Pericardial Effusion and Cardiac Tamponade Requiring Pericardial Window in an Otherwise Healthy 30-year-old Patient With COVID-19

A Case Report

Christina Walker; Vincent Peyko; Charles Farrell; Jeanine Awad-Spirtos; Matthew Adamo; John Scrocco

Disclosures

J Med Case Reports. 2020;14(158) 

In This Article

Case Presentation

A 30-year-old Caucasian woman with no past medical history presented to our hospital with a 3-day history of fever (maximum body temperature [TMax] 101.0 °F [38.3 °C]), dry cough, and exertional chest pain. She denied any shortness of breath, nausea, vomiting, diarrhea, dysuria, and rash. The patient works in healthcare and has had many possible exposures to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the novel coronavirus. She denied recent travel or immobilization. She had no risk factors or history of cardiac disease or thromboembolic disease. Her family history revealed that her mother had had a heart attack at an unknown age.

The patient's vital signs included a heart rate of 116 beats/minute, blood pressure of 107/74 mmHg, respiratory rate of 16 breaths/minute, body temperature of 96.8 °F (36.0 °C), and oxygen saturation of 97% on room air. She was tachycardic, but she otherwise had a normal physical examination result.

Her electrocardiogram (EKG) demonstrated sinus tachycardia. Basic chemistry test and cardiac enzyme test results were obtained. The patient's D-dimer was elevated at 264 ng/ml, so computed tomography angiography (CTA) was performed to evaluate for pulmonary embolism (PE). The results demonstrated no evidence of PE; however, there was evidence of interstitial pneumonia with subpleural interstitial densities and ground-glass opacities (Figure 1).

Figure 1.

Initial CTA suggesting pneumonia and ground-glass opacities

The patient appeared well upon reevaluation. Her tachycardia had improved with intravenous fluids, and she was stable for discharge. She was written prescriptions for cefdinir and azithromycin for presumed community-acquired pneumonia treatment as well as ipratropium-albuterol.

The patient was a healthcare worker, so COVID-19 testing (Abbott RealTime SARS-CoV-2 assay; Abbott Molecular, Abbott Park, IL, USA) was performed. She was discharged to home with isolation instructions and strict return precautions. Her COVID-19 test result was positive.

Two days later, the patient returned with worsening chest pain and shortness of breath. She had been compliant with discharge medications from the previous visit. Her fever had resolved. The result of her home pulse oximetry had remained above 97%. She had developed increased tachycardia with heart rates above 130 beats/minute.

The patient's physical examination revealed that she was well-appearing. She was tachycardic with dry mucous membranes. The remainder of the examination was unchanged. She exhibited no conversational dyspnea.

Her initial vital signs included a heart rate ranging from 116 to 134 beats/minute, blood pressure of 95/69 mmHg, respiratory rate of 18 breaths/minute, body temperature of 97.8 °F (36.6 °C), and oxygen saturation of 97% on room air. She was administered 1 L of intravenous fluids. Repeat laboratory tests and CTA of the chest were performed.

Significant laboratory values included brain natriuretic peptide of 7890 pg/ml. The patient's EKG again showed sinus tachycardia without any obvious ST elevation or depression, no electrical alternans, and normal voltage. A respiratory polymerase chain reaction viral panel result was negative for all pathogens tested.

CTA showed improvement of infiltrates with no evidence of PE. It also showed the presence of a pericardial effusion that was not seen on imaging from the previous visit (Figure 2).

Figure 2.

Repat CTA showing pericardial effusion

In addition, an echocardiogram at that time showed a moderate-sized pericardial effusion of approximately 12 mm (Figures 3 and 4).

Figure 3.

US showing pericardial effusion (pointer)

Figure 4.

US showing pericardial effusion

Soon after this time, the patient became hypotensive with a blood pressure of 77/58 mmHg. She was administered an additional 500 ml of normal saline.

A central line was placed in the right femoral vein, and phenylephrine was initiated, which led to slight improvement of her hypotension. However, she remained persistently tachycardic with a maximum heart rate of 134 beats/minute. She developed tachypnea with a respiratory rate of 44 breaths/minute, so she was placed on 6 L of nasal cannula oxygen after arrival in the intensive care unit. She was started on hydroxychloroquine as well.

Overnight, the patient remained hypotensive and tachycardic. She continued to be tachypneic with increased work of breathing, and the following morning, she was taken to the operating room for an emergent subxiphoid pericardial window for cardiac tamponade. She had over 150 ml of strawlike output. A mediastinal drain was placed.

On postoperative day (POD) 1, the patient's blood pressure remained stable on phenylephrine, and her tachycardia improved with a heart rate between 103 and 119 beats/minute. She was maintaining an oxygen saturation above 92% on a 3-L nasal cannula. Her pericardial drain output was 300 ml. Colchicine was initiated for acute pericarditis.

On POD 2, the patient was febrile with a TMax of 100.6 °F (38.1 °C). Her blood pressure remained stable on phenylephrine, and oral midodrine was initiated. Her tachycardia improved with a heart rate ranging from 100 to 108 beats/minute. The patient was placed on a 4-L nasal cannula, and the pericardial drain was removed.

On POD 3, the patient was afebrile. Vasopressors were discontinued, and her tachycardia improved. She remained on a 4-L nasal cannula.

On POD 4, the patient continued to experience mild chest pain and a mild cough, but she had improvement of her breathing. Her blood pressure and heart rate remained stable. She was transferred to a monitored telemetry floor with a 3-L nasal cannula.

The patient's symptoms continued to improve during her hospital course, and she was discharged to home on POD 7 with aspirin, colchicine, and pantoprazole for treatment of viral pericarditis. She was discharged with instructions to undergo a repeat echocardiogram 2–4 weeks after a negative COVID-19 test result. The results of blood and sputum samples from both her initial emergency department visit and hospital admission were negative.

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