Morning Report

Presented by Christopher El Hadi

Moderated by Dr. Jamil Barhoun
74 y.o. male presented for fatigue, and 1d hx of
dyspnoea, chills, fever and nausea
 History
Hypertension

Diabetes Mellitus type 2

Dyslipidemia

Benign prostatic hypertrophy

Heart failure with reduced ejection fraction (HF 40-45%)

Coronary artery disease, s/p CABG x2 (>15 y) & stent LAD+RCA (2022)
 History
TTE (1.5y ago, 2022)

LV function mild impairment

Antero-septal akinesia

Mild-moderate MR

Mild PHTN

EF 40-45%
 Home Meds
Nexium 40 (esomeprazole) QAM

Grepid 75 (plavix) QPM

Diuresal 40 (furosemide) ½ tab QPM

Aspirin 100 (acetylsalicylic acid) QAM

Janumet 50/1000 (Sitagliptin/metformin) QAM

Invokana 100 (Canagliflozin) QAM

Liponorm 40 (Simvastatin) QPM

Prostafine 0.4 (Tamsulosin) QPM

 On Presentation
Dyspnoea, pleuritic chest pain, tachypnoea

Chills, fever, nausea

3 day hx of fatigue
NO cough

NO flu-like symptoms

NO epigastric/abdominal pain

NO change in bowel habits

NO dysuria

NO urinary frequency

NO headache

NO change in mental status

NO focal deficit
 On Presentation
HGT 249, HR 130, BP 117/75, SpO2 83 on RA

Physical Examination:

Wheezing, bilateral crackles, ↓ air entry towards bases

Audible S1S2, no murmurs, no bruits, palpable symmetrical pulse

Soft non tender abdomen, no palpable spleen, no hepatomegaly

Clean skin, clean nails, clean tongue and palates, no palpable LN

 Differential Diagnoses
1. Exacerbation of heart failure

2. Pneumonia

3. Pericarditis

4. Myocarditis

5. Acute myocardial infarction

6. Diabetic keto-acidosis

7. Pericardial effusion

8. Pulmonary embolus

9. Cardiomyopathy (Takotsubo)
 Investigations
CBCD, chem9

Cardiac Enzymes, CRP

ABG

EKG

UA

Blood Ketones

Lactic acid

CXR
 Investigations
ABG 7.38/25/42/76

Na 135, K 4.7, Cl 102, CO2 12, Cr 0.88, BUN 56

WBC 14.07 (77.5%)

TropT 240 → 1116, CKMB 9/CPK 121 ~7.5% > 6%, CRP 24.6

UA ketones positive

Blood Ketones positive +1

Lactic acid 8.7

EKG – ST↓ at I + II, ST↑ III + aVR, & ST↑ V1, ST↓ V2-V6
CXR – congestion, cannot rule out infection
 In ER
Therapeutic Lovenox

15L non rebreather mask then BiPAP 12/7

Lasix 80mg IV

Combivent q4h

Solumedrol 40 OD

Started on Tavanic+Tazocin

6u insulin given, 6u/hr IVSP, 1.5L 0.45% NaCl + 40 mEq KCl

 ICU Admission: Work-up
Trop 9064

CKMB/CPK ~ 9.5% > 6%

PCR SARS-COV-2 positive, IL6 80

TTE: 20-25%, severe PHTN, severely dilated IVC

Coronary angiography: normal

Influenza A&B negative, Strep Ag + Legionella Ag negative

 Differential Diagnoses
1. Myocarditis

2. Exacerbation of heart failure

3. Pneumonia (COVID-19)

4. Diabetic keto-acidosis
5.

6.

7. Pericarditis

8. Pericardial effusion

9. Acute myocardial infarction

10. Pulmonary embolus

11. Cardiomyopathy (Takotsubo)

 COVID-19-related Myocardial Injury

Probable Myocarditis

+++ SUPPORTIVE CARE

START Remdesivir (anti-viral)

START Dexamethasone (Anti-inflammatory)

START Xeljanz (Jak Inhibitor)

SARS-COV2-related Myocardial
Injury: Overview
 Definition
Major causes: myocarditis, Takotsubo cardiomyopathy, and MI

No increased risk of myocarditis compared to controls

Myocarditis due direct infection is very rare → needs biopsy PCR

Myocarditis may be due to COVID-19 induced immune activation → biopsy

needed to confirm

Myocarditis and pericarditis frequently reported after mRNA vaccines

 Presentation

Two presentations

Fulminant myocarditis: onset <3 days + 2-w viral prodrome, hemodynamic

compromise → good prognosis with supportive care

Subacute myocarditis: unclear onset, rare hemodynamic compromise →

increased mortality (requires transplant)
 Diagnosis
Lab tests, ECG, and TTE jointly are valuable BUT Endomyocardial Biopsy (EMB) is the gold
standard

Troponin I or T (High Sp, poor Se)

TTE: Useful for assessing ventricular thickness due to edema and RV dilatation

Cardiac MRI: 80% Se; detects myocardial inflammation; can't distinguish acute from chronic

Viral serology: Not useful

ESR/CRP: Not recommended (poor Sp and Se)

Cardiac catheterization if suspecting MI

ANA and ANCA if suspecting autoimmune etiology

 Treatment
Largely supportive; if failed, can lead to dilated cardiomyopathy

Nematevir/Ritonavir or Azudine, Monolavir tablets or Ambavir and romisvir: mild/moderate infection

+ risk of progression to severe disease within 5 days. Inhibit the replication of the virus.

Glucocorticoids: reducing excessive immune activation

Monoclonal Antibodies to IL-6 (Tocilizumab, Baricitinib) in critically ill patients with elevated IL-6
levels

Avoid NSAIDs: increased mortality, ONLY useful in virus negative myocarditis

Antiviral (IFN-β), immunoadsorptive treatments

Consider intra-aortic balloon pump, left ventricular assist device, or ECMO as a temporizing measure or
bridge to heart transplantation (rescue therapy).
 References

Shu, H., Zhao, C., & Wang, D. W. (2023). Understanding COVID-19-related

myocarditis: pathophysiology, diagnosis, and treatment strategies. In Cardiology
Plus (Vol. 8, Issue 2, pp. 72–81). Ovid Technologies (Wolters Kluwer Health).
https://doi.org/10.1097/cp9.0000000000000046

Caforio ALP, Malipiero G, Marcolongo R, et al. Myocarditis: a clinical overview.

Curr Cardiol Rep. 2017;19(7):63.[PMID:28540649]

Cooper LT Jr. Myocarditis. N Engl J Med. 2009;360(15):1526–1538.

[PMID:19357408]