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Case report
peer-reviewed

Subacute Cardiac Tamponade in a COVID-19 Patient Despite Negative Testing



Abstract

COVID-19 infection has been documented to cause a wide range of symptoms including cardiac complications. We present a case of subacute cardiac tamponade in a patient infected with COVID-19 in the absence of respiratory symptoms; we also review the current literature on this rare sequela. Our patient is a 67-year-old man who presented to the hospital due to intermittent chest pain for three weeks. COVID-19 polymerase chain reaction (PCR) testing was negative two times. He had an outpatient echocardiogram that showed a moderate pericardial effusion about a week prior to the hospital presentation. On admission, a repeat echocardiogram showed a large pericardial effusion with tamponade physiology. Pericardiocentesis did not reveal a clear etiology of the hemorrhagic effusion but four days later, the patient was found to be positive for COVID-19 infection without any clear respiratory illness. Given the absence of other etiology and negative workup, cardiac tamponade was attributed to pericardial inflammation from this virus and our patient improved with colchicine and steroids. We, therefore, advise providers to consider COVID-19 as a cause of hemorrhagic, cryptogenic cardiac tamponade despite negative COVID-19 testing. We also review 42 additional reported cases of cardiac tamponade in patients infected with COVID-19. COVID-19 can cause cardiac tamponade even in the absence of pulmonary disease. This case and literature review highlight tamponade as a rare complication of COVID-19 and should be considered in the differential of any acute deterioration in this patient population.

Introduction

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a respiratory illness that has been associated with a wide range of symptoms with varying severity. It has been well documented that this virus can cause cardiac complications independent of a patient’s baseline comorbidities including acute coronary syndrome, pericarditis, myocarditis, and arrhythmia [1]. Cardiac tamponade, a life-threatening condition, has been documented as a rare sequela of COVID-19 infection. We report a case of an elderly man who presented with subacute cardiac tamponade attributed to COVID-19 infection without significant concurrent respiratory symptoms. We also review the current literature on this rare complication of COVID-19 infection.

Case Presentation

Our patient is a 67-year-old man who initially presented to the emergency department with chest discomfort and intermittent dyspnea. This patient had a medical history significant for melanoma treated with radiation therapy, Barrett’s esophagus, and hyperlipidemia. These symptoms originally started about three weeks prior to presentation during which time SARS-CoV-2 polymerase chain reaction (PCR) testing was negative two times. The following week he had a stress test negative for ischemia but underwent an echocardiogram that showed a moderate pericardial effusion. He was sent home from the clinic with a course of non-steroidal anti-inflammatory drugs (NSAIDs) at that time. His symptoms persisted which prompted him to return to the emergency department.

In the emergency department, presenting vitals and physical examination was unremarkable aside from tachycardia and distant heart sounds. Laboratory studies were significant for leukocytosis of 18.83 103/ul, C reactive protein of 31.25 mg/dl, normal electrolytes, and negative troponins. EKG was consistent with new atrial fibrillation with rapid ventricular response as well as low voltage in precordial leads (Figure 1). Bedside point of care ultrasound (POCUS) showed large circumferential pericardial effusion causing diastolic collapse of the right ventricle (Figure 2). Given the concern for early cardiac tamponade, the patient was taken for emergent pericardiocentesis with the removal of 750 cc of serosanguinous fluid. The patient was then started on colchicine as well as steroids and transferred to the intensive care unit for further monitoring.

The patient reported improvement in symptoms and reverted to sinus rhythm without need for cardioversion. The pericardial drain was removed the following day without complication. Repeat echocardiogram at time of discharge showed no re-accumulation of pericardial fluid and normal left ventricular (LV) systolic function of 55% (Figure 3).

