9
views
0
recommends
+1 Recommend
2 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: not found

      Endomyocardial biopsy findings in Kawasaki-like disease associated with SARS-CoV-2

      case-report

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Several paediatric cases with a multisystem inflammatory syndrome and acute heart failure associated with SARS-CoV-2 infection have been reported recently. The mechanism for heart failure in this setting remains unclear. We performed endomyocardial biopsy in a young COVID-19 patient presenting with a delayed multisystem inflammatory syndrome with acute heart failure. A 19-year-old patient was admitted for acute respiratory distress and a mixed distributive and cardiogenic shock. One month previously he was diagnosed with COVID-19 and was advised to recover at home because of mild illness that lasted 1 week. After 3 weeks without symptoms, he presented recurrent fever, cough, cervical adenopathy, and subsequently chest pain and dyspnoea. Upon arrival, he was febrile at 39°C, hypotensive (81/43 mmHg), and tachycardic (140 b.p.m.), with a respiratory rate of 45 breaths/min. Nasopharyngeal swab confirmed COVID-19. Laboratory test results revealed a profound elevation in inflammatory biomarkers: ferritin 4560 μg/L (normal <300), triglyceride 4 mM (normal <1.7), procalcitonin 155 μg/L (normal <0.5), type 1 interferon 6.1 (normal <2.3), neutrophil count 24 × 109/L (normal <8), lymphopenia 0.5 × 109/L (normal >1), and decreased complement activity CH50 <14 (normal >40). High-sensitivity troponin I and N-terminal probrain natriuretic peptide (NT-proBNP) were both elevated at 4200 ng/L (normal <79) and 17 377 pg/mL (normal <500), respectively. Left ventricular ejection fraction was impaired (20%) with a low cardiac output. The patient required protective mechanical ventilation. Emergent coronary angiography revealed normal coronary arteries. Endomyocardial biopsy was performed (four samples for pathological study and three for viral PCR). Histopathological study demonstrated a myocarditis with inflammatory infiltrates consisting of a majority of lymphocytes and neutrophils (≥14 leucocytes/mm2), oedema, but no typical myocyte necrosis. Cell-specific immunoperoxidase stains revealed CD4-positive T lymphocytes. CD20-positive B-lymphocytes were absent (Figure ). There was no granuloma, abscess, giant cell, or features of vasculitis. RT–PCR for SARS-CoV-2 and PCR for other cardiotropic viruses were negative on the myocardium. PCR was performed on a peripheral blood sample, to evaluate for co-existing viraemia, and was negative. Blood cultures were sterile. Bronchoalveolar lavage revealed a purulent fluid with high neutrophil count, without evidence of SARS-COV-2 or other infectious agent. Our management consisted of high-dose diuretics, broad-spectrum antibiotics, and supportive therapy with inotropic and vasopressive drugs. No immunosuppressive therapy was used. The patient improved promptly. Ejection fraction and inflammatory markers normalized spontaneously and the patient was discharged on day 12. In young patients, COVID-19 can present as a delayed multisystem inflammatory syndrome (also reported as Kawasaki-like disease) associated with acute heart failure. Similarly to previous paediatric cases, prominent features are: delayed presentation, multisystem inflammatory response with multiple organ failure and in particular heart failure, and rapid recovery. The endomyocardial biopsy suggests a fulminant lymphocytic myocarditis secondary to an imbalanced proinflammatory response without evidence of direct viral cytopathic effect as a potential mechanism for heart failure in this setting. Endomyocardial biopsy. Light microscopy, histopathological study (scale: 1, 300 μm; 2A, 90 μm; 2B, 80 μm). Inflammatory cell infiltration (black circle) with a majority of neutrophils (black arrows) and lymphocytes (yellow arrows) and rare eosinophils (blue arrow). The white arrow indicates a myocyte. Immunohistochemistry (staining: 3A, CD3; 3B, CD4; 3C, CD8) revealed T-lymphocyte infiltrates (CD3 positive) consisting of CD4-positive T lymphocytes. Conflict of interest: none declared.

          Related collections

          Author and article information

          Journal
          Eur Heart J
          Eur. Heart J
          eurheartj
          European Heart Journal
          Oxford University Press
          0195-668X
          1522-9645
          25 July 2020
          : ehaa588
          Affiliations
          [e1 ] Cardiology Department, Hôpital Croix-Rousse and Lyon Sud, Hospices Civils de Lyon , Lyon, France
          [e2 ] Histopathology Department, Hôpital Louis-Pradel, Hospices Civils de Lyon , Lyon, France
          Author notes
          Corresponding author. Hôpital de la Croix-Rousse, Cardiology Department, Grande Rue de la Croix-Rousse, Lyon, Rhône-Alpes, 69004, France. Tel: +33688124411, Email: marc.bonnet@ 123456chu-lyon.fr
          Author information
          http://orcid.org/0000-0003-1847-1583
          http://orcid.org/0000-0003-3867-8370
          http://orcid.org/0000-0001-5259-1613
          http://orcid.org/0000-0003-0400-6234
          Article
          ehaa588
          10.1093/eurheartj/ehaa588
          7454537
          32710612
          e96d120e-39aa-470b-9efa-351404ca0733
          Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.

          This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

          This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

          History
          Page count
          Pages: 2
          Categories
          Cardiovascular Flashlight
          AcademicSubjects/MED00200
          Custom metadata
          PAP

          Cardiovascular Medicine
          Cardiovascular Medicine

          Comments

          Comment on this article