key: cord-312835-a60bkohc authors: Kohli, Utkarsh; Meinert, Elizabeth; Chong, Grace; Tesher, Melissa; Jani, Priti title: Fulminant myocarditis and atrial fibrillation in child with acute COVID-19 date: 2020-10-18 journal: J Electrocardiol DOI: 10.1016/j.jelectrocard.2020.10.004 sha: doc_id: 312835 cord_uid: a60bkohc COVID-19 has manifested with ventricular dysfunction and cardiac arrhythmias, most commonly atrial fibrillation (AFib), in adults. However, very few pediatric patients with acute COVID-19 have had cardiac involvement. AFib, an exceedingly rare arrhythmia in otherwise healthy children, has not been reported in children with COVID-19. We report a 15 year-old girl with acute COVID-19, fulminant myocarditis and AFib. Serum pro-NT BNP, inflammatory markers and high sensitivity troponin concentration were all markedly elevated (Supplement 1). She was initially treated with intravenous immune globulin (1g/kg), intravenous methylprednisolone 60mg every 12 hours and subcutaneous low molecular weight heparin (Supplement 1). Epinephrine infusion was discontinued within 12 hours. Milrinone (0.7 mcg/kg/min) was continued until her ventricular function normalized (day 4). Hypotension recurred 24 hours post-admission, and immunomodulatory therapy was therefore intensified via addition of the IL-1 receptor antagonist, anakinra (100 mg subcutanous every 12 hours). She did not require any respiratory support though her chest radiograph showed minimal vascular engorgement. Atrial fibrillation with rapid ventricular conduction (ventricular rate 140s to 190s) developed 27 hours after admission and she was successfully cardioverted (50J, synchronous) ( Figure 1 ). Post-cardioversion, an amiodarone infusion was initiated and 12 hours later, transitioned to an oral regimen. Our patient denied a history of drug or alcohol abuse and the family history was negative for channelopathy, cardiomyopathy or early onset AFib. Her Following initiation of amiodarone, she has done well without any recurrence. Her cardiac and inflammatory biomarkers continue to trend downwards (Supplement 1). COVID-19 antibody test (Roche Elecsys Anti-SARS-CoV-2 antibody test, Roche labs, Basel, Switzerland) was obtained on day 2 of admission and was positive. COVID-19 PCR assay (Cepheid GeneXpert system, Sunnyvale, California, USA) was repeated on post-admission days 8 and 9 and was negative. While ventricular dysfunction and the whole gamut of arrhythmias have been reported in adults with acute COVID-19 [1] , pediatric patients have either been asymptomatic or have mostly manifested with mild respiratory illness [2] . Rare pediatric patients with COVID-19 have presented with ventricular dysfunction [3] ; however, arrhythmias such as AFib, which are exceedingly rare in otherwise healthy children, have not been reported in children with acute COVID-19 [4] [5] [6] [7] [8] [9] . A broad range of electrocardiographic abnormalities and arrhythmias such as T wave alterations, ST segment elevation, SI, QIII, TIII pattern, high degree atrioventricular block, atrial tachycardia, atrial flutter, ventricular tachycardia or fibrillation and pulseless electrical activity have been reported in adults with COVID-19 [10] . The pediatric data however remains somewhat limited. In a recently published single center pediatric series (n=36), nonsustained ventricular tachycardia (n=5) and sustained atrial tachycardia (n=1) were noted in approximately 17 % of children with acute COVID-19. Of note, all of these arrhythmias self-resolved. However, half of the children in this series were started on an anti-arrhythmic therapy. The electrocardiographic parameters like corrected QT interval was no different between children with and without cardiac arrhythmias [4] . One of these patients was on high dose epinephrine and nor-epinephrine infusions and the other patient had dyselectrolytemia (hypokalemia, hypomagnesemia and hypocalcemia). In addition, abnormal echocardiographic findings such as left ventricular dysfunction, left ventricular dilation and pericardial effusion were noted in twothirds of the patients. AFib in young patients (<18 yrs) is exceedingly rare and is usually associated with alcohol or drug abuse [5] , an inherited channelopathy such as Brugada syndrome, long QT syndrome, short Potential Effects of Coronaviruses on the Cardiovascular System: A Review Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults Pediatric Life-Threatening Coronavirus Disease 2019 With Myocarditis Atrial Fibrillation in Long QT Syndrome by Genotype Atrial fibrillation in young patients A KCNQ1 mutation causes a high penetrance for familial atrial fibrillation Cardiac Involvement in Children With COVID-19 International Society of Electrocardiology Young Community (ISE-YC). Value of electrocardiography in coronavirus disease 2019 (COVID-19) Life-Threatening Event Risk in Children With Wolff-Parkinson-White Syndrome: A Multicenter International Study The follow-up evaluation of electrocardiogram and arrhythmias in children with fulminant myocarditis Impact of Extracorporeal Membrane Oxygenation on Acute Fulminant Myocarditis-related Hemodynamic Compromise Arrhythmia in Children Cardiac and arrhythmic complications in patients with COVID-19 Inflammatory activation and carbohydrate antigen-125 levels in subjects with atrial fibrillation Splenectomy exacerbates atrial inflammatory fibrosis and vulnerability to atrial fibrillation induced by pressure overload in rats: Possible role of spleen-derived interleukin-10 Treatment Ameliorates High-Fat Diet-Induced Inflammatory Atrial Remodeling and Fibrillation Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) Investigators. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial Relation of milrinone after surgery for congenital heart disease to significant postoperative tachyarrhythmias Milrinone use is associated with postoperative atrial fibrillation after cardiac surgery