Late-onset Myocardial Infarction and Autoimmune Haemolytic Anaemia in a COVID-19 Patient Without Respiratory Symptoms, Concomitant With a Paradoxical Increase in Inflammatory Markers

A Case Report

Maria Chiara Pelle; Bruno Tassone; Marco Ricchio; Maria Mazzitelli; Chiara Davoli; Giada Procopio; Anna Cancelliere; Valentina La Gamba; Elena Lio; Giovanni Matera; Angela Quirino; Giorgio Settimo Barreca; Enrico Maria Trecarichi; Carlo Torti


J Med Case Reports. 2020;14(246) 

In This Article

Clinical Case Presentation

An 86-year-old Caucasian woman suffering from hypertension and anxiety-depressive syndrome was admitted to our Infectious and Tropical Disease Unit on April 1st, 2020. She tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by nasopharyngeal swab on March 26th, 2020, and did not report any symptoms other than nausea. Physical and neurological examinations on admission were normal, blood pressure was 120/85 mmHg, heart rate was 92 beats per minute, and temperature was 36.8°C. She resided in a long-term care facility and was on treatment with trazodone 60 mg/ml 3 drops daily and delorazepam 1 mg/ml 5 drops daily for an anxiety syndrome and furosemide 25 mg 1 tablet three times a week for high blood pressure. She was unmarried, had no children, was a housewife and lived in an urban area. She did not smoke and did not consume alcohol. In Table 1, we report the main laboratory findings at diagnosis and during the course of her hospital stay. The baseline twelve-lead electrocardiogram was normal (Figure 1a). Although she was asymptomatic, we performed a chest X-ray, which showed a"thickening of the interstitial design, in particular at the bases". Due to this finding, antiviral treatment with hydroxychloroquine and azithromycin was started according to a protocol reported elsewhere and clinical guidelines.[3,4] Due to hypomobility, thromboprophylaxis with enoxaparin 4000 IU once daily was also started (Padua score = 4).[5] During hospitalization, the patient did not need any oxygen support. Swabs were persistently positive over time until they became negative on May, 15th, 2020. Therefore, positivity lasted for a total of 54 days. Despite a favourable clinical course without any respiratory symptoms, c-reactive protein (CRP) and IL-6 increased progressively, with IL-6 reaching a peak of 165 pg/ml, concomitant with the occurrence of the complications described below (in particular AIHA).

Figure 1.

Baseline electrocardiogram (a) and the occurrence of myocardial infarction (b)

On April 11th, for abdominal and right shoulder pain, the patient underwent a computerized tomography (CT) scan, which demonstrated gallbladder lithiasis and areas of ground glass opacity in the lungs. A few days later, due to an accidental fall, she underwent a cerebral CT scan, which showed evidence of only chronic cerebral vasculopathy. As a precaution, due to the traumatic event, given the improvement in patient mobility, enoxaparin was stopped.

On May 8th, the patient developed paraesthesia of the left arm; therefore, an electrocardiogram was performed and showed evidence of an ST-elevation myocardial injury (Figure 1b). Cardiac biomarkers were elevated: the highest value of high-sensitivity troponin T was 268.3 ng/L, myoglobin was 128 ng/ml and creatine kinase-MB was 12.4 ng/ml, with a progressive reduction over the following days. Taking into account advanced age and patient fragility, cardiologists advised against a more aggressive approach, limiting medical therapy to intravenous acetylsalicylic acid 125 mg on the first day, followed by oral administration100 mg/day; oral clopidogrel 75 mg 4 tablets on the first day, followed by 75 mg/day; subcutaneous enoxaparin 4000 IU twice daily for 7 days; oral ramipril 5 mg once daily and oral atorvastatin 40 mg once daily. The patient was then transferred to the intensive care unit (ICU) for clinical and instrumental monitoring. An echocardiogram was performed, showing a hypertrophic left ventricle with normal systolic function (ejection fraction, EF, 55%), a normokinetic left ventricle apex, and normal right sections. The level of NT-proBNP was 5404 pg/ml. Moreover, for marked hypotension, therapy with norepinephrine (0.2 γ/kg/min) was prescribed.

After three days in the Intensive Care Unit (ICU), the patient's clinical condition improved; therefore, she was transferred again to our unit. A reduction in haemoglobin of 2 grams was found on May 13th, 2020, compared to a value of 10 grams/dl 5 days before. To understand the aetiology of anaemia, ferritin, sideraemia, vitamin B12, folic acid were measured, but only folic acid was low. Haemophagocytic lymphohistiocytosis syndrome was excluded.[6] Direct and indirect Coombs tests were performed as well, and the direct Coombs test was highly positive (i.e., 4+) for immunoglobulin (IgG). The consulting haematologist performed a peripheral blood smear, which indicated "anisopoikilocytosis of erythrocytes, several acanthocytes, some schistocytes". After consideration of this result, the consulting haematologist decided against a diagnosis of a lymphoproliferative disorder, there by suggesting the avoidance of bone biopsy and possible contraindications, such as the need for antiplatelet therapy for recent myocardial infarction. Since antibodies (IgG) against Cytomegalovirus (CMV) were positive, although IgM were negative, to exclude a possible role of Cytomegalovirus reactivation in the genesis of AIHA, CMV, Deoxyribo Nucleic Acid (DNA) was tested in serum using real time Polymerase Chain Reaction (PCR) (CMV Elite MGB® Kit, Elitech Group, Italia). With this method, CMV DNA was undetectable. Also, IgG for Parvovirus B-19 were positive, IgM were negative, and Parvovirus B19 DNA was undetectable in serum by real time PCR. Therefore, diagnosis of these two active infections was excluded.

High-dose corticosteroid treatment (prednisolone 0.8 mg/kg) was started, although anaemia was only mild because the patient had worsening asthenia and dyspnoea, while transfusion would have been dangerous due to the presence of IgG autoantibodies. Rapid improvement in haemoglobin levels was obtained (Table 1). On May, 27th 2020, echocardiogram was performed, which showed a hypokinetic cardiac apex and mild mitral regurgitation. The patient's clinical condition improved; therefore, the patient was discharged on July 3rd 2020 in good conditions and then hosted in a long-term care facility. The patient did not carry out follow-up visits.