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


J Med Case Reports. 2020;14(158) 

In This Article

Discussion and Conclusions

This report describes a case of our patient with viral pericarditis causing a pericardial effusion resulting in cardiac tamponade secondary to COVID-19 infection. Our patient initially presented with mild symptoms and stable vital signs. She returned 2 days later with worsening tachycardia and hypotension, and she had developed a pericardial effusion. This case demonstrates that COVID-19 can affect multiple organ systems beyond respiratory complications. COVID-19, even though it enters the lung via angiotensin-converting enzyme 2, can also affect the heart and kidneys.[1] Common COVID-19 presentations are still being elucidated, which highlights the importance of all presentations of the novel infection.

A review of current evidence discusses the first case of cardiac tamponade arising from COVID-19 in a previously healthy 47-year-old woman presenting with chest pain and shortness of breath with an echocardiogram demonstrating pericardial effusion; the patient was hypotensive despite fluid repletion and eventually underwent pericardiocentesis with improvement in hemodynamic status.[2] A recent case report documented a case of acute myopericarditis with systolic dysfunction 1 week after a patient developed a fever and cough arising from COVID-19.[3] Additionally, a recent meta-analysis reported that approximately 4.55% of chest computed tomographic scans obtained in patients with suspected or confirmed COVID-19 have shown evidence of pericardial effusion.[4] We suspect that more cases of viral pericarditis, pericardial effusion, and pericardial tamponade associated with COVID-19 exist that have gone unreported.

A systematic review of the PubMed, Embase, and WHO databases of publications discussed 919 patients with COVID-19 who developed pericardial effusion. The study described it as an uncommon finding associated with COVID-19.[5] This conclusion was echoed by a Chinese study of 90 patients with pericardial effusion associated with COVID-19.[6] However, we believe that pericardial effusion may be a useful clinical feature to help distinguish severe from mild disease. A review of 83 patients supports this, showing that 4 (16.0%) of 25 critical patients demonstrated pericardial effusion versus 0 (0%) of 58 patients with mild disease.[7]

Acute pericarditis is diagnosed by at least two of the following four features: chest pain, a pericardial rub, saddle-shaped ST elevation and/or PR depression (sinus tachycardia with PR shortening and any depression), and nontrivial new or worsening pericardial effusion.[8] Our patient exhibited two of four features, including chest pain and pericardial effusion.

Approximately 90% of acute pericarditis cases are idiopathic or viral. Viral cultures and antibody titers are often not useful clinically.[9] Pericarditis has been described in cases of other coronaviruses, including SARS-CoV and Middle East respiratory syndrome CoV, making the diagnosis of acute pericarditis in our patient with COVID-19 reasonable.[10,11] Thus, we felt it appropriate to continue treatment for acute pericarditis due to our patient's COVID-19 infection.

Four days after discharge, our patient was contacted for follow-up. She was still requiring oxygen and was short of breath with exertion, but felt much better each day. She had follow-up appointments with her primary care physician and cardiothoracic surgeon scheduled for the following week.

In addition to a focus on other symptoms, prevention is important. The basic reproductive number (R0) is higher than previously thought.[1] This means that COVID-19 is significant and demands focused nonpharmacologic prevention strategies such as wearing masks, social distancing, quarantining, isolation, and diligent hand hygiene.[12]