Myocardial localization of coronavirus in COVID-19 cardiogenic shock

Abstract

We describe the first case of acute cardiac injury directly linked to myocardial localization of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a 69-year-old patient with flu-like symptoms rapidly degenerating into respiratory distress, hypotension, and cardiogenic shock. The patient was successfully treated with venous-arterial extracorporeal membrane oxygenation (ECMO) and mechanical ventilation. Cardiac function fully recovered in 5 days and ECMO was removed. Endomyocardial biopsy demonstrated low-grade myocardial inflammation and viral particles in the myocardium suggesting either a viraemic phase or, alternatively, infected macrophage migration from the lung.

Keywords: Cardiac injury; Cardiogenic shock; Coronavirus; Extracorporeal membrane oxygenation; Myocardial inflammation; SARS-CoV-2.

Figure 1

Light microscopy immunostaining of the inflammatory infiltrate. (A,B) Low‐ and high‐power views of endomyocardial biopsy, with sparse CD45RO positive interstitial cells. (C,D) Large, vacuolated macrophages immunostained with anti‐CD68 antibodies. (E) Ultrastructural morphology of a large and cytopathic macrophage. (A–D: the bar scale is in the left low corner of each panel. E: the bar scale is in the right low corner of the panel and corresponds to 2 μm).

Figure 2

Examples of small groups of viral particles (A and B; panel C shows a higher magnification of one of the viral particles squared in dashed red box of panel B) or single particles (D–F) observed within the interstitial cells of the myocardium of the patient. The red arrows indicate the most typical and easy‐to‐recognize viral particles, whose size varies from about 70 nm to 120 nm (see the white bars in the panels). Morphology also shows small differences with more or less prominent spikes of the viral crown. The morphology may also show viral particle disruption (E, green arrow) or attenuation of spikes of the crown (D and F), or viral particles in budding attitude (F). (Bar scale: A and B, 200 nm; C, 50 nm; D, 100 nm; E, 100 nm; F, 50 nm).

Figure 3

Electron micrograph showing a cytopathic interstitial inflammatory cell (A) that contains viral particles (some of them are magnified in panel B that corresponds to the yellow squared area of panel A). The interstitial cell is in close contact with the adjacent cardiac myocyte (left). The viral particles show diameter variability in the range of 70–120 nm. Although the inflammatory cell and myocyte are closely adjacent, no viral particles are observed in the myocyte.