The etiology for pericardial effusion remained unclear at this time with viral pericarditis being the leading diagnosis even though viral panel, as well as SARS-CoV-2 PCR, was negative. Fluid from the pericardiocentesis was largely bloody with analysis showing 28,000 red blood cells/mm3 and 1,233 white blood cells/mm3 with 79% neutrophilic predominance. Fluid bacterial cultures, acid-fast stain, and autoimmune testing were all negative. Cytology and flow cytometry of pericardial fluid was also negative for malignancy. Pericardial fluid was not sent for SARS-CoV-2 testing. Due to clinical improvement, the patient was discharged home after a two-day hospital course with a regimen of colchicine and steroids for presumptive viral pericarditis.

Four days later, the patient re-presented to the emergency department due to recurrent chest pain and persistent cough. Initial vitals and examination were unremarkable with oxygen saturation of 95% on room air. The patient tested positive for SARS-CoV-2 at this time by nasal PCR. Inflammatory markers were mildly elevated with lactate dehydrogenase of 287 units/L, C reactive protein of 3.67 mg/dL, and D-dimer of 3.05 ug/ml. Repeat echocardiogram showed a small pericardial effusion. CT Chest redemonstrated the small effusion, as well as a left lower lobe, infiltrate (Figure 4).

The patient was treated with colchicine as well as dexamethasone. He remained without any significant respiratory symptoms and was discharged home after a four-day hospital course with a negative PCR test result. The patient was followed up in the cardiology clinic a week post discharge where repeat echocardiogram showed minimal pericardial fluid.

Discussion

Cardiac tamponade is a life-threatening condition that has a rare association with COVID-19 infection. The exact mechanism of cardiac injury by this virus is not well understood but is proposed to be due to the robust “cytokine storm” induced by the virus and the direct downregulation of myocardial ACE-2 receptors [1]. However, this pathogenesis is less likely in our case given the clinical picture and lack of elevated inflammatory markers especially C-reactive protein but could result from direct inflammation as usually in viral pericarditis. A meta-analysis of CT findings in patients infected with COVID-19 found that 4.55% of patients had evidence of pericardial effusion [2]. The clinical significance of this is unclear but may be related to myopericarditis induced by the virus. There have been several established cases including our patient that have documented the accumulation of pericardial fluid leading to tamponade physiology in patients infected with COVID-19.

Our case adds to a growing body of evidence that COVID-19 can lead to pericardial inflammation and cardiac tamponade independent of the patient’s cardiac risk factors. After careful literature review, we identified 44 other documented cases of cardiac tamponade in the context of COVID-19 infection (Table 1).

