dos casos apresentados com doença coronavírus de 2019 (COVID-19) induzida por miocardite aguda. Nesta revisão baseada em casos, buscamos descrever as características clínicas, achados de imagem e curso hospitalar de miocardite aguda. Além disso, as limitações em relação ao diagnóstico de miocardite foram discutidas, uma vez que apenas casos de miocardite fulminante foram mencionados na literatura atual.

MÉTODOS

Fizemos uma revisão da literatura de todos os pacientes diagnosticados com miocardite aguda induzida por COVID-19 com a utilização das bases de dados PubMed, Embase e Cochrane.

RESULTADO

Dezesseis casos relatados estão relacionados com a miocardite aguda induzida pela COVID-19. Observamos que os achados de ECG na maioria dos pacientes com COVID-19 não eram específicos, incluindo elevação difusa do segmento ST, atraso não específico da condução intraventricular, taquicardia sinusal e ondas T invertidas em pistas anteriores. Os resultados ecocardiográficos de doentes com miocardite aguda COVID-19 variaram entre a fração de ejeção ventricular esquerda preservada (LVEF) sem anomalias segmentais e a LVEF reduzida com hipocinésia global. Curiosamente, alguns pacientes com COVID-19 induzidos à miocardite aguda fulminante eram sensíveis aos esteroides e tinham uma melhoria com glucocorticoides e terapia com imunoglobulina.

CONCLUSÃO

Apesar da pandemia de COVID-19 em todo o mundo, um número limitado de casos tem sido compartilhado na literatura atual. Há muitas dificuldades para o diagnóstico diferencial de miocardite aguda no contexto da COVID-19.

