key: cord-0734841-0t56l62h authors: De Vita, Stefano; Ippolito, Sonia; Caracciolo, Maria Michela; Barosi, Alberto title: Peripartum cardiomyopathy in a COVID‐19‐infected woman: differential diagnosis with acute myocarditis—A case report from a Hub Institution during the COVID‐19 outbreak date: 2020-09-28 journal: Echocardiography DOI: 10.1111/echo.14873 sha: e4edfecc856805180a24450f05824ae58d5019ff doc_id: 734841 cord_uid: 0t56l62h We report the case of a healthy 35‐year‐old woman who had experienced a flu‐like syndrome during the week before childbirth and heart failure symptoms 10 days before the current hospitalization and presented to our emergency department with clinical signs of congestive heart failure, echocardiographic evidence of a severely dilated and hypokinetic heart, laboratory evidence of SARS‐CoV‐2 disease, and radiologic findings consistent with both virus‐related pneumonia and heart failure. Early cardiac magnetic resonance was crucial for the diagnosis of postpartum cardiomyopathy and for the exclusion of virus‐related myocarditis, allowing us to decide on a prudent and supportive clinical approach. Our Institution is one of two National Designed Hospitals for Infectious Diseases and the Milan Hub for Infectious Diseases. It has been directly and heavily involved in COVID-19 patient care since the beginning of the outbreak, taking care of patient no. 1 in Italy (and in Europe) and of his COVID-infected pregnant wife. Peripartum cardiomyopathy (PPCM) is a well-known cause of heart failure complicating pregnancy or the early postpartum period, presenting with heart failure symptoms secondary to left ventricular systolic dysfunction, where no other cause of heart failure is found. It is a diagnosis of exclusion. The clinical course SARS-CoV-2 infection is dominated by pneumonia and respiratory tract symptoms, possibly culminating in the acute respiratory distress syndromes 1 ; knowledge regarding the direct cardiovascular involvement by COVID-19 is sparse and the object of ongoing speculation. COVID-19-related myocarditis has been described so far in reports from Hubei 2 and Northern Italy. [3] [4] [5] The diagnosis of myocarditis is ideally made with the demonstration of the direct presence of the virus in the myocardium with an endomyocardial biopsy (EMB). However, in clinical practice it is currently achieved with cardiac magnetic resonance (CMR), given the potential complications and false negatives associated with the EMB. In particular, the presence of tissue edema in T2-weighed sequences and that of myocardial fibrosis in LGE in PSIR sequences, together with an increased T1 "native" value, are the hallmarks for the diagnosis of myocarditis at CMR. We report on a postpartum woman with clinical signs of heart failure and hypokinetic heart; the differential diagnosis included virus-induced cardiomyopathy versus PPCM. Early CMR was crucial for the diagnosis of PPCM and for the exclusion of virus-related myocarditis. On April 22, 2020, an otherwise healthy 35-year-old primigravida with no personal or family history of cardiovascular disease, cardiomyopathy, or sudden cardiac death (SCD) presented to our emergency department (ED) coming from home with worsening fatigue, dyspnea on minimal exertion, and orthopnea in the previous week without fever. The patient uneventfully gave birth on March 21, 2020. During the week before delivery, she had experienced influenza-like symptoms, with fever, cough, and altered sense of taste and smell. The symptoms gradually disappeared after childbirth. She breastfed her child in the following weeks in a well-being condition. On arrival to our ED, her blood pressure was 110/70 mmHg, heart rate 120 b/m, respiratory rate 26/minute, and temperature 36.6°C. Peripartum cardiomyopathy (PPCM) is a rare form of pregnancyassociated cardiac dysfunction. Currently, the ESC defines PPCM as "an idiopathic form of cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found". 6 To substantiate the diagnosis, the left ventricle does not need to be dilated, but the ejection fraction needs to be <45%. Notably, mononuclear inflammatory infiltration in heart tissue but no viral inclusion bodies was observed in COVID-19 autopsy studies. 9 Myocardial injury, as defined by an increased troponin level, is known to occur in 35% of myocarditis cases. In the setting of ARDS and hypoxia due to COVID-19, many patients may be expected to develop such injury. Elevated troponin levels are described in many patients infected with COVID-19, with significant differences between patients who died and those who survived. 10 Reports have also suggested that acute cardiac injury is frequent in patients with COVID-19 and is associated worse prognosis. 9 Prior studies in other coronavirus species (MERS-CoV) have demonstrated evidence of acute myocarditis using CMR. 11 A limitation of our study is the unavailability of T1 mapping at CMR in our Institution. We believe this one of the first reported cases of peripartum cardiomyopathy during the COVID-19 outbreak. 12 Early CMR avoided the unnecessary exposure of our patient to as yet unproven antiviral regimens. We maintain that this case underscores the need to keep in mind non-COVID-19-related disorders, even in the setting of the COVID-19 epidemic and in a patient with COVID-19 disease. Furthermore, it is to be noted that our patient showed evidence The data that support the findings of this study are available from the corresponding author upon reasonable request. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study First case of COVID-19 complicated with fulminant myocarditis: a case report and insights Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19) Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection Myocardial localization of coronavirus in COVID-19 cardiogenic shock Long-term prognosis, subsequent pregnancy, contraception and overall management of peripartum cardiomyopathy: practical guidance paper from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy Peripartum cardiomyopathy: disease or syndrome? Cardiac endotheliitis and multisystem inflammatory syndrome after COVID-19 Pathological findings of COVID-19 associated with acute respiratory distress syndrome Sanchis-Gomar F. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): evidence from a meta-analysis Acute myocarditis associated with novel Middle East respiratory syndrome coronavirus Two cases of coronavirus 2019-related cardiomyopathy in pregnancy