Patient Age/Sex Comorbidities Presenting symptoms Presenting exam Inflammatory markers Cardiac markers Radiographic findings EKG 2D Transthoracic Echo Pneumonia Mechanical ventilation Management Pericardial fluid  Outcome
1. current case 67 yo M Melanoma, HLD Chest pain, Dyspnea Tachycardia CRP-31.25 mg/dl Troponin-negative Unremarkable Sinus tachycardia, Low voltage in precordial leads Large circumferential pericardial effusion, RV diastolic collapse, LVEF-55% None None Pericardiocentesis, Colchicine, NSAID Bloody  Recovered
2. Hua et al. [3] 47 yo F Prior myocarditis Cough, Dyspnea, Chest pain, Fever Hypotension, Tachycardia - Troponin T-0.225 ng/ml Mild pulmonary congestion Sinus tachycardia, Concave infero-lateral ST elevation Global pericardial effusion, LVEF-Normal None None Pericardiocentesis, Vasopressor Serosanguinous Recovered
3. Dabbagh et al. [4] 67 yo F HFrEF (40%) Cough, dyspnea, shoulder pain Tachycardia CRP-15.9 mg/dl, Ferritin-593 ng/ml, D-dimer-6.52 ug/mL Troponin I-<0.018 ng/ml, pro-BNP-54 pg/ml Unremarkable Low voltage limb leads, Nonspecific ST elevation Circumferential pericardial effusion, Early RV diastolic collapse LVEF-40% None Yes Pericardiocentesis, HCQ, Colchicine, Steroids Bloody  Recovered
4. Asif et al. [5] 70 yo F CAD, DM2, HTN Chest pain, Dyspnea Fever, Hypoxia - - Enlarged cardiac silhouette, Bilateral pulmonary infiltrates, Retro-cardiac opacities Diffuse 1-mm ST-segment elevations, PR depression  Large circumferential pericardial effusion, RV diastolic collapse, Septal bounce, LVEF-55% Yes Yes Pericardiocentesis, Vasopressor, Colchicine Serosanguinous, Exudative Recovered
5. Purohit et al. [6] 82 yo F Paroxysmal AF, PPM, HTN Cough, Fever, Chills Unremarkable - Troponin-0.037 ng/ml Significant circumferential pericardial effusion, Bilateral pleural effusions A-paced rhythm, Diffuse T wave inversions Circumferential pericardial effusion, Early RV diastolic collapse, LVEF-55% None None Pericardiocentesis Straw colored, Exudative Recovered
6. Hakmi et al. [7] 48 yo M Obesity, DM2 Dyspnea, Fatigue Unremarkable CRP-19.74 mg/dl Troponin I-negative Enlarged cardiac silhouette - Large pericardial effusion, Tamponade physiology None None Pericardiocentesis Yellow Recovered
7. Hakmi et al. [7] 56 yo M None Cough, Chest pain, Fever, Chills Hypotension CRP-24.9 mg/dl Troponin I-0.012 ng/ml - - Large pericardial effusion, Tamponade physiology, LVEF-20% None None Pericardiocentesis Serous Expired
8. Hakmi et al. [7] 55 yo M Obesity, HTN Cough, Fever, Chills Hypotension CRP-205.2 mg/dl Troponin I-0.004 ng/ml Bilateral lung opacities, Mildly enlarged cardiac silhouette - Large pericardial effusion, Tamponade physiology, Biventricular failure Yes Yes Pericardiocentesis, Vasopressor, ECMO Serosanguinous Expired
9. Ruiz-Rodríguez et al. [8] 65 yo M None - Hypotension, Hypoxia Ferritin-0.3233 ng/ml, Fibrinogen-8.8 g/L, D-dimer-0.895 ug/ml  Troponin-0.192 ng/ml - - 3 cm pericardial effusion Yes Yes Pericardiocentesis, Vasopressor, HCQ Serous Expired
10. Parsova et al. [9] 58 yo F HTN Dyspnea, Bilateral lower extremity edema Tachypnea, Hypoxia, Tachycardia, Lung crackles Unremarkable Troponin T-0.00007 ng/ml - AF with rapid ventricular response, Low R voltage in the precordial leads  Circumferential pericardial effusion, Restricted diastolic filling, LVEF-30% Yes None Pericardiocentesis Serosanguinous, Exudative Recovered
11. Torabi et al. [10] 42 yo F Crohns disease, Guillain barré syndrome AMS, Fever Hypotension, Hypoxia, Tachycardia, Diffuse crackles CRP-14.7 mg/dl Ferritin-310.1 ng/ml, D-dimer-2.26 ug/ml  Troponin-I-0.29 ng/ml, pro BNP-612 pg/ml Patchy consolidative opacities Low voltage in limb leads Moderate pericardial effusion, RA systolic collapse, LV EF-20% Yes Yes Pericardiocentesis, Intra-aortic balloon pump, Vasopressor Serous Expired
12. Singh et al. [11] 62 yo M CAD w/ 1 stent, DM2, COPD, Obesity AMS, Dyspnea Hypotension, Hypoxia D-dimer-2.90 ug/ml  Troponin-negative Bilateral infiltrates, Right pleural effusion Low voltage QRS Large pericardial effusion, Tamponade physiology Yes Yes Pericardiocentesis, Vasopressor, HCQ, Lopinavir-Ritonavir Bloody, Transudative Recovered
13. Dalen et al. [12] 55 yo F None Fatigue, Near syncope Unremarkable CRP-11 mg/dl Troponin T-0.108ng/ml, pro-BNP-1025 pg/ml Unremarkable Sinus tachycardia, Insignificant ST-elevation in inferior leads, T-wave inversion in precordial leads, Low voltage Large pericardial effusion, Tamponade physiology None None Pericardiocentesis, Fluids, Vasopressor  Serosal Recovered
14. Derveni et al. [13] 89 yo M COPD Dyspnea Hypoxemia CRP-24.77 mg/dl, Ferritin-227,900 ng/ml, D-dimer-1.65 ug/ml Troponin-I-0.35 ng/ml Bilateral lung infiltrates, Emphysema Incomplete RBBB, New onset infero-lateral ST elevation Anterior pericardial effusion, RV collapse LVEF-60% Yes Yes Pericardiocentesis, HCQ, Azithromycin, Colchicine Serous Expired
15. Khatri et al. [14] 50 yo M HTN, CVA Cough, Dyspnea, Fever Hypoxia ESR-46 mm/hr, D-dimer-1.07 ug/ml, CRP-11.85 mg/dL, Ferritin-66,165 ng/ml Troponin-0.544 ng/ml, CK-2135 u/l, CK-MB 54.3 ng/ml Diffuse bilateral patchy opacities Sinus tachycardia, ST-elevation in leads II, III, aVF, ST-depression in leads I, aVL  Large pericardial effusion with organizing material, Tamponade physiology Yes Yes Pericardiocentesis, Vasopressor, IVIG Serosanguinous Expired
