Newsletter Edition October 2020 - Corner Case - 2

Contributed by Dr Priya Chudgar
Jupiter Hospital,
Thane, Mumbai
55-year-old physician with co-morbidities was diagnosed with severe COVID-19 pneumonia. His stay was unremarkable and was managed as per protocol and discharged. 20 days post discharge, he presented to the hospital with incessant hiccough associated with loss of smell. He was diagnosed to have a delayed cytokine storm and was treated accordingly and discharged from the hospital. After a few days, he complained of dyspnoea on exertion. Troponin I was not performed. A cardiac MRI was then requested to investigate further.

Cardiac MRI revealed normal morphology and size of cardiac chambers. There was no evidence of regional wall motion abnormality. LV wall thickness was well preserved. Subtle patchy mid -wall and sub-epicardial late gadolinium enhancement was noted in inferior wall and interventricular septum, where, RV side of the septum was also involved. No pericardial enhancement or intracavitary thrombus was seen.

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Fig 1. SSFP images reveal normal size and morphology of cardiac chambers with preserved LV wall thickness.

Fig. 2: CMR late gadolinium enhancement images short axis, 3 chamber, 2 chamber and 4 chamber views

Images reveal intermediate signal intensity mid-wall (orange arrows) myocardial and sub-epicardial (red arrows) late gadolinium enhancement involving interventricular septum and inferior wall

Fig. 3: Representative axial sections of Plain CT chest in lung window

Images reveal peripheral multifocal and confluent ground glass densities in both lungs, consistent with COVID-19 infection.

Discussion:

COVID-19 is primarily a respiratory disease, however multisystem involvement and cardiovascular complications are well known.

One study showed significant cardiac injury,  independent of the severity of the original COVID-19 infection, even after recovery from COVID-19 infection.1

SARS-CoV-2 virus causing COVID-19 infection, can affect the heart and rest of the cardiovascular system directly and indirectly.

Fig. 4 Potential mechanisms and resultant myocardial injury in COVID-19 infection.1,2,3

Other cardiovascular complications:
  • Cardiac arrhythmias due to persistent myocardial damage and scar.
  • Cardiac arrhythmias secondary to drug induced rhythm disturbances due to hydroxychloroquine and Remdesivir.
  • Chronic myocardial damage can lead to heart failure.
  • Elevated long-term cardiovascular risk in patients with history of pneumonia, hypercoagulability and residual systemic inflammatory activity.
  • Non-cardiogenic pulmonary oedema and  ARDS as well as multi-organ dysfunction due to altered vascular permeability.


Advantage of CMR: It allows for non-invasive assessment of myocardial injury. It is the modality of choice to distinguish ischemic from non-ischemic myocardial injury. Myocarditis, Takutsubo cardiomyopathy and myocardial infarction, as listed in the complications above, can be diagnosed and differentiated from one another by CMR. CMR utilising the Modified Lake Louise criteria defined by the presence of myocardial oedema, non-ischemic myocardial  injury and supportive criteria such as pericarditis and systolic LV dysfunction can rightly diagnose myocarditis.

Learning point: CMR can help diagnose type of myocardial injury in COVID-19 recovered patients.

References:

  1. Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol.Published online July 27, 2020. doi:10.1001/jamacardio.2020.3557
  2. Cardiac Involvement in Patients Recovered From COVID-2019 Identified Using Magnetic Resonance ImagingLu Huang, Peijun Zhao, Dazhong Tang, Tong Zhu, Rui Han, Chenao Zhan, Weiyong Liu, Hesong Zeng, Qian Tao, Liming XiaAm Coll Cardiol Img. 2020 Aug 19. Epublished DOI:10.1016/j.jcmg.2020.05.004
  3. ESC Guidance for Diagnosis and Management of CVD during the COVID-19 Pandemic.