ABC | Volume 114, Nº5, May 2020

Case Report Novel Coronavirus Pneumonia and Cardiomyopathy: A Case Report Mustafa Ahmet Huyut 1 Yeni Yuzyil University – Cardiology, 1 Istanbul – Turkey A clustering of pneumonia was first recorded in Wuhan, Hubei, China in December 2019. 1 A coronavirus has been established as the pathogen responsible for the disease, and has since been called Severe Acute Coronavirus Syndrome-2 (SARS-CoV-2). The disease triggered by SARS-CoV-2 is called COVID-19, which has spread worldwide since then. Figures tend to climb in Europe, and the extent of COVID-19 lethality cannot be correctly measured. In older patients, lethality appears to be particularly higher when compared to seasonal influenza. 2 CT is very helpful in COVID-19 diagnosis. 3 Also, TTE examination is a very important tool to asses LVEF. Previous studies reported that the real-time polymerase chain reaction (RT-PCR) was the current gold standard for COVID-19 diagnosis. 3 But in some cases, the CT sensitivity is higher than that of RT-PCR. 4 We report a confirmed case of COVID-19 pneumonia in a 59-year-old female. We found a mild decrease in LVEF without troponin-I elevation, which might be considered as cardiomyopathy due to the increased cytokine release in COVID-19. To the best of our knowledge, this is the first report in the literature demonstrating the association between TTE and CT images in COVID-19, and we found that the worsening in the TTE findings is in line with the progression of CT images. Case report A 59-year-old female had had fever for 4 days, after catching a cold. One day before visiting the hospital, she had fever and cough, but no chest tightness, chest pain, chills, nausea and vomiting or diarrhea. She did not feel better after receiving antifebrile agents. Then, she was admitted to our outpatient clinic in BHT Clinic Tema Hospital. Four days before, the patient had had contact with her relative who had traveled from Europe. In her previous medical history, bariatric surgery had been performed 3 years before and she had still type II diabetes mellitus, hyperlipidemia, and hypertension as pre-existing conditions. She was hospitalized in our hospital on March/20/2020, and still had fever after admission, with the highest temperature of 39.5 °C, heart rate of 119 beats per minute; the electrocardiography was consistent with sinus tachycardia and QTc was calculated at 0.398 seconds, blood pressure at 94/60 mmHg, and conspicuous tachypnea with a respiratory rate of 24/min with sufficient oxygenation (95% ambient air saturation). The identification of 2019 novel coronavirus (2019-nCoV) in RT-PCR was positive from a throat swab. The risk of simultaneous contamination with other respiratory viruses and other pathogens were negative for the throat swab. The CT characteristics of the patient were similar to the case series reported by Pan et al. 5 (Figure 1: A-B). Laboratory results showed leukopenia, with 4.1×10 9 /L, lymphopenia with 0.8×10 9 /L, an only slightly increased CRP level, with 18.4 mg/L and a low procalcitonin level, with 0.01 ng/mL. The patient underwent a TTE examination with a 3.5-MHz transducer (Vivid-7 GE Medical System, Horten, Norway). Examinations and measurements were performed according to the recommendations of the American Echocardiography Unit. Simpson’s method was used to calculate LVEF. 6 At the admission, LVEF was calculated at 65%, with normal TTE findings. The patient was isolated, and initiated nasal high flow therapy for respiratory insufficiency and treated with the antiviral drug (oseltamivir, 75mg/capsule, 1 capsule each time, twice a day, for 5-days), antibiotic (azithromycin, 500mg/tablet on the first day, and after that, 250mg/tablet, once a day for 4-days), antipyretic (paracetamol 1gr/100 mL, twice a day), mucolytic (N-acetylcysteine ampule, 300mg/3ml intravenous (IV), twice a day), anticoagulant (enoxaparin 4000 anti-Xa IU/0,4 mL, once a day), corticosteroid (methylprednisolone, 40mg intravenous (IV), once a day, for 5 days), proton-pump inhibitor (esomeprazole ampule, 40 mg IV, once a day), and antimalarial drug (hydroxychloroquine sulfate 200mg/ tablet, 400 mg/tablet twice a day on the first day, and after that, 200mg/tablet twice a day, for 6-days). After 5 days of the treatment, the patient’s temperature dropped to normal and the symptoms disappeared. However, on day 6, a repeated CT was consistent with increasing expansion of the GGOs and progressed to which are called “crazy paving consolidations” (Figure 1: C-D). Moreover, LVEF was calculated at 52%, but the troponin-I level was still normal. Due to the CT scan results and TTE findings, we added favipiravir to the treatment (200mg/tablet on the first day, 1600mg/tablet twice a day, and 600mg/tablet, twice a day for 4 days) instead of oseltamivir. On day 12, a repeated CT showed that the previous consolidations and GGOs in both lungs were mostly absorbed, leaving some fibrous lesions that may indicate residual organizing pneumonia (Figure 1: E-F). Also, LVEF was calculated at 65% and a repeated RT‑PCR was negative and the patient was discharged. No other follow-up CT examinations were performed. The infection is primarily spread through respiratory droplets. Fever and dry cough are the primary clinical signs of COVID-19 in patients, accompanied by body aches or Mailing Address: Mustafa Ahmet Huyut • Yeni Yuzyil University – Cardiology - Merkez Mahallesi, Çukurçeşme Caddesi, 51 34245 Gaziosmanpaşa, Istanbul – Turkey E-mail: ahuyut@yahoo.com Manuscript received March 31, 2020, revised mnauscript April 03, 2020, accepted April 08, 2020 Keywords Cardiovascular Diseases/complications; Coronavirus; COVID-19; Myocarditis; Cardiomyopathies; Infectious Diseases; Acute Respiratory Syndrome; Pneumonia; Echocardiography/methods; Tomography, X-Ray Computed/ methods; Hospitalization. DOI: https://doi.org/10.36660/abc.20200268 843