16. Walker et al. [15] 30 yo F None Fever, Cough, Chest pain Tachycardia D-dimer-0.26 ug/ml  pro-BNP-7890 pg/ml Interstitial pneumonia, Subpleural interstitial densities and ground- glass opacities  Sinus tachycardia 12mm pericardial effusion Yes None Pericardial window, Vasopressor, HCQ, Colchicine, Aspirin Straw Colored Recovered
17. Cairns et al. [16] 58 yo F DM2, HTN Fever, Diarrhea Hypotension, Elevated JVP, Pulsus Paradoxus Elevated Troponin-0.3888 ng/ml  Bilateral chest consolidation - Large pericardial effusion, Tamponade physiology None None Pericardiocentesis, Vasopressor Serous Recovered
18. Farina et al. [17] 59 yo M CAD w/ CABG Dyspnea, Chest Pain Tachycardia CRP-0.58 mg/dl, D-dimer-4.57 ug/ml Troponin-I-22 ng/ml “Ground glass areas," “Crazy paving pattern" in both lungs - Severe circumferential pericardial effusion, Collapse of the right heart sections  Yes None Pericardiocentesis, Lopinavir-ritonavir, HCQ Hemorrhagic, COVID+ Recovered
19. García-Cruz et al. [18] 64 yo M CAD Chest Pain, Cough Fever Hypoxia, Diffuse rales - - Bilateral diffuse interstitial infiltrates ST elevation in inferior and posterior leads Pericardial effusion, Tamponade physiology Yes None Pericardial window Hemorrhagic Recovered
20. Sauer et al. [19] 51 yo M Asthma Chest Pain, Dyspnea Unremarkable CRP-22.3 mg/dl Troponin I-919 ng/ml Moderate peripheral ground glass opacities, Voluminous pericardial effusion Diffuse elevation of the ST segment, Low QRS voltage  Circumferential pericardial effusion, RV Compression Yes None Pericardiocentesis, Colchicine Hemorrhagic Recovered
21. Sauer et al. [19] 84 yo F HTN Dyspnea, Fever Decreased breath sounds, LE edema CRP-6.6 mg/dl Troponin-negative Large, bilateral pleural effusion  - Large pericardial effusion, Tamponade physiology None None Pericardiocentesis, Colchicine Serous Recovered
22. Tiwary et al. [20] 30 yo M DM1, CKDIII, HTN Dyspnea, Abdominal pain Hypoxia CRP-8.9 mg/dl Troponin I-0.09 ng/ml "Typical changes consistent with COVID-19," R pleural effusion and pericardial effusion  Accelerated idioventricular rhythm Large pericardial effusion, Early diastolic RV prolapse, Markedly thickened ventricular wall  Yes Yes Pericardial window, CRRT, Vasopressor  - Recovered
23. Ejikeme et al. [21] 54 yo M None Chest Pain Hypoxia - Troponin-negative Cardiomegaly, Diffuse bilateral infiltrates Non specific ST abnormalities Large pericardial effusion, Decreased LVEF Yes None Pericardiocentesis, HCQ, Steroids Serosanguinous, Transudative Recovered
24. Heidari et al. [22] 28 yo M None Chest Pain, Dyspnea Hypotension, Tachycardia, Hypoxia CRP-28.1 mg/dl. ESR- 90 mm/hr Troponin-negative Severe pericardial effusion, Left lower lobe collapse, Bilateral pleural effusion  Sinus tachycardia, Electrical alternans Large pericardial effusion, RA inversion, RV diastolic collapse  None None Pericardiocentesis, NSAID, Colchicine, Lopinavir-Ritonavir Hemorrhagic Recovered
25. Gioia et al. [23] 57 yo F HTN Dyspnea Hypotension, Tachycardia, Hypoxia - Troponin-I-64 ng/ml Mild pulmonary congestion Diffuse ST segment elevations Moderate pericardial effusion None Yes Pericardiocentesis, Vasopressor Serous Expired
26. Raymond et al. [24] 7 yo F None Chest Pain, Cough, Orthopnea Tachycardia CRP-5.11 mg/dL, ESR-43 mm/hr, Ferritin-134 ng/ml  Troponin I-0.01 ng/ml Enlarged cardiac silhouette, Bilateral small pleural effusions Sinus tachycardia, T-wave inversion in inferior and lateral leads, Low voltage QRS with electrical alternans Large circumferential pericardial effusion, RA and RV wall collapse None Yes Pericardiocentesis, NSAID, Colchicine, Pericardiectomy Transudative Recovered
27. Johny et al. [25] 30 yo M None Dyspnea, Orthopnea, Palpitations Tachypnea, Tachycardia, Muffled heart sounds - - Enlarged cardiac silhouette, Large left pleural effusion Low voltage complexes Large pericardial effusion, RA and RV diastolic collapse, Tamponade physiology None None Pericardiocentesis,  Colchicine, NSAIDs, Steroids, Antibiotics            Hemorrhagic Recovered
28. Gill et al. [26] 34 yo F None Dyspnea, Chest Pain, Weakness Tachypnea, Tachycardia, Cold extremities Unremarkable Troponin-0.55 ng/ml Unremarkable Low amplitude, PR depressions Large pericardial effusion, RV diastolic collapse, Severe biventricular systolic dysfunction, LVEF- 20% None None Pericardiocentesis, Colchicine, NSAID, ECMO Serous Recovered
29. Al-Kaf et al. [27] 21 yo M Down syndrome Dyspnea, Nasal congestion, Cough, Vomiting, Poor oral intake Tachypnea, Hypoxia, Hypotension, Raised JVP, Distant heart sounds CRP-5.2 mg/dl, D-dimer-2.0 ug/ml, Interleukin-6-130 pg/ml Troponin T-0.043 ng/ml Enlarged cardiac silhouette, Bilateral lung infiltrates Diffuse low QRS voltage Large circumferential pericardial effusion, RV diastolic collapse Yes Yes Pericardiocentesis, Steroids, Heparin drip, Tocilizumab Straw Colored, Exudative Recovered
30.Mohammed Sheata et al. [28] 50 yo F HTN, CKD Fever, Cough Tachypnea, Hypoxia, Hypertension, Tachycardia CRP-15.9 mg/dl, Ferritin-1200 ng/ml, D-dimer-3.4 ug/ml Troponin-0.149 ng/ml Bilateral ground-glass appearance, Right sided pleural effusion, Enlarged cardiac silhouette Sinus tachycardia, Diffuse low QRS voltage Large circumferential, Pericardial effusion, RV diastolic collapse, Dilated inferior vena cava Yes Yes Steroids, Vasopressor, Pericardiocentesis Serous Recovered
31. Gopal et al. [29] 40 yo M CAD None Fever Ferritin-195,321 ng/ml, D-dimer-8.03 ug/ml - - Concave ST elevation in chest and limb leads, Reciprocal ST depression and PR elevation in aVR Moderate pericardial effusion, Early signs of tamponade, Global biventricular dysfunction None Yes Inotrope, Remdesivir, Steroids Hemorrhagic Expired
32. Gopal et al. [29] 49 yo M CAD None Fever, Hypoxia Ferritin-2,166 ng/ml, D-dimer-3.95 ug/ml  - - - Pericardial effusion, Tamponade physiology Yes Yes Remdesivir, Steroids,  Inotrope - Recovered
33. Sampaio et al. [30] 45 yo F None Dyspnea, Fever,  Myalgia Tachycardia, Orthostatic hypotension, Tachypnea CRP-2.1 mg/dl, Ferritin-478 ng/ml, D-dimer-0.543 ug/ml  Troponin I-0.867 ng/ml Bilateral pulmonary infiltrates, Pleural and pericardial effusions - Moderate pericardial effusion,  RV diastolic restriction Yes Yes Antibiotics, Pericardial Drainage, ECMO, Vasopressors         Tocilizumab, Steroids, Convalescent Plasma, Immunoglobulin Citrine yellow Recovered
34. Flores Cevallos et al. [31] 51 yo F None Syncope, Dyspnea Hypotension - - Bilateral infiltrates, Mild pericardial effusion, Pericardial thickening Diffuse superior concave ST elevations Pericardial effusion. Tamponade physiology, Deteriorated biventricular systolic function Yes Yes Vasopressor, Pericardiocentesis - Recovered
35. Kogler et al. [32] 71 yo F HTN Chest Pain, Dyspnea Tachycardia, JVD, Decreased heart sounds - Troponin T-0.14 ng/ml Bilateral diffuse opacities Low voltage Moderate pericardial effusion, RV systolic compression, Paradoxical RV septal motion, End-diastolic RA collapse, Plethoric IVC Yes None Fluids, NSAID, Colchicine, Steroids, Pericardiocentesis - Expired
36. Kogler et al. [32] 51 yo F HTN, Obesity  Chest Pain, Dyspnea Tachycardia       Hypotension, Cold extremities - Troponin T-0.93 ng/ml Bilateral patchy ground glass opacities  Low voltage, Diffuse ST elevations Moderate effusion, Late RA diastolic collapse, RV compression, LVEF-20% Yes None Fluids, Pericardiocentesis Inflammatory, Exudative Expired
37. Foster et al. [33] 44 yo F Factor V Leiden deficiency, Pulmonary emboli, Hypothyroidism Chest Pain - ESR-10 mm/hr,  CRP-0.75 mg/dl, D-dimer-0.273 ug/ml Troponin-0.4 ng/ml Unremarkable Borderline diffuse ST elevations, PR depression in leads II, III, AVF, mild PR elevation in aVR Large pericardial effusion, RV diastolic invagination None None Pericardial window, Colchicine                    - Recovered
38. Fox et al. [34] 43 yo M None Orthopnea, Dyspnea,  Chest pain, Cough, Fever Tachycardia, Hypoxia, Tachypnea, JVD, Pulsus paradoxus, Friction rub D-dimer-6.32 ug/ml, Ferritin-1,077 ng/ml, CRP-36.8 mg/dl Troponin-<0.006 ng/ml Cardiomegaly Low voltage, Diffuse concave ST elevations and PR depressions, PR elevation in aVR Moderate circumferential pericardial effusion, Respiratory variation to LV inflow None None Pericardiocentesis, Colchicine, NSAID Serosanguinous Recovered
39. Reddy et al. [35] 63 yo F Myelofibrosis, Stem Cell Transplant, Graft-versus-host disease Chest pain - CRP-5.9 mg/dl, D-dimer-0.743 ug/ml Troponin-I-normal Elevated right hemidiaphgram PR depression, Saddle ST elevation in inferolateral leads Large global pericardial effusion, RV diastolic collapse None None Antibiotics, NSAID, Colchicine, Pericardiocentesis Serosanguinous,       Exudative Recovered
40. Naderi et al. [36] 61 yo F HTN, DM2, ESRD, Pacemaker Dyspnea, Orthopnea Vomiting, Weakness                     Hypoxia, Hypotension - - Bilateral consolidations Pacemaker rhythm Massive pericardial effusiom Yes Yes Vasopressor, Lopinavir/Ritonavir, IVIG, Pericardiocentesis Exudative Expired
41. Beckerman et al. [37] 55 yo M HTN, Gout, Obesity - - CRP-18 mg/dl, ESR-100 mm/hr - - Low voltage, Nonspecific T wave changes in inferior leads Circumferential pericardial effusion, RV collapse Yes Yes Antibiotics, NSAID, Tocilizumab, Remdesivir, Convalescent plasma, Colchicine, Pericardiocentesis Serosanguinous Recovered
42. Deana et al. [38] 77 yo M Chronic HF,  HTN,  DM2, COPD, CKD - Hypotension,  Tachycardia - - - - 1.5cm pericardial effusion None None Vasopressor, Pericardiocentesis,  Steroid, Colchicine Exudative, Inflammatory Recovered
43. Schnaubelt et al. [39] 72 yo M DM2, Persistent AF, Obstructive sleep apnea                    Fever                Fatigue                    Bilateral crackles, Irregular heart rhythm, Hypoxemia         Tachycardia Elevated Troponin T-0.08 ng/ml Bilateral consolidations - 2-3 cm pericardial effusion, LVEF-30%          Yes Yes Pericardiocentesis, Vasopressor, Steroids, Fluids - Expired
44. Darvishi et al. [40] 42 yo M None Chest pain, Diaphoresis, Dyspnea Hypotension, JVD, Muffled heart sounds - Elevated - Acute extensive anterolateral STEMI  2 cm pericardial effusion, LVEF-20% Yes Yes - - Expired
45. Sollie et al. [41] 29 yo F None Chest Pain, Dyspnea Tachycardia. JVD, Distant heart sounds, Pulsus paradoxus - - Pericardial effusion Electrical alternans >3.5cm pericardial effusion, RV diastolic collapse None None Pericardiocentesis  Aspirin, Colchicine, Steroids Serosanguinous Recovered

The first case of cardiac tamponade caused by COVID-19 was documented in early 2020 by Hua et al. in a 47-year-old female without any significant medical history. Of the total 45 cases examined, only 11 (24%) had any prior cardiac comorbidities with one patient having a prior history of myocarditis. There was no troponin elevation described in seven of the cases as well which suggests that this virus can mediate inflammation of the pericardium and accumulation of fluid without direct myocardial injury. Furthermore, 20 of the 45 patients did not have a concomitant pneumonia; in fact, 18 patients were not noted to have significant respiratory symptoms from COVID-19 infection and had primarily cardiac manifestations of this illness. Such observational data reinforces the premise that COVID-19 can cause significant pericarditis without respiratory involvement.natriuretic

Our patient proved to be a challenging diagnosis as on first presentation there was no clear etiology for the pericardial effusion. The only reported symptoms were intermittent chest pain and shortness of breath for three weeks without any other respiratory involvement or signs of infection. The differential included infectious process, malignancy given prior history of cancer, or autoimmune etiology; initial workup, however, was negative for any clear cause. We unfortunately were unable to send pericardial fluid for SARS-CoV-2 PCR testing. Our patient had a hemorrhagic pericardial effusion which has been demonstrated in some viral pericarditis, most prominently coxsackie virus [42]. However, hemorrhagic effusions have also been documented in the current literature on tamponade in COVID-19 patients and this patient had no other risk factors for a hemorrhagic effusion aside from remote history of malignancy for which cytology was negative. Our patient later tested positive for COVID-19 and we acknowledge the possibility that he could have been subsequently infected after the initial diagnosis of pericardial effusion. However, in absence of any other cause, direct COVID-induced pericarditis leading to pericardial effusion and tamponade was the most likely diagnosis.

