Concurrent myopathy and inflammatory cardiac disease in COVID-19 patients: a case series and literature review

Abstract

Adult COVID-19 patients can present with acute muscle and/or cardiac involvement. Our study aims to describe the incidence and characteristics of patients with the co-occurrence of COVID-19 myopathy and inflammatory cardiac disease. We retrospectively reviewed all COVID-19 patients admitted to a large tertiary center to assess the co-occurrence of myopathy and inflammatory cardiac disease. We conducted a literature review of prior relevant case reports. There were three COVID-19 patients with concurrent involvement from our center and five cases in the published literature. Overall, mean age was 57.7 ± 16, four were females (50%) and only two patients (25%) had major relevant comorbidities. Muscle involvement included rhabdomyolysis or myositis and cardiac involvement included myocarditis or pericarditis. Most patients (75%) had no respiratory COVID-19 symptoms. Troponin and creatine phosphokinase levels were higher than twofold of the upper limit of normal for all patients. Steroids were used in the treatment of most patients (75%). All patients had a resolution or improvement of their extra-pulmonary involvement while two (25%) deteriorated due to COVID-19 pneumonia. The incidence for this co-occurrence is 0.07% among hospitalized COVID-19 patients. Patients with these rare COVID-19 simultaneous manifestations have distinct features. They are generally younger, present with extra-pulmonary symptoms and do not have severe respiratory compromise. An underdiagnosis causing treatment delay is possible. Further study is needed.

Keywords: COVID-19; Cardiac inflammatory disease; Myocarditis; Myopathy; Myositis.

Fig. 1

Flow chart of the inclusion process. CPK creatine phosphokinase. ^aDiagnosed by positive oropharyngeal SARS-CoV-2 polymerase chain reaction (PCR) swab. ^bDiagnoses recorded by the treating physician during admission, including myositis, myasthenia gravis, rhabdomyolysis, myopathy, pericarditis, myocarditis, or cardiomyopathy. ^cRegarded as the laboratory criteria

Fig. 2

Electrocardiograms from case 1, upon arrival (A) showing low QRS voltage and at day 2 (B) showing enlargement of QRS in precordial leads

Fig. 3

Computed tomography from case 1, symmetric bilateral edema of the proximal lower limb musculature (white arrows), consistent with myositis

Fig. 4

Chest radiograph from case 3, from 2018 (A) and upon arrival (B) with enlarged heart silhouette due to pericardial effusion