Infecções por coronavírus; Betacoronavírus; Miocardite; Cardiomiopatias

Case, author	Age, sex	Risk factors	Presenting symptoms	Admission findings	ECG findings	Lab findings
Case 1, Inciardi et al.⁴	53, F	-	Fatigue, chest pain and dyspnea	Fever: 36.6 ^oC HR:100 beats SBP: 90 mm Hg DBP:50 mm Hg Spo₂:98	Minimal diffuse ST-segment elevation (more prominent in the inferior and lateral leads), and an ST-segment depression with T-wave inversion in lead V1 and aVR	WBC: 8.0×10³/µL Lymphocyte: 1.4×10³/µL CRP: 25 mg/dl D-dimer: 500 U/F Troponin: 300 ng/L BNP: -
Case 2, Kim et al.⁵	21, F	-	Coughing, sputum, diarrhea, and shortness of breath	-	Nonspecific intraventricular conduction delay and multiple premature ventricular complexes	WBC: - Lymphocyte: - CRP: - D-dimer: Troponin: 1.26 ng/L BNP: 1929 pg/mL
Case 3, Zeng et al.⁶	63, M	-	Shortness of breath and chest tightness after activity	Fever: 39.3 ^oC HR: - SBP: - DBP: - Spo₂: 91	Sinus tachycardia and no ST-segment elevation	WBC: - Lymphocyte: - CRP: - D-dimer: - Troponin: 11.37 g/L BNP: 22.600 pg/ mL
Case 4, Doyen et al.⁷	69, M	Hypertension	Cough, fever, dyspnea	Fever: 39.1 ^oC HR: - SBP: - DBP: - Spo₂: 91	Inverted T waves in anterior leads	WBC: 15.400 g/L Lymphocyte: 141.9×10⁹ per L CRP: - D-dimer: - Troponin: 9002 ng/L BNP: 22.600 pg/ mL
Case 5, Trogen et al.⁸	17, M	Obesity, asthma, spondylolysis	fever and neck pain, diarrhea	Fever 103 °F HR: 150 bpm S BP: 79 mm Hg DBP: 66 mm Hg Spo₂: 91	Sinus tachycardia and T-wave inversion particularly in the inferior leads	WBC: 15.4 g/dL Lymphocyte: 0.9×10³/µL CRP: 167 mg/L D-dimer: 1218 ng/mL Troponin: 2.97 ng/ml BNP: 2124 pg/mL
Case 6, Sardari et al.⁹	31, M	-	Dyspnea on exertion and low-grade fever	Fever: 37.8 ^oC HR: 70 bpm SBP: 110 mm Hg DBP: 70 mm Hg Spo₂: 98	Normal findings	WBC: - Lymphocyte: - CRP: 105 mg/L D-dimer: - Troponin: 2.97 ng/ml BNP: -
Case 7, Coyle et al.¹⁰	57, M	Hypertension	Shortness of breath, fevers, cough, myalgia, decreased appetite, nausea and diarrhea	Fever: - HR: - SBP: - DBP: - Spo₂: -	Sinus tachycardia without ST/T wave changes	WBC: - Lymphocyte: Lymphopenia CRP: Elevated D-dimer: - Troponin: Rapid rise BNP: Rapid rise
Case 8, Beşler and Arslan¹¹	20, M	-	Febrile sensation and chest pain	Fever: 39 ^oC HR: 111bpm SBP: 149 mm Hg DBP: 63 mm Hg Spo₂: 97	-	WBC: 6.74 × 10⁹ per L Lymphocyte: Lymphopenia CRP: 0.0812 g/L D-dimer: - Troponin: 0.572 ng/mL BNP: 127 ng/L
Case 9, Yuan et al.¹²	33, M	Hypertension	Chest pain, fever, and muscle ache.	Fever: 37.3 ^oC HR: 121bpm SBP: 115mm Hg DBP: 79 mm Hg Spo₂: -	Ventricular tachycardia.	WBC: - Lymphocyte: - CRP: - D-dimer: - Troponin: - BNP: -
Case 10, Cizgici et al.¹³	78, M	-	Chest pain and shortness of breath.	Fever: 37.3 ^oC HR: 150 bpm SBP: 115 mm Hg DBP: 79 mm Hg Spo₂: -	Atrial fibrillation with 150 beats/minute and concave ST elevation except for aVR lead	WBC: Leukocytosis Lymphocyte: Lymphopenia CRP: 94.6 mg/L D-dimer: - Troponin: 998.1 ng/L BNP: 127 ng/L
Case 11, Asif and Ali¹⁴	64, M	Hypertension, hyperlipidemia	Dyspnea	Fever: - HR: 80 bpm SBP: 85 mm Hg DBP: 50 mm Hg Spo₂: 70	Non-specific T wave changes	WBC: Leukocytosis Lymphocyte: Lymphopenia CRP: 94.6 mg/L D-dimer: - Troponin: 0.17 ng/ml. BNP: -
Case 12, Asif and Ali¹⁴	71, F	Multiple myeloma	Fever, cough, and dyspnea	Fever: - HR: 125 bpm SBP: 70 mm Hg DBP: 41 mm Hg Spo₂: 70	1 mm ST elevation in leads V2–V6 with associated Q waves in leads V4–V6	WBC: - Lymphocyte: - CRP: - D-dimer: - Troponin: 1.6 ng/ml BNP: -
Case 13, Juusela et al.¹⁵	45, F Pregnant (39 weeks)	Obesity, gestational diabetic	Contractions and emesis	Fever: 99.6 ^oF HR: 120 bpm SBP: 183 mm Hg DBP: 114 mm Hg Spo₂: 96	Nonspecific T-wave abnormalities	WBC: - Lymphocyte: - CRP: - D-dimer: - Troponin: 0.046 ng/mL BNP: 114 pg/mL
Case 14, Juusela et al.¹⁵	26, F Pregnant (33 weeks)	Obesity, polycystic ovary syndrome	Shortness of breath, dyspnea,	Fever: 99.6 ^oF HR: 130 bpm SBP: 110 mm Hg DBP: 70 mm Hg Spo₂: 95	Supraventricular tachycardia	WBC: - Lymphocyte: - CRP: 7.68 mg/dL D-dimer: - Troponin: 0.046 ng/mL, BNP: <10 pg/mL,
Case 15, Pavon et al.¹⁶	64, M	Pulmonary sarcoidosis and epilepsy	Chest pain and dyspnea.	Fever: 39.3°C HR: - SBP: - DBP: - SpO2: -	Unremarkable	WBC: 18.7 gr/L Lymphocyte: - CRP: - D-dimer: 1210 ng/ml Troponin: 1843 ng/L BNP: -
Case 16, Irabien- Ortiz et al.¹⁷	59, F	Hypertension, cervical degenerative arthropathy, chronic lumbar radiculopathy, erythema nodosum, migraine	Anginal chest pain in the absence of respiratory symptoms.	Fever: 39.3°C HR: - SBP: 75 mm Hg DBP: 53 mm Hg Spo₂: 96	Concave ST-segment elevation and PR-segment depression, as well as low voltages	WBC: 14.17x 10⁹/L Lymphocyte: 2.59x10⁹/L CRP: - D-dimer: 23.242 ng/mL Troponin: Elevated BNP: 4421 ng/L

