key: cord-288336-io1t141z
authors: Singh, Rahul; Fuentes, Stephanie; Ellison, Henry; Chavez, Miguel; Hadidi, Omar F.; Khoshnevis, Gholamreza; Chang, Su Min
title: Case of Hemorrhagic Cardiac Tamponade in a Patient with COVID-19 Infection
date: 2020-06-04
journal: CASE (Phila)
DOI: 10.1016/j.case.2020.05.020
sha: 
doc_id: 288336
cord_uid: io1t141z

• There are protean manifestations of cardiac involvement with COVID 19; • Hemorrhagic pericardial effusion may be the sole cardiac manifestation of COVID 19.

COVID 19 is known to affect the heart in multiple ways. Here we present a case of COVID 19 causing hemorrhagic cardiac tamponade in a 62-year old man who required pericardiocentesis and admission to the Intensive Care Unit.

A 62 year-old man with multiple co-morbidities was brought to the emergency room (ER) due to progressive shortness of breath and altered mental status. He had a past medical history of coronary artery disease (previous drug-eluting stent to left anterior descending artery four years prior to admission), hypertension, hyperlipidemia, diabetes mellitus, chronic obstructive pulmonary disease, alcoholism and morbid obesity.

In the Emergency Room (ER) he was found to be hypotensive (BP 80/50 mmHg) and in hypoxic respiratory failure (pO2 of 76 on arterial blood gas). He was emergently intubated in the ER, started on pressors and transferred to the ICU. Chest x-ray revealed bilateral infiltrates with a right pleural effusion ( Figure 1 ). EKG showed normal sinus rhythm with new low voltage and old left axis deviation ( Figure 2 ). Lab results showed hyponatremia, acute kidney injury, leukocytosis with lymphopenia, mildly macrocytic anemia, coagulation panel within normal limits, an elevated D-dimer and negative serial troponins (Table 1 ) An echocardiography was emergently done and revealed a large pericardial effusion with tamponade physiology (Figure 3 , Video 1). He underwent emergent pericardiocentesis from an anterior approach since the patient's obesity precluded subxiphoid approach. Pericardial pressure was noted to be 35 mmHg and 1.1 liters of sanguinous fluid was drained. Right heart cath was done pre-and post-pericardiocentesis with pressure measurements detailed in Table 1 . Fluid analysis confirmed bloody sanguinous fluid with 1.2 million RBCs. Cytology revealed peripheral blood components only with no malignant cells. Initial nasopharyngeal swab for Coronavirus disease-2019 (COVID 19) was negative but subsequent testing from a broncheoalveolar lavage sample two days later came back positive. Output from the drain decreased and eventually stopped. Repeat echo done five days later showed resolution of the pericardial effusion ( Figure 4 ) and the drain was removed. The patient had a prolonged and complicated hospital stay. For his COVID infection he was treated with a course of hydroxychloroquine, ribavirin and lopinavir-ritonavir combination. He also received steroids and single doses of tocilizumab and anakinra to suppress inflammation. To aid his oxygenation, he was put on inhaled epoprostenol briefly. Although his pressor and inotropic support requirement decreased after pericardiocentesis, he had a component of septic shock from COVID 19 as well and was finally weaned of inotropic and pressor support ten days after pericardiocentesis. He underwent thoracentesis for the right pleural effusion which drained 1.6 liters of transudative, non-bloody fluid. Bacterial and fungal cultures of pleural fluid were negative. A few complications during his course included renal failure requiring continuous renal replacement therapy for a few days, upper gastrointestinal bleed that resolved with conservative management and development of a lower extremity deep vein thrombosis.He was finally extubated eighteen days after admission and was in the hospital for a total of twenty-eight days. He was followed up in clinic with a repeat chest CT still showing ground-glass opacities with residual right pleural effusion ( Figure 5 ). 

Our patient's presentation with respiratory failure due to COVID 19 pneumonia with concomitant hemorrhagic pericardial effusion not present on recent echocardiography leads us to believe that his pericardial effusion was caused by COVID 19 itself. At this point, our laboratory's COVID-19 PCR assay has not been approved for specimen apart from sputum, nasopharyngeal swabs or oropharyngeal swabs. Hence we were not able to send the fluid for COVID 19 testing. We did freeze a sample for future testing. However, other common causes of hemorrhagic pericardial effusion were highly unlikely 1,2 .

Cultures from pericardial fluid showed no evidence of bacterial or fungal infection. Cytology of the pericardial fluid pointed against malignancy. He had no recent cardiac interventions or trauma that would account for such effusion. Furthermore, his coagulation parameters were within normal limits ruling out any bleeding diathesis. The patient's pleural effusion was thought to be from COVID 19 infection as well since it was transudative. However we were unable to send this COVID testing as well. The patient was extubated after two days of thoracentesis and hence the pleural effusion may have had a substantial contribution to his respiratory status as well.

Although not as common, viral pericarditis can cause hemorrhagic pericardial effusion, especially Coxsackie virus [5] [6] [7] . Two possible mechanisms for this phenomenon are direct cytoxic activity by the virus or immune-mediated pathways 8 . Further work as to the pathogenesis of hemorrhagic effusion with COVID 19 will be required.

The interesting point in our case is that the patient had no predisposing risk factors to develop a hemorrhagic effusion. Hence we have a very high clinical suspicion that it was caused by COVID 19.

As we continue to take care of the COVID population, its protean cardiac manifestations will be better understood. It is imperative to note that hemorrhagic pericardial effusion leading to tamponade may be the sole yet potentially lethal manifestation of this viral infection.

Highlights:

• There are protean manifestations of cardiac involvement with COVID 19

• Hemorrhagic pericardial effusion may be the sole cardiac manifestation of COVID 19

Clinical clues to the causes of large pericardial effusions

Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s?

Cardiac Tamponade Secondary to COVID-19. JACC Case Rep

Life-threatening cardiac tamponade complicating myopericarditis in COVID-19

Hemorrhagic pericarditis with cardiac tamponadedue to Coxsackie virus infection

Bloody pericardial effusion: clinically significant without intrinsic diagnostic specificity

Cardiac tamponade caused by acute coxsackievirus infection related pericarditis complicated by aortic stenosis in a hemodialysis patient: a case report

ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS)

Video 1: Transthoracic echocardiography showing cardiac tamponade