key: cord-0924600-13n4st4q
authors: Blaivas, Michael
title: Unexpected finding of myocardial depression in 2 healthy young patients with COVID‐19 pneumonia: possible support for COVID‐19‐related myocarditis
date: 2020-06-13
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12098
sha: a66a8151e0895abf081fe5dedc8b940002826b91
doc_id: 924600
cord_uid: 13n4st4q

COVID‐19 is proving to be a devastating pandemic with both tragic economic and health consequences worldwide. Point‐of‐care ultrasound (POCUS) of the lungs has been thrust into the forefront of resources that could be used in the management of COVID‐19 acute care patients. However, relatively little attention has been paid to POCUS utility in assessing the heart in COVID‐19 patients. Anecdotal reports suggest encounters of likely COVID‐19 induced pericardial effusions and myocardial electrical dysfunction. This article presents 2 cases of generally healthy patients who were noted to have classic COVID‐19 bilateral pneumonia findings on lung ultrasound and incidentally discovered to have unsuspected left ventricular dysfunction likely resulting from myocarditis. POCUS videos are presented as illustrations of this potentially overlooked complication.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians. also been widespread recognition that lung point-of-care ultrasound (POCUS) is highly accurate for pneumonia diagnosis and monitoring, as well as other settings outside of COVID-19, without the high cost and radiation exposure encountered with chest CT. 3, 4 Radiological societies have recommended not using chest CT and have openly stated lung ultrasound should be performed preferentially in potential COVID-19 patients. 5 Decontamination of an ultrasound machine requires simple wiping, as opposed to a CT scanner, which is a significant process that can bring down badly needed scanners for an hour at a time, impacting other patients in the health system. Additionally, patient transportation increases healthcare provider exposures.

However, in addition to lung involvement, there are increasing anecdotal reports regarding pericardial effusions and electrical However, bilateral pleural abnormalities were found associated with scattered sub-pleural consolidations and comet tail artifacts in a distribution consistent with typical lung ultrasound findings in COVID-19 pneumonia (Video 1). 4 The patient was given 500 mL intravenous normal saline bolus and did not require further fluid blousing or administration in the ED.

The emergency physician also assessed the patient's heart and 

A 21-year-old male with no medical history and 3-pack-a-year smoking history presented to the ED after being sent from work as a fast food counter clerk for "coughing too much and a fever." He noted that he had recently been told to monitor his blood pressure. He reported aches, chills, and cough for ∼7 days and 2 days of diarrhea that resolved 3 days prior to ED arrival. His temperature was 38.6 • C, respiratory rate = 25, heart rate 136, blood pressure of 195/103 mm Hg, and oxygen saturation was 88% on room air. He was diaphoretic, appeared uncomfortable, and noted that "Things he ate did not taste much." He denied any contact with COVID-19 patients or exposures.

A POCUS lung and cardiac examination was performed. Lung ultrasound showed multiple bilateral lesions with irregular, thickened pleura with associated discontinuities and sub-pleural consolidations (Video 3). These findings were felt to be in keeping with COVID-19 bilateral pneumonia reported around the world. 4 The patient's heart was evaluated to rule out a pericardial effusion. No pericardial effusion was noted, but the patient's left ventricular ejection fraction was moderately to severely depressed with an approximate ejection fraction in the range of 25%-30% from multiple views (Video 4). This was surprising given his age, lack of history, and fever. Laboratory values showed an elevated WBC to 14,400/mm 3 , a mildly elevated troponin I to 0.14 ng/mL (upper normal range of 0.08 ng/mL), brain 

Although much attention has been focused on the pulmonary mani- Neither showed viral infiltration in the myocardium on biopsy, but both were COVID-19-positive. 13 The cardiologist felt both cases were COVID-19-related myocarditis. 13 As seen in Case 2 above, with more severe myocardial depression, troponins were mildly elevated.

These cases serve to raise the awareness of emergency physicians and others treating COVID-19 patients to consider evaluating the heart with POCUS, not just for pericardial effusion but also for left ventricular systolic function on a more routine basis. Considering that a POCUS cardiac evaluation is reasonable for most patients presenting to the ED with dyspnea, it should be considered in most COVID-19 patients who are also undergoing lung ultrasound. Additionally, with the COVID-19 patient population skewed toward the elderly and those with comorbidities, a focused evaluation of the heart appears prudent.

MB is a consultant with EchoNous Inc, 410Medical, Ethos Medical and Sonosim Inc. These companies had no influence or contribution to this manuscript, nor knowledge of its creation.

Michael Blaivas MD, MBA https://orcid.org/0000-0001-7196-9765

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