ABC | Volume 114, Nº5, May 2020

Case Report Huyut Covid-19 and cardiomyopathy Arq Bras Cardiol. 2020; 114(5):843-845 exhaustion and most patients were aged between 40 and 60 years-old. Also, in some cases headache and hemoptysis and diarrhea may occur. Moreover, severe patients may progress to ARDS and intubation may be required in certain patients. 1 The clinical signs of COVID-19 are the same as those of normal upper respiratory tract infections, but the chest CT shows certain details. 5 However, it is difficult to distinguish COVID-19 from other viral pneumonia based on CT findings alone. It is still necessary to clarify and define the epidemiological history, and it should be diagnosed by RT-PCR. Acute myocarditis is a documented risk of viral infections, such as influenza. Clinical presentation ranges from asymptomatic to fulminant myocarditis, which may contribute to severe hemodynamic instability. 7 Previous autopsy-based studies on fatal cases showed that during the 1957 Asian influenza pandemic and during the Spanish influenza pandemic, 39.4% and 48% complication rates of focal to diffuse myocarditis were recorded, respectively. 8 These deadly incidents of myocarditis showed both severe pneumonia and multiple organ involvement. As a consequence, myocarditis is expected to be a fatal risk in a pandemic influenza outbreak. Miura et al. 9 also found a viral antigen in the myocardium with immunohistochemical staining of the autopsied heart. 9 Bowles et al. 10 evaluated endomyocardial biopsy samples from 624 patients and objectively identified myocarditis utilizing PCR for different viral genes. Of the 239 samples tested positive for viral genes, adenovirus was found in 142 samples, enterovirus in 85 samples and influenza A in just five (0.8%) samples. 10 Thus, although the pathogenesis of COVID-19-associated cardiomyopathy or myocarditis remains unclear, the literature suggests that endothelial dysfunction may have an important role in the pathogenesis of myocarditis and cardiomyopathy. Electron microscopic findings of the heart from a murine influenza myocarditis model showed many infiltrating lymphocytes directly attached to the cardiac myocytes, and proinflammatory cytokines in the pathogenesis of acute myocarditis. 7-9 The over-release of cytokines in COVID-19 is already known. 1-2 We hypothesized that cytokines such as TNF- α , IL-1, IL‑6, IL-8, IL-10, which are known to have cardio-depressant Figure 1 – Axial CT images. (A-B) : At admission, CT shows the bilateral presence of mild GGOs in the parenchyma. (C-D) : On day 6, a repeated CT was consistent with increasing expansion of the GGOs and progressed consolidations, which are called crazy paving consolidations. (E-F) : On day 12, a repeated CT showed that the previous consolidations and GGOs in both lungs were mostly absorbed, leaving fibrous lesions that may indicate residual organizing pneumonia. CT: computer tomography, GGOs: ground-glass opacities. 844