Elevated Troponins in a Middle-Aged Male Presenting with Cough, Dyspnea, and Chest Pain




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Background: Respiratory complications from SARS-CoV-2 infection are most commonly reported; however, adverse cardiac events such as acute coronary syndromes, thromboembolic syndromes, and myocarditis have been described. A study by the Centers for Disease Control estimates an overall incidence of COVID-related myocarditis to be at around 150 cases per 100000 individuals in the United States.

Case Presentation: A 45-year-old male with a past medical history of exercise-induced asthma, obstructive sleep apnea, and gastroesophageal reflux disease was admitted to our hospital from the emergency department due to chest pain, shortness of breath on exertion, and cough. Patient reports having a cough that started three days prior to ED presentation. He managed his cough conservatively over the weekend, but his symptoms increased in severity and he developed a headache and chest pain radiating to his neck and jaw. Upon presentation to the ED, patient endorses the chest pain to be resolved. His vitals at the ED were temperature 97.8F, HR 97, RR 16, BP (MAP) 121/82 (95), O2 96% on room air. At the ED, his electrocardiogram showed ST depression in leads III and aVF, but no ST elevations to suggest STEMI. Initial workup shows unremarkable electrolytes, mild hyperglycemia with glucose 119 mg/dL, mild transaminase elevation with ALT 46 IU/L and AST 46 IU/L, and elevated troponin 0.308 ng/mL (normal: 0.00-0.013 ng/mL). Patient also tested positive for SARS-CoV-2 via rapid test. Serial troponins were monitored in the ED and rose to 0.910 ng/mL then 4.446 ng/mL before admission to inpatient floor. No radiographic evidence of acute pulmonary disease was identified. ACS protocol was initiated and patient received dual antiplatelet therapy, heparin, and metoprolol/lisinopril. Cardiology was consulted and an echocardiogram was performed which showed normal chamber sizes, normal left ventricular systolic function, and mild concentric left ventricular hypertrophy. Due to patient’s stable clinical presentation and echocardiogram results, the cardiologist recommended serial troponin measurements and felt that a stress test was not indicated. Troponins continued to trend upward to 16.7 ng/mL two days later.

Conclusions: This case highlights the cardiac manifestations of COVID-19 in a patient with stable clinical presentation and markedly elevated troponin levels. The magnitude of troponin elevation in hospitalized patients with COVID-19 is typically associated with worse outcomes; however, this case illustrates the wide array of clinical cardiac presentation in patients with COVID-19-related myocardial injury.