ABC | Volume 114, Nº5, May 2020

Case Report Rente Coronavirus and the Heart Arq Bras Cardiol. 2020; 114(5):839-842 Patient admitted to the ward with wet cough, fever for 4 days, taking amoxicillin + clavulanate for 2 days without improvement; no travel abroad or contact with anyone with symptoms of COVID-19. Diabetes with personal history, but not regular treatment. Admission to the ward. Glasgow 15, eupneic in O 2 catheter, acyanotic. Two-stroke regular heart rhythm; heart rate: 90 bpm; blood pressure: 120 x 70 mmHg. Globally decreased vesicular murmur with sparse diffuse snores. Chest radiography, radiopacity bilaterally pronounced in the lung fields. Laboratory tests on March 16, 2020: Hb: 15,5; leukocytes: 16,150 mil; band cells: 323; Vhs: 23; Na: 135; K: 4.3; urea: 2; creatinine: 0,6; CRP: 23,6; blood glucose: 344. Diagnostic hypothesis of pneumonia and decompensated diabetes was suggested. Request for chest tomography, respiratory isolation, COVID-19 investigation (swab and CRP). Piperacillin + tazobactan 4.5 mg every 6 hours was initiated, dextro-transposition. On March 17, 2020, the patient evolved with general malaise, fever (38.3 °C), refractory to medication; 85% desaturation in O 2 3L/min; tachycardia, 104 bpm; tachypneic; 84 ipm; blood pressure: 120x70 mmHg. Tachycardiac heart rhythm with muffled heart sounds, chest pain, jugular venous distensionwith signs of diastolic dysfunction. Vesicular murmur with crackles all across the right hemithorax. On March 17, 2020, electrocardiography presented no signs of ischemia. Laboratory tests on March 17, 2020: Hb: 14,2; hT: 41%; leukocytosis: 15.030; platelets: 143 mil; CRP: 25; urea: 36; creatinine: 0.60; Na: 135; K: 4.2. Hypothesis of pulmonary focus sepsis; viral etiology. Thepatient opted for a definitive airway with orotracheal intubation. Blood pressure: 154x91 mmHg; HR: 48; bpm sat O 2 : 82%; FiO 2 : 100%; Peep: 12 bpm; controlled blood pressure: Due to hemodynamic instability, the patient was kept in the emergency room waiting for a place in the intensive care unit (ICU). Computed tomography (CT) of the chest (Figures 3 to 6) revealed selective intubation of the right mainstem bronchus; extensive ground-glass opacity in both lungs, affecting all lobes predominantly in the lower lobes, which present consolidations with air bronchograms, suggesting inflammation/infection. Viral etiology cannot be ruled out. Presence of myocardial edema secondary to an inflammatory process associated with myocardial wall thickening with a slight increase in the cardiac area. New successful orotracheal intubation, antibiotic therapy and measures for acute respiratory failure maintained. On March 18, 2020, the patient developed general malaise — tachycardia, sedated, tachydyspneic (Ramsey 6), on mechanical ventilation. Tachycardiac cardiac rhythm, with hypophonesis of b1 and b3 in outline, presence of jugular venous distension, edema on lower limbs 1/4+. Vesicular murmur with diffuse snores. Observation for acute myocarditis + pulmonary focus sepsis was initiated. Antibiotic therapy associated with hemodynamic monitoring was maintained if necessary; initiation of vasoactive drug. ICU spot was provided at Hospital das Clínicas (HC) de São Paulo, but the patient died on admission due to respiratory failure — COVID-19. Relevant findings: On March 17, 2020, additional tests presented the following findings: • Quantitative troponin: 0.49 ng/dl • D-dimer: 0.1 mg/L • Venous lactate: 2.0 mmol/L • Rapid HIV test: negative Oropharyngeal swab (rapid test for COVID-19) was performed on March 17, 2020 and tested negative; however, it is clear that the specificity of nasal swab is around 63%, so it is used in the first screening. The gold standard test for detecting COVID-19 consists of collecting in vivo or post-mortem CRP samples (2019-nCoV CRP), which tested positive (collected on March 19, 2020 — post-mortem). The tests performed in the state of São Paulo — sourced from the Brazilian public health system (SUS) — were analyzed by Instituto Adolfo Lutz Central, completing diagnosis of infection with the novel coronavirus. Discussion In view of the current pandemic and a disease still under investigation, we cannot rule out infection among young people and children, especially those with chronic conditions. Reports of clinical experience demonstrate that many patients aged 20 to 40 are being infected by the novel coronavirus, developing multiple comorbidities associated with the infection. Figure 2 – Chest radiography referring to the second appointment. 840