Medical Case: Myocarditis and COVID-19 in a 16-year-old patient

A 16-year-old boy is examined in the ER because of chest pains. Careful investigation by physicians reveals acute myocarditis and SARS-CoV-2 infection. The young patient, apart from fever, never showed any typical signs of COVID-19.

The clinical case reported by the physicians of the Policlinico San Matteo in Pavia, Italy, is featured in the Lancet

A 16-year-old boy is examined in the ER because of chest pains. Careful investigation by physicians reveals acute myocarditis and SARS-CoV-2 infection. The young patient, apart from fever, never showed any typical signs of COVID-19.

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A 16-year-old boy was examined in the ER complaining of severe pain in his chest and left arm, which had begun an hour earlier. The previous day he had a fever (38.5 °C), which decreased after taking 100mg of nimesulide. He reported no other symptoms, no significant medical history, and no contact with positive COVID-19 subjects.

At the hospital, his vital signs were normal, apart from a temperature of 38.5°C. At auscultation of the patient's chest, heart tones were normal, with no pericardial rubbing and no abnormal respiratory signs determined. No lymphadenopathy, no rash, and no areas of increased sensitivity on the chest wall were found. The electrocardiogram (ECG) showed an inferolateral ST-segment elevation. Transthoracic echocardiography showed hypokinesia of the lower and inferolateral segments of the left ventricle, with a preserved ejection fraction of 52%. No pericardial effusion was noted. 

The results of laboratory tests showed: cardiac troponin I (9449 ng/L), creatine-phosphokinase (671.0 U/L), C-reactive protein (32.5 mg/L), lactate dehydrogenase (276.0 U/L). The leukocyte count was 12.75×109 per L, the neutrophil count was 10.04×109 per L, and the lymphocyte count was 0.78×109 per L.

The boy was given aspirin for pain relief and was transferred to a coronary unit. He was diagnosed with acute myocarditis. The patient's pain gradually improved and after 2 hours it completely resolved.

However, during the first night, he reported further chest pain. The ECG was repeated, but no significant changes were observed. 600mg ibuprofen was administered 3 times daily intravenously and both the symptoms and the increased temperature were resolved. Tests for autoantibodies and cardiotropic viruses were negative. On day 3 the nasopharyngeal swab test for SARS-CoV-2 was positive. Therapy with hydroxychloroquine and antiviral was then started. Serial measurements of the patient's troponin concentration showed a gradual reduction. Inflammatory markers also returned to normal and the ST-segment elevation on the ECG was resolved. On day 12, after two negative nasopharyngeal swab tests and in the absence of symptoms, the patient was discharged. 

Physicians emphasize that during the entire duration of hospitalization, the patient had no typical signs or symptoms (apart from fever) of COVID-19. According to physicians, pediatric patients who report chest pain and have other suggestive features of acute myocarditis - with or without respiratory symptoms - should test for SARS-CoV-2 infection.

Source:
Gnecchi M, Moretti F, Bassi EM, Leonardi S, Totaro R, Perotti L, Zuccaro V, Perlini S, Preda L, Baldanti F, Bruno R, Oltrona Visconti L. Myocarditis in a 16-year-old boy positive for SARS-CoV-2. The Lancet. Volume 395, Issue 10242, 2020, Page e116, ISSN 0140-6736. https://doi.org/10.1016/S0140-6736(20)31307-6.

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