key: cord-1052641-cv20koaq authors: Garot, Jérôme; Amour, Julien; Pezel, Théo; Dermoch, Firas; Messadaa, Kamel; Felten, Marie-Louise; Raymond, Valérie; Baubillier, Eric; Sanguineti, Francesca; Garot, Philippe title: SARS-CoV-2 Fulminant Myocarditis date: 2020-06-05 journal: JACC Case Rep DOI: 10.1016/j.jaccas.2020.05.060 sha: c740bbdae7094c996f335097675ec91de3c961b5 doc_id: 1052641 cord_uid: cv20koaq ABSTRACT A 18-year-old man without prior medical history developed fulminant myocarditis concomitant to severe COVID-19 pneumonia and confirmed by serial cardiac magnetic resonance. This may have important diagnostic, monitoring, and pathogenic implications. An 18 year-old male without prior medical history was admitted for cough, fever (38.5°C), fatigue and myalgias. From his vital signs, blood pressure was 120/70 mm Hg, heart rate 110 bpm, he had tachypnoea (22/min) and oxygen saturation was 94% in room air. He had no neurological symptoms. He did not have any past medical history. Primary differential included community acquired pneumonia, atypical pneumonia and COVID-19. The reverse transcriptase -polymerase chain reaction assay was positive for SARS-CoV-2 (COVID-19) on the nasopharyngeal swab while chest computed tomography demonstrated diffuse peripheral opacity ("crazy paving") compatible with COVID-19-related lesions. ( Figure 1 ). pg/mL), fibrinogen of 9.5 g/L, peak creatine kinase 2216 UI/L, C-reactive protein 351 mg/L (N<5). ECG demonstrated sinus tachycardia (120 bpm) with negative T waves from V2 to V4. (Figure 2) . The left ventricle (LV) was mildly enlarged (32 mm/m² end-diastolic diameter) on echocardiography with increased LV wall thickness (interventricular septum and posterior walls 14 mm) and marked diffuse hypokinesis (ejection fraction (EF) 30% by biplane Simpson's method). Following the intubation , there was a rapid and significant respiratory and hemodynamic improvement along with adequate diuresis, allowing spontaneous breathing and extubation on The patient was treated with paracetamol (3g/day), hydroxychloroquine (400 mg daily) and 2l/min nasal oxygen. Then, he was treated on 1 mg/h noradrenalin because of severe hypotension (75/45 mm Hg) and antibiotics (intravenous cefotaxime and rovamycine). Clinical (7). In support, a potential binding to a viral receptor of the myocyte could facilitate the internalization and replication of the capsid proteins and the viral genome (8) (9) . Because of the rapid clinical recovery of the patient, endomyocardial biopsy was not performed and the presence of the coronavirus in the myocardium was not demonstrated. CMR on Day 14 showed a significant LV reverse remodelling (wall thickness 11 mm, LV telediastolic index 88 ml/m², LV ejection fraction 54%, Video 2), a clear decrease of focal myocardial edema and EGE in the posterolateral wall, and stable LGE lesions in the subepicardium of the posterolateral wall (Figure 3) . The evolution of native T1-T2 relaxation times and ECV are reported in Table 1 . The patient had complete clinical recovery with normal respiratory function and hemodynamics, and was discharged on Day 15 with bisoprolol and ACE inhibitors. This report demonstrates that fulminant myocarditis may occur during the acute phase of COVID-19 pneumonia and suggest a direct pathogenic role of the virus on the myocyte, although this has not been proven by histopathology. We believe this finding may have important implications for diagnostic and monitoring purposes, but also for the evaluation of future treatment strategies of acute myocarditis related to SARS-CoV infection. • To be able to make a diagnosis of fulminant myocarditis concomitant with COVID-19 pneumonia. • To understand the value of serial cardiac magnetic resonance after myocarditis due to COVID-19. Presence of diffuse typical COVID-19-related lesions (typical peripheral opacity, "crazy paving"). Sinus tachycardia (100 bpm) with negative T waves from V2 to V4. International Consensus Group on Cardiovascular Magnetic Resonance in Myocarditis. Cardiovascular magnetic resonance in myocarditis: a JACC White Paper World Health Organization. Pneumonia of unknown cause-China World Health Organization. Novel coronavirus-China Clinical features of patients infected with 2019 novel coronavirus in Wuhan Cardiovascular complications of severe acute respiratory syndrome Cardiac involvement in a patient with Coronavirus Disease 2019 (COVID-19) Molecular biology and pathogenesis of viral myocarditis Advances in the understanding of myocarditis Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding