This case report information was obtained by analyzing medical records; the data was acquired by the medical team, recording images of complementary exams and reviewing the literature.

Coronavirus disease 2019 (COVID-19) has been declared a worldwide public health emergency. According to data from the Brazilian Society of Cardiology (SBC), cardiovascular involvement related to the new coronavirus can manifest itself as arrhythmias (16%), myocardial ischemia (10%), myocarditis (7.2%), and shock (1-2%).¹ A study published in the Journal of the American Medical Association (JAMA), conducted in 02 North American hospitals, shows that cases of takotsubo increased during the COVID-19 outbreak. Before the pandemic, approximately 5 to 12 patients presented the takotsubo syndrome upon hospital admission; after an increase in SARS-CoV-2 cases, the number of patients with takotsubo reached 20.²

A 47-year-old female patient, from São Paulo, with controlled diabetes, sought out the emergency department of a tertiary hospital, reporting that she was admitted seven days earlier with a diagnosis of COVID-19 and myocarditis.

She returned reporting sudden, severe, tight chest pain, unrelated to physical exertion, associated with sweating and dyspnea. Upon initial assessment and physical examination, the patient was considered to be in good general condition and eupneic; the cardiac auscultation was rhythmic, with normal heart sounds; and no murmurs were observed. In pulmonary auscultation, a rhonchi in the right hemithorax was audible. The patient had a blood pressure of 170 x 100 mmHg, a heart rate of 53 bpm, and blood saturation of 96% in ambient air.

The electrocardiogram (EKG) performed upon hospital admission revealed a 1st degree atrio-ventricular block (AVB) ( Figure 1 ). Laboratory tests showed an increase in troponin 0.99 (normal range (NR) < 0.034), NT pro-BNP 2470 (NR<100), and D-Dimer 1165 (NR < 500).

Figure 1

A triple-rule-out computed tomography (CT) of the chest ( Figure 2 ) revealed ground glass opacity, associated with thickening of the interlobular septal, together with signs of pulmonary congestion in the peribronchovascular interstitium; therefore, inflammatory/infectious processes could not be ruled out. The CT exam of the coronary and pulmonary arteries showed an absence of coronary calcifications and atherosclerotic luminal reduction ( Figures 3 and 4 ). The presence of segmental systolic dysfunction of the left ventricle proved not to be related to the coronary territory. The existence of a non-ischemic pattern of myocardial fibrosis with lipomatous metaplasia was also found, suggesting a previous myocarditis ( Figure 5 ), with no signs of pulmonary thromboembolism ( Figure 6 ). The pattern of left ventricular segmental contractility found in the CT exam of the heart could suggest stress-induced cardiomyopathy (Takotsubo syndrome), since the changes in the myocardial fibrosis were not suggestive of an acute condition (lipomatous metaplasia) ( Figure 7 ).

Figure 2

Figures 3

Figures 4

Figure 5

Figure 6

Figure 7

Patient was hospitalized with broad-spectrum antibiotic therapy that was initiated due to recent hospitalization. Diuretic therapy, angiotensin-converting enzyme inhibitors (ACE inhibitors), and beta-blockers were also prescribed, followed by complementary investigation.

Cardiac magnetic resonance (CMR) showed moderate left ventricular systolic dysfunction (ejection fraction of 41%) and an aspect compatible with previous myocarditis without signs of current inflammatory process. There were also changes in contractility of the left side ventricle (LV), with anterior and mediobasal akinesia with localized feature, preserving the apex and more basal portions, which did not allow us to rule out adrenergic cardiomyopathy, Takotsubo syndrome ( Figure 8 ).

Figure 8

The patient also presented frequent ventricular extrasystoles, solved using beta-blockers. After improvements in the condition, the patient was discharged, using ACE inhibitors, beta-blockers, and loop diuretics.

After 45 days, the patient remained asymptomatic and underwent CMR ( Figure 9 ), which showed preserved biventricular systolic function and the presence of non-ischemic inferior and inferobasal fibrosis, although nonspecific, which could correspond to previous old inflammatory cardiomyopathy. Compared to the first CMR, there was an improvement in the left ventricular segmental contractility. The patient also underwent a new chest CT scan that showed a resolution of the previous pulmonary condition ( Figure 10 ).

Figure 9

Figure 10

This case report aims to demonstrate the association between COVID-19 and cardiac involvement, most likely causing takotsubo cardiomyopathy.

The cardiovascular outcome is a real possibility in the clinical experience of the new coronavirus pandemic. The clinical signs should always guide us to put forward such possibilities, thus continuing the alert for myocarditis and Takotsubo syndrome. The patient of this case report presented myocardial injury both at an early stage of the disease and at a later stage. Therefore, cardiovigilance is recommended in these patients, since, in view of the current knowledge, it is not clear if myocardial dysfunction or other complications may occur at a later point in time.