Asymmetric septal edema masking as hypertrophy in an infant with COVID-19 myocarditis

Abstract

Cardiac disease in pediatric patients due to coronavirus SARS-CoV-2 disease (COVID-19) includes myocarditis and multisystem inflammatory syndrome, both of which can present with a broad range in severity. Here we describe an infant with COVID-19 causing fulminant myocarditis with inotrope-resistant acute heart failure requiring extracorporeal membrane oxygenation. The patient demonstrated an atypical finding of localized septal thickening suggestive of hypertrophic cardiomyopathy, but the diagnosis of myocarditis was confirmed by cardiac MRI. Serial echocardiography illustrated complete resolution of septal hypertrophy and normalized cardiac function. The current report highlights the potential severity of COVID-19 associated myocarditis, the potential for recovery, and the utility of cardiac MRI in confirming the mechanism.

Keywords: BNP, brain natriuretic peptide; COVID-19; COVID-19, coronavirus SARS-CoV-2 disease; ECMO, extracorporeal membrane oxygenation; Extracorporeal membrane oxygenation; ICU, intensive care unit; MIS-C, multisystem inflammatory syndrome; MRI, magnetic resonance imaging; Magnetic resonance imaging; Myocarditis; PCR, polymerase chain reaction.

Fig. 1

(A–D) Serial echocardiography imaging with septal size dimension and z-score in parentheses: A. Baseline echocardiogram performed at age 4 months for follow up of small conoventricular VSD (5.2 mm; z = 0.5). B. Echo performed on illness day 6 (6.5 mm; z = 1.5). C. Echo performed on day 23 of illness (11 mm, z = 7.5). D. Echo performed 75 days after onset of symptoms demonstrating complete resolution of septal thickening (4.7 mm; z = −1.0).

Fig. 2

(A, B) Cardiac MRI performed after recovery of ventricular function, on day of illness 23, under general anesthesia. Steady state free precession imaging. Four chamber (A) and LVOT (B) views. The wall thickening was most prominent along the ventricular septum (1.2 cm, white arrows) with some extension to part of the superior wall, compared to the lateral wall which measures 0.5 cm (black arrows). On the four chamber view a small pericardial and left pleural effusion are observed (asterisks). LVOT = Left Ventricular Outflow Tract.

Supplemental Fig. 1

Four chamber view cardiac MRI. T2-weighted dark blood imaging to assess myocardial edema. There is significantly increased myocardial (arrow) to skeletal (*) muscle signal intensity ratio consistent with myocardial edema. T2 relaxation times were increased most prominently in the septum.