Working Diagnosis:
Final diagnosis: Post COVID/Long COVID syndrome

Treatment:
The athlete’s chest tightness and dyspnea on exertion gradually resolved.
Repeat labs
D-Dimer
1.07
1.23

Outcome:
The athlete began a graduated return to play protocol over 7 days once symptoms resolved with activities of daily living (ADLs) and had no significant issues.

Author's Comments:
This athlete with chest tightness and dyspnea brought up the question of athletes heart or myocarditis. There are similarities and differences in these diagnoses.
Findings in athletes heart: high sensitivity troponin may be elevated after exercise, EKG with athletic heart related changes, CT angiography showing cardiomegaly without filling defects, echocardiogram with concentric hypertrophy with preserved function, and cardiac MRI with concentric hypertrophy.
Findings in myocarditis: high sensitivity troponin may be elevated or normal, EKG with ectopy, pathologic Q waves, arrhythmia, ST segment/T wave changes, CT angiography showing cardiomegaly, echocardiogram with right and left ventricle dysfunction, pericardial effusion and cardiac MRI with late gadolinium enhancement, edema.

This past year a new diagnosis also emerged, post-COVID syndrome which includes symptoms of fatigue, shortness of breath, cough, joint pain, chest pain, mood disturbance, and cognitive difficulty. This was ultimately the final diagnosis of this athlete.

Editor's Comments:
The management of athletes with COVID changed dramatically since the start of the pandemic. At the time of the athletes presentation many best practices and recommendations included a cardiac evaluation regardless of symptoms prior to return to sports. As new evidence emerged this screening protocol was modified and cardiac evaluation was based on symptoms during infection and return to play. It was extremely important to keep up to date with the frequently changing guidelines.

Additional information that could help in the diagnosis of this athlete would include a detailed family history of cardiac disease. Additional physical examination could include a more detailed cardiopulmonary exam, including auscultation for murmur with provocation, checking point of max impulse of the heart, and peripheral pulses. In addition, a gastrointestinal GI exam should be done as part of a thorough cardiopulmonary exam.

This patient had a very thorough workup and he did have spontaneous resolution of symptoms without treatment. It is a good example of what may be seen in the post-COVID athlete and consideration of limited workup in this setting may be considered.

References:
1. Carvalho-Schneider C, Laurent E, Lemaignen A, et.al. Follow-up of adults with noncritical COVID-19 two months after symptom onset. Clinic Microbiol Infect. 2021 Feb; 27(2): 258–263. doi: 10.1016/j.cmi.2020.09.052
2. Tenforde MW, Kim SS, Lindsell CJ, et. Al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Care Systems Network – United States, March – June 2020. MMWR Morb Mortal Wkly Rep. 2020; 69:993-998. doi: http://dx.doi.org/10.15585/mmwr.mm6930e1external_icon
3. Brosnan, M., & Rakhit, D. (2018). Differentiating Athlete’s Heart From Cardiomyopathies — The Left Side. Heart, Lung And Circulation, 27(9), 1052-1062. doi: 10.1016/j.hlc.2018.04.297
4. Phelan, D., Kim, J., Elliott, M., Wasfy, M., Cremer, P., & Johri, A. et al. (2020). Screening of Potential Cardiac Involvement in Competitive Athletes Recovering From COVID-19. JACC: Cardiovascular Imaging, 13(12), 2635-2652. doi: 10.1016/j.jcmg.2020.10.005
5. COVID-19 and Your Health. (2021). Retrieved 23 March 2021, from https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html
6. Millar, L., Fanton, Z., Finocchiaro, G., Sanchez-Fernandez, G., Dhutia, H., & Malhotra, A. et al. (2020). Differentiation between athlete’s heart and dilated cardiomyopathy in athletic individuals. Heart, 106(14), 1059-1065. doi: 10.1136/heartjnl-2019-316147

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