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Cardiac tamponade as a cause of cardiac arrest in severe COVID-19 pneumonia

  • Juan Carlos Ruiz-Rodríguez
    Correspondence
    Corresponding author. Department: Intensive Care Department, Institute/University/Hospital: Vall d’Hebron University Hospital, Street Name & Number: Passeig de la Vall d’Hebron, 119-129, City, State, Postal code, Country: 08023 Barcelona, Spain. Tel.: +34932746000 4735.
    Affiliations
    Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain

    Shock, Organ Dysfunction and Resuscitation Research Group. Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
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  • Luis Chiscano-Camon
    Affiliations
    Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain

    Shock, Organ Dysfunction and Resuscitation Research Group. Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
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  • Daniel Ruiz
    Affiliations
    Anesthesiology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
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  • Judit Sacanell
    Affiliations
    Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain

    Shock, Organ Dysfunction and Resuscitation Research Group. Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
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  • Eduard Argudo
    Affiliations
    Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain

    Shock, Organ Dysfunction and Resuscitation Research Group. Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
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  • Francesc Xavier Nuvials
    Affiliations
    Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain

    Shock, Organ Dysfunction and Resuscitation Research Group. Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
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  • Ricard Ferrer
    Affiliations
    Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain

    Shock, Organ Dysfunction and Resuscitation Research Group. Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
    Search for articles by this author
      Descriptive studies of patients with SARS-CoV-2 infection show that in addition to cardiovascular disease as a predisposing factor, the infection itself seems to trigger acute myocardial injury.
      • Wang D.
      • Hu B.
      • Hu C.
      • et al.
      Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.
      Previous studies on MERS-CoV and SARS-CoV, with a similar pathogenic mechanism, already describe the development of myocardial damage in an infected patient and the complexity of managing them.
      We present a 65-year-old man with no relevant history who presented with community acquired pneumonia by SARS-CoV-2. He associated distributive shock with an hyperinflammatory picture (ferritin 3233 mg/dl, IL-6 996 pg/ml, fibrinogen 8.8 g/L, D-dimer 895 ng/ml). He received Tocilizumab, Ceftriaxone, Azithromycin and Hydroxychloroquine for five days. He required invasive mechanical ventilation, prone position and low-dose vasoactive drugs.
      He developed myocarditis secondary to viral infection with elevated highly sensitive troponin (hs-cTnI) (192 ng/L) and right overload with hyperbilirubinemia and cytolysis. The echocardiography did not show abnormalities.
      On the sixth day meanwhile in a prone position, the patient presented suddenly progressive arterial hypotension without response to norepinephrine followed by pulseless electrical activity. Transthoracic ultrasound revealed a 3-centimeter-thick pericardial effusion in the anterior and posterior compartment without right ventricular dilation. Advanced life support was started and pericardiocentesis was performed with serous fluid extraction from the anterior pericardial compartment, without return of spontaneous circulation (ROSC). After 30 min without ROSC, the patient was deceased. It was oriented as cardiac tamponade secondary to pericardial effusion due to viral myocarditis. Necropsy could not be performed due to epidemiological issues.
      Patients affected by COVID-19 are predisposed to myocardial injury, especially in severe forms and including fulminant presentation. Those with preexisting cardiovascular diseases have a significantly increased risk of death with SARS-CoV-2.
      • Ruan Q.
      • Yang K.
      • Wang W.
      • Jiang L.
      • Song J.
      Clinical predictors of mortality due to COVID-19 based on an análisis of data of 150 patients from Wuhan, China.
      It has also been seen that critically ill patients generally have significantly higher Troponin I and pro-BNP values, and that this could be related to prognosis.
      Myocarditis is present in 12–23% of cases.
      • Huang C.
      • Wang Y.
      • Li X.
      • et al.
      Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
      The key element is ACE-2, which is expressed in myocytes and endothelial cells (in addition to the gastrointestinal, kidney and lung systems) and acts as a functional receptor for the coronavirus, which would explain direct injury to the myocardium and blood vessels.
      • Zhang H.
      • Penninger J.
      • Li Y.
      • Zhong N.
      • Slutsky A.
      Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target.
      The gold standard diagnostic test is endomyocardial biopsy,
      • Caforio A.
      • Pankuweit S.
      • Arbustini E.
      • et al.
      Current state of knowledge on aetiolgy, diagnostis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.
      which cannot be performed in our patient. Pericardial fluid culture is also included as a diagnostic element, however, our result was negative, as well as the result of the only case of pericardial effusion due to COVID-19 published to date.
      In COVID-19 patients, the myocarditis also could be due an adverse effect of drugs, mainly hydroxychloroquine and azithromycin; however, these effects are associated with chronic treatments
      • Chatre C.
      • Roubille F.
      • Vernhet H.
      • Jorgensen C.
      • Pers Y.M.
      Cardiac complications attributed to chloroquine and hydroxychloroquine: a systematic review of the literature.
      and the pericardial effusion has not been described.
      This case report highlights that myocarditis and secondary pericardial effusion can be a complication of SARS-CoV-2 infection, so it must enter the differential diagnosis of the deteriorating patient. Myopericardial injury must be evaluated initially and consecutively.

      Statement of ethics

      We complied with the guidelines for human studies and our research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Information revealing the subject's identity is to be avoided. Consent for the publication of the clinical case has been obtained through the patient's immediate family.

      Funding

      No funding.

      Authors’ contribution

      We were all involved in providing care for the patient. We were all involved in writing and reviewing the manuscript.

      Conflict of interest

      The authors have no conflicts of interest to declare.

      Acknowledgement

      No contributions from individuals or organizations.

      References

        • Wang D.
        • Hu B.
        • Hu C.
        • et al.
        Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.
        JAMA. 2020; https://doi.org/10.1001/jama.2020.1585
        • Ruan Q.
        • Yang K.
        • Wang W.
        • Jiang L.
        • Song J.
        Clinical predictors of mortality due to COVID-19 based on an análisis of data of 150 patients from Wuhan, China.
        Intensive Care Med. 2020; https://doi.org/10.1007/s00134-020-05991-x
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        • Wang Y.
        • Li X.
        • et al.
        Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
        Lancet. 2020; 395: 497-506
        • Zhang H.
        • Penninger J.
        • Li Y.
        • Zhong N.
        • Slutsky A.
        Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target.
        Intensive Care Med. 2020; 46: 586-590
        • Caforio A.
        • Pankuweit S.
        • Arbustini E.
        • et al.
        Current state of knowledge on aetiolgy, diagnostis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.
        Eur Heart J. 2013; 34: 2636-2648
        • Chatre C.
        • Roubille F.
        • Vernhet H.
        • Jorgensen C.
        • Pers Y.M.
        Cardiac complications attributed to chloroquine and hydroxychloroquine: a systematic review of the literature.
        Drug Safe. 2018; 41: 919-931