Working Diagnosis:
COVID-19 myocarditis imaged in the sub-acute phase

Treatment:
The patient started limited to non-contact football training one week after ablation. He was also treated with two weeks of colchicine and one week of ibuprofen for presumed myocarditis.

Outcome:
He will be cleared for full return to play after completing his three month course of anticoagulation.

Author's Comments:
Myocarditis imaged in subacute phase may have normal MRI findings. Myocarditis can also cause ventricular arrhythmias such as atrial fibrillation or atrial flutter. Current guidelines recommend comprehensive evaluation including Cardiac MRI, which may exhibit myocardial edema, fibrosis, impaired RV function. In a recent study of 26 COVID-positive patients with cardiac symptoms, 11 had negative Cardiac MRI findings, suggesting resolution of acute edema from myocarditis or other etiology. In this case study, whether the pre-existing re-entrant circuit was unmasked or symptoms originated from COVID-19 myocarditis imaged in the sub-acute phase remains unclear.

Editor's Comments:
Palpitations may be a presenting symptom in over 7% of patients with COVID-19. In a study on 138 hospitalized patients, arrhythmias were seen in as high as 44.4% for those in the ICU and 6.9% in non-ICU patients. In a review of 16 case reports of COVID-19-induced fulminant myocarditis, ECG findings were non-specific, including diffuse ST-segment elevation, non-specific intraventricular conduction delay, sinus tachycardia, and inverted T-waves in anterior leads. Viral myocarditis caused by COVID-19 is thought to be a potential mechanism for cardiac arrhythmias in COVID-19, but the actual prevalence of arrhythmias in COVID-19 patients, especially those not requiring hospitalization, currently still remains unknown.

References:
1. Baggish, Aaron et al. “Resurgence of sport in the wake of COVID-19: cardiac considerations in competitive athletes.” British journal of sports medicine vol. 54,19 (2020): 1130-1131. doi:10.1136/bjsports-2020-102516
2. Huang, Lu et al. “Cardiac Involvement in Patients Recovered From COVID-2019 Identified Using Magnetic Resonance Imaging.” JACC. Cardiovascular imaging, S1936-878X(20)30403-4. 12 May. 2020, doi:10.1016/j.jcmg.2020.05.004
3. Inciardi RM, Lupi L, Zaccone G, et al. “Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19).” JAMA Cardiol. 2020;5(7):819–824. doi:10.1001/jamacardio.2020.1096
4. Manolis, Antonis S. “Contemporary Diagnosis and Management of Atrial Flutter: A Continuum of Atrial Fibrillation and Vice Versa?.” Cardiology in review vol. 25,6 (2017): 289-297. doi:10.1097/CRD.0000000000000162
5. Puntmann, Valentina O et al. “Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19).” JAMA cardiology, e203557. 27 Jul. 2020, doi:10.1001/jamacardio.2020.3557
6. Goette, Andreas et al. “EHRA/HRS/APHRS/SOLAECE expert consensus on Atrial cardiomyopathies: Definition, characterisation, and clinical implication.” Journal of arrhythmia vol. 32,4 (2016): 247-78. doi:10.1016/j.joa.2016.05.002
7. Frustaci, A et al. “Biopsy evidence of atrial myocarditis in an athlete developing transient sinoatrial disease.” Chest vol. 108,5 (1995): 1460-2. doi:10.1378/chest.108.5.1460
8. Warnier MJ, Rutten FH, Kors JA, Lammers JW, de Boer A, Hoes AW, de Bruin ML. Cardiac arrhythmias in adult patients with asthma. J Asthma. 2012 Nov;49(9):942-6. doi: 10.3109/02770903.2012.724132. Epub 2012 Sep 27. PMID: 23013453.

Return To The Case Studies List.