This is the fourth installment of our 8-part series on cardiovascular complications in patients with COVID-19. In this installment, we will discuss acute pericarditis, myocarditis, and perimyocarditis in patients with COVID-19.

A 36-year-old woman presents to an urgent care clinic with complaints of a headache equivalent to past sinus infections, fatigue, and exhaustion with some associated shortness of breath. She tests positive for COVID-19 and is treated with zinc and vitamin C. All clinical symptoms resolve approximately 8 days later. Nineteen days after testing positive for COVID-19, the patient awakes with extreme shortness of breath, chest pain at the midsternum that improves when leaning forward, and labored breathing after walking 15 feet. The patient initially is seen in the emergency room and, after ruling out acute cardiac injury, is referred for outpatient workup with a cardiologist.

The patient’s initial troponin level and erythrocyte sedimentation rate are within normal limits. Other laboratory test result include: hemoglobin (13.7 g/dL), hematocrit (34.0%), and platelet count (222 x103/µL). Her C-reactive protein is mildly elevated at 1.3 mg/dL.


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An electrocardiogram (ECG) reveals sinus tachycardia with no acute changes. Cardiac magnetic resonance (CMR) imaging reveals no significant defect at rest or under stress and the ejection fraction rate is 58%. Transthoracic echocardiogram reveals global systolic function of 55% and no pericardial effusion, significant valvular stenosis, or regurgitation.

Significant Medical History

The patient’s medical history includes Graves’ disease, hypothyroidism secondary to radiation of the thyroid nodule, supraventricular tachycardia, and COVID-19 infection less than 3 weeks prior to presentation.

Physical Examination

The patient is a healthy-appearing woman in mild respiratory distress. She has labored breathing with tachypnea (28 breaths/min), pericardial friction rub, and sinus tachycardia (118 beats/min).

Diagnosis and Treatment

The patient is diagnosed with pericarditis and treated with ibuprofen and colchicine. She has complete resolution of symptoms within 1 week of treatment initiation.

Discussion

Several cases of acute pericarditis, myocarditis, and myopericarditis associated with COVID-19 infection have been reported. The term pericarditis refers to inflammation of the pericardial sac.1 Myocarditis refers to inflammation of the cardiac muscle.2 Pericarditis and myocarditis often occur together and the term used to describe this phenomenon is myopericarditis (predominate myocarditis with pericardial involvement) or perimyocarditis (pericarditis with concomitant myocardial involvement).3

According to the European Society of Cardiology guidelines, 2 of the following 4 criteria must be met for diagnosis of acute pericarditis3:

  • Chest pain, improved by sitting up or leaning forward
  • Pericardial rub
  • ECG changes
  • New or worsening pericardial effusion.

Myopericarditis and perimyocarditis present similarly to pericarditis with the addition of elevated cardiac biomarkers and/or evidence of myocardial inflammatory involvement on imaging. Diagnosis of independent myocarditis relies on imaging studies and endomyocardial biopsy (EMB).2,5

Electrocardiogram
Complete blood count, troponin, erythrocyte sedimentation rate, C-reactive protein, and blood cultures (if temperature >38 °C or signs of sepsis)
Chest radiograph
Echocardiography
Cardiac magnetic resonance imaging
Coronary angiogram: rule out acute coronary syndrome with positive cardiac biomarkers
Endomyocardial biopsy for myocarditis if diagnosis in doubt
Computed tomography for pericarditis
Pericardiocentesis and pericardial biopsy for pericarditis