Diagnostic dilemma: COVID-19 related cardiomyopathy or peripartum cardiomyopathy?

Abstract

Peripartum cardiomyopathy is a relatively rare condition, that usually presents with features of heart failure in the peripartum period. The ongoing pandemic caused by coronavirus disease 2019 (COVID-19) has been reported to be associated with myocarditis, with progression to dilated cardiomyopathy and heart failure. Dilated cardiomyopathy in a peripartum patient with COVID-19 infection may present a diagnostic dilemma. We report a case of dilated cardiomyopathy in a peripartum patient with COVID-19 infection. She presented with shortness of breath in the peripartum period. Chest X-ray showed a grossly enlarged heart with bilateral pulmonary infiltrates consistent with congestive heart failure or viral pneumonia. Echocardiography revealed dilated chambers with 22% left ventricular ejection fraction (LVEF) and global hypokinesis. Despite completing 5 days of remdesivir and dexamethasone, she had worsening dyspnea on postpartum day 10, a repeat echocardiogram showed further reduction in LVEF to 10-15% and was discharged with a life-vest after acute management. She had multiple hospital admissions for decompensated heart failure. Myocardial core biopsy showed marked acute inflammation and necrosis. She had an intra-aortic balloon pump, left ventricular and right ventricular assist devices placed on account of persistent hemodynamic instability, and is now scheduled to have a cardiac transplant. <Learning objective: Coronavirus disease 2019 (COVID-19) is an inflammatory disease involving multiple organs including the heart. Myocarditis and cardiomyopathy are possible short-term and/or long-term sequelae of COVID-19 infection. In peripartum women with COVD-19 infection, it may be difficult to distinguish between peripartum cardiomyopathy and COVID-19 related cardiomyopathy. This case report highlights such a dilemma.>.

Keywords: COVID-19; Cardiomyopathy; Heart failure; Peripartum cardiomyopathy.

Fig. 1

Chest X-ray showing cardiomegaly and bilateral pulmonary opacities consistent with congestive heart failure/ atypical or viral pneumonia.

Fig. 2

Transthoracic echocardiogram showed global hypokinesis with a reduced left ventricular ejection fraction of 15%.

Fig. 3

Cardiac magnetic resonance imaging showed severely dilated left ventricle with normal wall thickness and severely decreased left ventricular function, ejection fraction 10%, and moderately dilated right ventricle with severely decreased right ventricular, ejection fraction 17%. Findings were consistent with non-ischemic cardiomyopathy without evidence of macroscopic myocardial scarring or fibrosis.