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. 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. 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. 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. 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. This conclusion was echoed by a Chinese study of 90 patients with pericardial effusion associated with COVID-19. 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.
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. 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. 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. 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.
COVID-19: Coronavirus disease 2019; CTA: Computed tomography angiography; EKG: Electrocardiogram; PE: Pulmonary embolism; POD: Postoperative day; SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2; TMax: Maximum body temperature
We have no acknowledgements.
Availability of data and materials
All data generated or analyzed during this study are included in this published article and its supplementary information files.
Ethics approval and consent to participate
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
J Med Case Reports. 2020;14(158) © 2020 BioMed Central, Ltd.