Amongst the 36 patients with tamponade whose pericardial fluid was reported, 19 patients identified in this literature review were noted to have hemorrhagic or serosanguinous effusions on analysis after pericardiocentesis. Most commonly, hemorrhagic effusions are associated with malignancy, inflammatory states, or post infarction [43]. As mentioned above, viral pericarditis is typically noted to have a benign course, but there have been reports of hemorrhagic effusion most described in coxsackie virus infection where it is believed that the virus causes direct damage to myocardial cells or an immune-mediated injury [42]. Given the robust inflammatory response elicited by the COVID-19 infection and its cytokine storm, it may mediate hemorrhagic effusions through a similar mechanism. We urge providers to keep COVID-19 high on the differential when cryptogenic, hemorrhagic effusions of tamponade physiology are identified, even if repeat COVID-19 testing is negative.

Our patient presented with subacute cardiac tamponade as he had been experiencing symptoms intermittently for weeks prior to presentation. This case draws parallels to the patient described by Ejikeme et al. who presented with indolent symptoms and no hemodynamic compromise [21]. In fact, of the cases reviewed, only 16 (36%) presented with hemodynamic changes of hypotension and suspicion was only raised in other cases after echocardiogram showed a large pericardial effusion. This suggests that cardiac tamponade should be on the differential if a patient infected with COVID-19 experiences acute deterioration and hemodynamic compromise.