Case, author	Echocardiographic findings	CMR imaging findings	EMB findings	In-hospital treatment	In-hospital course
Case 1, Inciardi et al.⁴	Diffuse hypokinesia, with an estimated left ventricle ejection fraction of 40%	Diffuse biventricular hypokinesia, especially in the apical segments, and severe LV dysfunction	-	Hydroxychloroquine (200 mg twice daily), lopinavir/ritonavir (2 tablets of 200/50 mg twice daily), and intravenous methylprednisolone (1 mg/kg daily for), 50 mg of kanrenone, 25 to 50 mg of furosemide, and 2.5 mg of bisoprolol	Cardiogenic shock, clinical follow-up
Case 2, Kim et al.⁵	Severe left ventricular systolic dysfunction	Diffuse high signal intensity in the left ventricle myocardium on T2 short inversion recovery image	-	-	Discharged
Case 3, Zeng et al.⁶	An enlarged left ventricle (61 mm), diffuse myocardial dyskinesia along with a low left ventricular ejection fraction of 32%	-	-	High-flow oxygen, lopinavir-ritonavir, interferon α-1b, methylprednisolone, immunoglobulin, piperacillin-tazobactam, and continuous renal replacement therapy	Cardiogenic shock, exitus
Case 4, Doyen et al.⁷	Mild left ventricle hypertrophy, the left ventricular ejection fraction and wall motion were within normal limits	Subepicardial late gadolinium enhancement of the apex and inferolateral wall—suggestive of myocarditis	-	Hydrocortisone, aspirin, fondaparinux	Acute respiratory distress syndrome, discharged
Case 5, Trogen et al.⁸	Left ventricular ejection fraction qualitatively noted to be mildly depressed without obvious intracardiac clots or pericardial effusion	Normal size left ventricle (LV) with mildly decreased systolic function (40%) and normal right ventricular (RV) size with mildly diminished systolic function (RVEF of 39%). There was an area of mid-wall late gadolinium enhancement at the inferior LV–RV junction corresponding to an area of increased T2 signal, as well as an area of hypokinesia	-	Hydroxychloroquine, piperacillin/tazobactam, enoxaparin	Discharged
Case 6, Sardari et al.⁹	Mild left ventricular dysfunction	Normal left ventricular size with a mildly reduced ejection fraction of 50%. T2-weighted sequence with its post-analysis showed edema/inflammation in the mid inferoseptal and inferior wall. Late gadolinium enhancement showed subepicardial fibrosis in the mid inferior wall	-	Bisoprolol and lisinopril	Discharged
Case 7, Coyle et al.¹⁰	Moderate diffuse hypokinesia with relative apical sparing and a left ventricular ejection fraction of 35- 40%	Diffuse bi-ventricular and bi-atrial edema with a small area of late gadolinium enhancement	-	Hydroxychloroquine, azithromycin, ceftriaxone, methylprednisolone, colchicine	Discharged
Case 8, Beşler and Arslan¹¹	-	Short tau inversion recovery (STIR) sequence revealed a subepicardial high signal intensity in the mid posterolateral wall of the left ventricle which suggests myocardial wall edema	-	Hydroxychloroquine, azithromycin, ceftriaxone, tigecycline, favipiravir, colchicine	Discharged
Case 9, Yuan et al.¹²	-	The signal of T2 weighted image in the apical region of the left ventricle was increased, which indicated the possibility of myocardial cell edema. Left ventricular systolic function was slightly decreased	-	-	-
Case 10, Cizgici et al.¹³	Not being able to perform echocardiography	Not being able to perform magnetic resonance imaging	-	Furosemide, beta-blocker, and angiotensin-converting enzyme inhibitor was added to his Covid-19 specific therapy.	-
Case 11, Asif and Ali¹⁴	Normal left ventricle ejection fraction of 70–75% with no regional wall motion abnormalities	-	-	Aspirin 81 mg, clopidogrel 75 mg, heparin, azithromycin, hydroxychloroquine, meropenem, tocilizumab, norepinephrine, phenylephrine, vasopressin, atracurium, propofol, fentanyl	Intubated
Case 12, Asif and Ali¹⁴	Normal left ventricle ejection fraction of 65–70% with no regional wall motion abnormalities	-		Aspirin 81 mg, clopidogrel 75 mg, heparin, azithromycin, cefepime, vancomycin, tocilizumab, norepinephrine, phenylephrine, midazolam, and fentanyl	Intubated
Case 13, Juusela et al.¹⁵	Moderately reduced left ventricular ejection fraction of 40% with global hypokinesia	-	-	IV methylprednisolone, hydroxychloroquine, tocilizumab .	Intubated, (a primary cesarean)
Case 14, Juusela et al.¹⁵	Moderately reduced left ventricular ejection fraction of 40-45% with global hypokinesia	-	-	Metoprolol	Cesarean
Case 15, Pavon et al.¹⁶	Moderately reduced left ventricular ejection fraction of 47%.	T2-mapping sequences showed myocardial edema and sub-epicardial late gadolinium enhancement in the anterior interventricular septum, in the inferior and inferolateral walls	-	Piperacillin/tazobactam	Discharged
Case 16, Irabien- Ortiz et al.¹⁷	Preserved left ventricular ejection fraction without segmental abnormalities, and moderate pericardial effusion with no clear signs of hemodynamic deterioration	-	-	Immunoglobulins (80 mg/d) methylprednisolone (500 mg/d), antiviral treatment consisting of interferon-B (0.25 mg/48 h) and ritonavir/lopinavir (400 mg/100 mg/12 h)	Cardiogenic shock

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[1] CORRESPONDING AUTHOR: Tufan Çınar Department of Cardiology, Haydarpasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey Tel: +90 216 542-2010 / Fax: +90 216 542-2020 E-mail: drtufancinar@gmail.com