A 39-year-old woman was admitted with chest pain, orthopnea, and cough that had arisen for 1 week before admission. Also, she had a history of asthma. Vital signs were as follows: body temperature = 37.2°C, systolic blood pressure = 100/60 mmHg, heart rate = 125/min, and O2 saturation = 90% without oxygenation. The ECG showed sinus tachycardia. The patient had a positive nasal and oropharyngeal PCR test for COVID-19 and the lung CT scan showed GGO in both lungs (Figure ). Echocardiography represented an LVEF of 30%–35%, normal LV size, mild RV enlargement (restrictive diastolic pattern), moderate tricuspid and mitral regurgitation, and mild pericardial effusion. Cardiac magnetic resonance (CMR or cardiac MRI) imaging showed myocardial edema and hyperemia suggestive of active myocarditis. Also, coronary CT angiography was normal. Subepicardial and subendocardial fibrosis in the middle part of the inferoseptal wall was also present. Her vital signs and oxygen saturation (98% on room air) improved after dexamethasone administration for 3 days. Echocardiography revealed an LVEF of 45% and a hypermobile thrombus in the LV (1.5 × 1.5 cm; Figure ). Although the cardiac surgeon suggested surgical removal of the thrombus, the patient refused the surgery. So, the patient was subjected to anticoagulation therapy (heparin 24,000 U/24 h). After 3 days, the thrombus had disappeared on the echocardiography, and there were no clues of embolism. The patient was discharged in a satisfying condition on β-blocker, angiotensin-converting enzyme (ACE) inhibitor, spironolactone, and warfarin. Follow-up of the patient for 3 months showed an LVEF of 45%–50%.
An 18-year-old woman (with no underlying disease) was admitted with a sudden loss of consciousness, fever, and headache that had occurred for 2 days before admission. At the time of admission, vital signs were as follows: body temperature = 36.8°C, systolic blood pressure = 80/60 mmHg, heart rate = 110/min, and O2 saturation = 80% without oxygenation. Glasgow Coma Scale (GCS) score was 11. She was intubated and treated with vasopressors. Also, rales were heard on pulmonary auscultation. Initial electrocardiogram (ECG) demonstrated sinus tachycardia (110/min) and low voltage QRS. Transthoracic echocardiography (TTE) indicated a small left ventricle (LV) with an end-diastolic dimension of 42 mm, a left ventricular ejection fraction (LVEF) of 10% with global hypokinesis, a normal right ventricle (RV), and pulmonary arterial pressure (PAP), no pericardial effusion (PE) or thrombosis, and no significant valve lesions or dysfunction. Chest computed tomography (CT) scan revealed diffuse bilateral ground-glass opacities (GGO) and basal consolidations (Figure ). Moreover, the patient had a positive nasal and oropharyngeal polymerase chain reaction (PCR) test for COVID-19. Laboratory findings are summarized in Table . The patient received intravenous immunoglobulin (IVIG; 1 g/kg), broad-spectrum antibiotics (meropenem [500 mg] and doxycycline [200 mg/day]), high-dose corticosteroid (methylprednisolone 1 g/day), and remdesivir for COVID-19. However, she died due to cardiac arrest (less than 24 h after admission).