Management of cardiac tamponade is focused on prompt removal of the effusion and monitoring of hemodynamics post pericardiocentesis as well as volume resuscitation. One of the mainstays is to avoid positive pressure ventilation as increased intrathoracic pressure can impair cardiac filling [44]. This poses a problem in patients infected with COVID-19 as many require mechanical ventilation. Of the cases reported, 21 were on mechanical ventilatory support and 13 of those patients expired during hospitalization. Prompt evaluation using bedside US and drainage of pericardial fluid is of utmost importance in these patients presenting with cardiac tamponade.

Ultimately, our patient was diagnosed with cardiac tamponade due to viral pericarditis mediated by COVID-19 infection. The fact that he displayed little to no respiratory symptoms, no signs of myocardial damage, and initially tested negative for COVID-19 several times contributes to the uniqueness of this as a subacute presentation of tamponade. This case along with the others highlighted in this review document cardiac tamponade as a rare complication of COVID-19 infection.

Conclusions

COVID-19 infection presents in many different ways and has been shown to affect a multitude of organ systems including the heart. We present a case of an elderly man with no cardiac comorbidities and minimal respiratory symptoms who presented with a very subacute cardiac tamponade caused by viral pericarditis secondary to COVID-19 infection. This case along with other well-documented reports included in this review highlight cardiac tamponade as a rare sequelae of this viral infection. We furthermore hope to inform providers to recognize COVID-19 as a considerable differential when encountering cryptogenic, hemorrhagic pericardial effusions of tamponade physiology, even without respiratory disease.


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Case report
peer-reviewed

Subacute Cardiac Tamponade in a COVID-19 Patient Despite Negative Testing


Author Information

Neil R. Kumar Corresponding Author

Internal Medicine, Jackson Memorial Hospital, University of Miami, Miami, USA

Shreyans Patel

Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, USA

Bridget Norwood

Internal Medicine, Miller School of Medicine, University of Miami, Miami, USA


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.



Case report
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Subacute Cardiac Tamponade in a COVID-19 Patient Despite Negative Testing


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