The following are key points to remember from this Cardiovascular Flashlight article/case report on a patient with coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin:

Clinical picture:

A 37-year-old male patient was admitted to the hospital on January 14, 2020, with chest pain and dyspnea for 3 days, accompanied by diarrhea. His blood pressure (BP) decreased to 80/50 mm Hg.

Investigation:

• Chest X-ray showed significant enlargement of the heart (cardiothoracic ratio, 0.70).
• Chest computed tomography (CT) examination indicated lung infection, cardiomegaly, and pleural effusion.
• The ECG suspected ST-segment elevation myocardial infarction (III, AVF ST-segment elevation).
• CT coronary angiography revealed no coronary stenosis.
• Markers of myocardial injury: Troponin T was >10.000 ng/L. Creatine kinase isoenzyme (CK-MB) = 12.9 ng/L. B-type natriuretic peptide (BNP) = 2,1025 ng/L.
• Echocardiography revealed an enlarged heart and a marked decrease in ventricular systolic function (left ventricular end-diastolic dimension [LVEDD] 58 mm, left atrium (LA) 39 mm, right ventricle (RV) 25 mm, right atrium (RA) 48 mm, LV ejection fraction [LVEF] 27%, trace 2 mm pericardial effusion).
• Sputum was examined for 13 viral nucleic acids related to respiratory tract. Only the coronavirus nucleic acid test was positive. All of the other 12 nucleic acid tests were negative, including influenza A virus, adenovirus, bocavirus, rhinovirus, influenza A (H1N1) 2009, parainfluenza, chlamydia, partial pulmonary virus, influenza B virus, mycoplasma pneumoniae, influenza A virus H3N2, and respiratory syncytial virus.

Diagnosis by the authors of this case report: Fulminant coronavirus myocarditis with pulmonary infection.

Therapy included:

• Methylprednisolone. to suppress inflammation (200 mg/day, 4 days), and immunoglobulin to regulate immune status (20 g/day, 4 days)
• Norepinephrine to raise BP
• Diuretic therapy (torsemide and furosemide) to reduce cardiac load
• Milrinone to increase myocardial contractility
• Piperacillin sulbactam for infection
• Pantoprazole, to inhibit gastric acid

Clinical course:

After treatment, the patient’s symptoms improved significantly.

One week later:

• X-ray chest film showed heart size normal (cardiothoracic ratio, 0.49).
• Echocardiography showed that the size and function of the heart had returned to normal (LVEDD 42 mm, LA 34 mm, RV 24 mm, RA 33 mm, LVEF 66%).

Markers of myocardial injury:

• After 1 week of treatment: Troponin T was 220.5 ng/L. CK-MB was 9.14 ng/L. BNP was 1587 ng/L.
• After 3 weeks, the myocardial injury markers had fully recovered to the normal range. Troponin T was 21.4 ng/L. CK-MB was 2.25 ng/L. BNP was 139 ng/L.

Conclusions:

The case report authors suggest that early glucocorticoid anti-inflammatory therapy and immunoglobulin therapy is of value to this type of patient.

Perspective:

The authors of this case report need to be congratulated for methodically documenting their experience and sharing this with the medical community given the rapid spread of the coronavirus pandemic. Although this report is anecdotal, the therapy they utilized may need to be considered in a coronavirus patient with a similar clinical picture. However, other published reports (Lancet 2020;Mar 11:[Epub ahead of print] and Lancet 2020;395:473-5) suggest that high-dose steroids may not be beneficial in such patients, particularly with lung injury. Given that IL-6 levels are elevated in such patients (Lancet 2020;Mar 11:[Epub ahead of print]), the clinical picture of coronavirus syndromes may be akin to cytokine storm (described with CAR-T cell therapy); currently, IL-6 antagonist tocilizumab is being evaluated in such patients (Lancet 2020;Mar 16:[Epub ahead of print]).

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Anti-Inflammatory Agents, Blood Pressure, Chest Pain, Coronary Angiography, Coronavirus, Coronavirus Infections, Creatine Kinase, MB Form, Diarrhea, Diuretics, Dyspnea, Echocardiography, Electrocardiography, Glucocorticoids, Heart Failure, Immunoglobulins, Inflammation, Interleukins, Methylprednisolone, Milrinone, Myocarditis, Natriuretic Peptide, Brain, Norepinephrine, Respiratory Syncytial Virus Infections, Secondary Prevention, Tomography, X-Ray Computed, Troponin T

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