key: cord-0919953-pxcok5pb authors: Gerber, Nicole; Flynn, Patrick A.; Holzer, Ralf J. title: Coronary Artery Dilation in an Asymptomatic Pediatric Patient with COVID19 Antibodies date: 2021-02-06 journal: Pediatr Cardiol DOI: 10.1007/s00246-021-02566-5 sha: 3b494427d26f80562351b24c2d8691d1fe0dfe14 doc_id: 919953 cord_uid: pxcok5pb We describe a 16-year-old asymptomatic male who presented with coronary artery dilation (z score + 2.3) identified on echo performed solely for presence of COVID-19 antibodies. This case raises the question of whether cardiac screening should be considered for all patients with a history of COVID-19. proximal dilation, measuring 0.41 cm (Boston z score + 2.3) [Fig 1] . The patient was physically active, playing basketball several times a week without limitations. At this cardiology visit, he was placed on low-dose Aspirin and initially restricted from exercise until a stress test could be performed. Stress test documented a VO2 max of 55.3 (111% predicted). Spirometry, EKG, blood pressure, and heart rate response were normal. Given the normal findings of the stress test, the duration of time since the COVID-19 infection, and the patient's strong desire to resume physical activities, exercise restrictions were lifted. During this cardiology visit, the patient also had a variety of laboratory investigations performed which revealed a normal Troponin I, normal C-reactive protein, normal erythrocyte sedimentation rate, and a normal b-natriuretic peptide. The only abnormality was an elevated creatine kinase of 3,235 U/L (normal range 46.0-171.0 U/L). has been shown to have cardiac effects in both adults [2] and children, [3] including significant cardiac involvement in pediatric patients who develop Multisystem inflammatory syndrome in children (MIS-C). In a recent article published in the New England Journal of Medicine, Feldstein and colleagues identified cardiovascular involvement in 80% of patients presenting with this entity. [4] Coronary artery aneurysms (with a z score ≥ 2.5) were present in 8% of these patients. [4] It is unclear whether the In the adult population, it has been recommended that patients with mild to severe COVID-19 disease undergo cardiac evaluation prior to returning to strenuous physical activity. [5] [6] [7] In the pediatric population, a more narrow approach has been suggested involving testing only in patients with MIS-C or with moderate to severe disease. [8] However, there is still little data to support these recommendations. This patient likely had a mild presentation of COVID-19, although this was not able to be confirmed by COVID PCR at that time. He did not have any history of MIS-C, and was completely asymptomatic at the time when the dilated right coronary artery was identified by echocardiography. Using the coronary artery z score to determine abnormality does have its limitations. The z score for this patient is borderline elevated (+ 2.3), so it is conceivable that future CT angiography may document a large dominant right coronary artery system without aneurysm. It is also possible that this patient could have had an unrecognized past episodes of asymptomatic Kawasaki's disease, which has been described. [9] However, as coronary artery aneurysms can lead to rupture [10, 11] or myocardial infarction, [11, 12] they are important to identify and monitor. [10] . Identifying coronary artery dilation, albeit borderline, in a patient with COVID-19 antibodies and a history of only mild COVID-19 infection therefore raises a difficult question regarding the management of pediatric patients with COVID-19. This patient was started on low-dose Aspirin with a plan to continue the medication for a year, with continued echocardiographic monitoring. If the z score remains unchanged over the course of the year, the patient will undergo CT angiography for further characterization. This asymptomatic pediatric patient underwent echocardiography solely due to the presence of COVID-19 antibodies, without notable COVID illness nor clinical suspicion for MIS-C. The patient was found to have borderline coronary artery dilation of unknown significance and will be followed closely by cardiology. The finding of borderline coronary artery dilation in this patient raises the question of the need for cardiac screening in pediatric patients who have had COVID-19 identified either by PCR during active infection, or IgG antibodies following the infection. Conflict of Interest None of the authors have any conflicts of interest to declare. Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors. Normal echocardiographic values for cardiovascular structures Enlarged right coronary artery. 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