key: cord-303667-z3tmy8hw authors: Yousefzai, Rayan; Bhimaraj, Arvind title: Misdiagnosis in the COVID era: When Zebras are Everywhere, Don’t Forget the Horses date: 2020-04-27 journal: JACC Case Rep DOI: 10.1016/j.jaccas.2020.04.018 sha: doc_id: 303667 cord_uid: z3tmy8hw Abstract We report a patient who presented with respiratory failure, chest pain, and fever. In the COVID-19 pandemic era, the focus was diverted to the coronavirus infection, and STEMI was missed. Even though we need to be vigilant in the diagnosis of COVID-19, we should not forget about the common pathologies. Abbreviation: ECG = Electrocardiogram ECHO = Echocardiogram STEMI = ST-elevation myocardial infarction ARDS = Acute respiratory distress syndrome LV = left ventricle RV = right ventricle LAD = left anterior descending artery LCX = left circumflex artery RCA = right coronary artery ECMO = extracorporeal membrane oxygenation Abstract: We report a patient who presented with respiratory failure, chest pain, and fever. In the COVID-19 pandemic era, the focus was diverted to the coronavirus infection, and STEMI was missed. Even though we need to be vigilant in the diagnosis of COVID-19, we should not forget about the common pathologies. A 56-year-old male patient presented with shortness of breath. His symptoms started ten days prior to the admission. He had a virtual visit with his primary care doctor. At that visit, he described his symptoms as shortness of breath and cough associated with dull chest pain. He also reported fatigue, myalgia, and a recorded temperature of 102 Fahrenheit. On further questioning, he also mentioned similar episodes of chest pain in the past, with exertion. He was started on bronchodilators and antibiotics. Three days after the virtual visit with his primary care doctor, his symptoms continued to worsen, and he decided to call 911. On presentation to the hospital, he was found to be in respiratory distress. The patient had a history of hypertension, on Lisinopril 20 mg daily and hydrochrothizide 12.5 mg daily. He had a 40-pack year smoking history. He worked in different restaurants and had exposure to a large number of people. Acute coronary syndrome, infectious or inflammatory process, including COVID-19, ARDS, and pulmonary embolism. Chest x-ray showed diffuse patchy airspace opacities throughout the lungs (Figure 1 ). Arterial blood gas on presentation showed PH 7.11, PaCO2 66 mmHg, PaO2 50 mmHg, and bicarbonate 20.1 mmol/L. The patient was intubated. On 100% FiO2, arterial blood gas showed PH 7.02, PaCO2 84 mmHg, PaO2 97 mmHg, and Bicarbonate 21 mmol/L, with a PaO2/FiO2 ratio of 97g. COVID-19 PCR test was ordered. ECGwas done, which showed a new left bundle branch block (Figure 2) , which was not present previously on an ECG, two months ago ( Figure 3 ). Troponin was 56.82 ng/ml (normal range 0.00-0.04 ng/ml), and BNP was 2493 pg/ml (normal range 0-100 pg/ml). ECHOwas performed, which showed severe LV dysfunction with wall motion abnormalities ( Figure 4 , Video 1). Based on his symptoms on the presentation and his history, there was a suspicion for COVID-19 infection. The patient was intubated, but soon a veno-venous (VV) ECMO was considered emergently. The troponin elevation was considered a presentation of myocarditis. had mild symptoms, 13.9% had severe symptoms requiring oxygen, and 4.7% were critically ill needing ICU care (4). In a case series from Zhongnan Hospital of Wuhan University, the manifestation of myocardial injury included 8.7% shock, 16.7% arrhythmia, and 7.2% acute cardiac injury (5) . In another series (7), 6% of the COVID-19 positive patients presented with VT/VF, and 27.8% had myocardial injury by elevated troponin. The COVID-19 pandemic has undoubtedly alerted the cardiology community to the cardiovascular manifestation of COVID (5) . The vigilance and precautions needed for COVID suspected patients in no way should be relaxed, but the fear should not preclude us from delivering appropriate care. For example, in the case of the patient that we presented, before the COVID era, most likely, he would have been referred for a further evaluation immediately. The patient has significant risk factors for coronary artery disease, with a history suggestive of chronic angina; therefore, further investigations were warranted. In the COVID era, the hesitation of the patients to go to the hospital to avoid exposure, the reservation of the providers to send their patients to the health care facilities, and the limitation of the resources, have created a significant barrier for evaluation. Even in the case of the patients who are already admitted to the hospital, when the suspicious for COVID is raised, it can affect the care either by distracting from other diagnoses or delaying the procedures to avoid the exposure. For example, in this case, while the patient was being considered for ECMO, with proper protection, an angiogram should have been performed. Recently, the neurology community released a plea to the public not to ignore symptoms of a stroke. We also plea to the cardiology community to do the same and be vigilant about the common cardiac-related diagnosis that we might mislabel in the COVID-19 era. Since he had completed the LAD infarct ( Figure 8) , the decision was made against LAD revascularization. The patient was taken to the operating room, and Impella 5.5 was placed through the axillary artery, and ECMO was weaned off successfully. Currently, he remains in the ICU recuperating from an arduous journey to be able to be considered for options of potential revascularization (after proven viability), LVAD placement ( if cannot wean off the Impella) vs. cardiac recovery ( if able to successfully wean off the Impella). We have presented a 56-year-old male with risk factors for coronary artery disease who presented with STEMI. In the COIVD-19 era, the diagnosis was diverted towards COVID-19, and STEMI was missed. COVID-19 patients can present with cardiovascular manifestations. We have to be vigilant in diagnosing COVID-19 patients; however, we should not forget about the common diagnosis. The appropriate diagnostic tests and care should be delivered to the patients suspicious for COVID-19 with taking the proper precautions. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China A pneumonia outbreak associated with a new coronavirus of probable bat origin Clinical features of patients infected with 2019 novel coronavirus in Wuhan Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic Cardiovascular implications of fatal outcome of patients with coronavirus disease 2019 (COVID-19) In the COVID era, the vigilance for timely diagnosis, isolation, and treatment of the COVID-19 patients is imperative; however, the fear should not deter us from recognizing common pathologies.