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

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.

Figure 1

EKG on presentation showing new atrial fibrillation with rapid ventricular response as well as low voltage in precordial leads

Figure 2

2D transthoracic echocardiogram on admission showing large pericardial effusion with diastolic collapse of right ventricle consistent with tamponade physiology

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).

Figure 3

2D transthoracic echocardiogram post pericardiocentesis with removal of 750 cc of serosanguinous fluid

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).

Figure 4

CT chest showing a small pericardial effusion as well as a left lower lobe infiltrate

Red arrow refers to pericardial effusion; yellow arrow refers to left lower lobe infiltrate.

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).

Table 1

Covid-19 Cardiac Tamponade

AF - atrial fibrillation, AMS - altered mental status, BNP - brain naturetic peptide, CAD - coronary artery disease, CABG - coronary artery bypass graft, CK - creatinine kinase, CKD - chronic kidney disease, COPD - chronic obstructive pulmonary disease, CRP - C reactive protein, CRRT - continuous renal replacement therapy, CVA - cerebrovascular accident, DM - diabetes mellitus, ECMO - extracorporeal membrance oxygenation, ESRD - end stage renal disease, HF - heart failure, HFrEF - heart failure with reduced ejection fraction, HCQ - hydroxychloroquine, HLD - hyperlipidemia, HTN - hypertension, IVC – inferior vena cava, MV - mechanical ventilation, NSAID - non-steroidal anti-inflammatory drug, PPM - permanent pacemaker, RA - right atrium, RV - right ventricle, "-" refers to data that was not available

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.