Cardiac troponin elevation in a middle-aged female consistent with COVID myocarditis




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Background: Coronavirus (SARS-CoV-2) is known to cause severe acute respiratory syndrome, but more recently, it has been linked to increased cardiac involvement. It has recently been suggested by evidence that increased troponin levels seen in patients with severe COVID-19 reliably identifies myocardial damage. However, few longitudinal observations on troponin levels in mild COVID-19 cases over time have been published. Given its recent discovery, our understanding of the long-term effects of Coronavirus infections on individuals remains incomplete. The Center for Disease Control has recently estimated an overall incidence of myocarditis secondary to COVID-19 infection to be at around 150 cases per 100000 individuals in the United States alone.

Case Presentation: A 45 year-old caucasian female with past medical history of T2DM, HTN, HLD, CKD, PCOS, and past COVID-19 infection presented to the Emergency Department with recurrent chest pain associated with shortness of breath, left hand numbness, and diaphoresis while at rest. A month prior, this female was admitted for NSTEMI with cardiac catheterization showing normal coronary arteries, echo demonstrating EF of 50-55% without wall motion abnormalities, and CTA demonstrating no signs of PE. Patient had been compliant with all medications since discharge, states nitroglycerin helped with pain, and had not been taking aspirin due to scheduled hysterectomy. Initial troponin levels were 3.409 ng/mL (0.00-0.013), glucose level 107, and platelet count was 426. A focused cardiac ultrasound performed by the emergency physician demonstrated absence of pericardial effusion, normal LV function, mild LV dilation, absent RV dilation, and absence of pericardial tamponade. EKG showed no signs of acute ischemia and repeated EKG was normal. However, cardiology was consulted due to evidence of myocardial injury as indicated by elevated troponins. The patient received ASA, Plavix, and Lovenox in the ED and heparin was started as part of ACS protocol. Tylenol 650 mg Q6H PRN and Morphine 2mg Q30M PRN were added for pain. Troponin levels continued to trend upward to 7.115 over the course of 7 days. Normal studies and images led to the conclusion that this patient would benefit from a heart MRI and outpatient medical management.

Conclusions: This case highlights the long-term impact of Coronavirus infections on cardiac health, as indicated by notable elevations in troponin levels. It also demonstrates the atypical presentation of elevated troponin levels in the absence of acute ischemic myocardial injury.