Acute symptomatic COVID-19 myocarditis: Case series

Abstract

Background: Coronavirus disease 2019 COVID-19 still remains a major cause of morbidity and mortality worldwide, mainly due to Acute Respiratory Distress Syndrome (ARDS). Nevertheless, other extra-pulmonary pathological aspects of COVID-19, notably cardiovascular, were disclosed as the global understanding of the pathogen agent advanced.

Objectives: To detect and evaluate acute myocarditis in patients with active and symptomatic COVID-19 infection.

Materials and methods: In this prospective analysis, patients presented with active COVID-19 illness and meeting the inclusion criteria were identified at the University Hospital Complex of Rabat between January and September 2021.

Results: Fifteen patients (8 males and 7 females) aged from 17 to 52 were included during the analysis period, the average delay between the confirmation of COVID-19 and the onset of myocarditis symptomatology was 17 days. The symptomatology was dominated by chest pain, unexplained cardiogenic shock and palpitations. The ECG showed essentially diffuse repolarization disorders. The inflammatory markers were significantly disturbed with an elevation of ultra-sensitive cardiac troponin I in all patients. Cardiac MRI showed impaired global longitudinal strain (GLS) myocardial edema, early and late subepicardial Gadolinium enhancement, compared to the control group (p < 0,01).

Conclusion: Cardiac involvement was detected in a proportion of patients with active COVID-19. Age, gender, clinical and electrical presentations didn't seem to influence the diagnosis. Cardiac MRI played an essential role for detecting and evaluating active myocarditis. Patients who presented myocardial injury had to have a longer follow-up as current understanding of long-term prognosis is still lacking.

Keywords: Acute myocarditis; COVID-19; Cardiac MRI; Myocardial injury; SARS-CoV-2.

Fig. 1

ECG of a 30-year-old male patient, with no previous medical history nor cardiovascular risk factors, presented with acute chest pain with flu-like symptoms one week before, note the concave ST-segment elevation in lateral and inferior leads.

Fig. 2

CMR Imaging findings in adult female with active COVID-19 presenting chest pain after 10 days. Upper panel: (A) short axis and (B) four chamber view. T2-weithed images visualizing areas of myocardial edema in the lateral wall (yellow arrows) concordant to regional late gadolinium enhancement with subepicardial distribution (white arrows). Lower panel: late gadolinium enhancement imaging. (C) short axis (D) four chamber view.