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\begin{document}

\title{A case of acute pericarditis and subsequent pericardial effusion in
COVID-19 patient: a case report}



\author[1]{Waddah Osman}%
\author[1]{Abdelmuniem Ahmed}%
\author[1]{Omer Elawad}%
\author[1]{Ahmed Albashir}%
\affil[1]{University of Gezira Faculty of Medicine}%


\vspace{-1em}



  
  \date{June 02, 2024}


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\selectlanguage{english}
\begin{abstract}
Acute pericarditis and pericardial effusion are rare extrapulmonary
presentations of COVID-19. They can occur without concomitant pulmonary
disease or myocardial injury. A high index of suspicion is necessary to
assure early diagnosis and treatment.%
\end{abstract}%



\sloppy


\textbf{Keywords:}

Covid-19, acute pericarditis, pericardial effusion, case report.

\textbf{Key Clinical Message} Acute pericarditis and pericardial
effusion are one of the rare extra-pulmonary presentations of COVID-19.
They can occur without concomitant pulmonary disease or myocardial
injury. Studies are needed to determine the exact mechanism of acute
pericarditis and pericardial effusion in COVID-19 patients and the
optimal therapeutic strategies.

\textbf{Introduction:}

Coronavirus disease 2019 (COVID-19) is a current pandemic outbreak
caused by a novel coronavirus now called severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2). The commonest cardiac complications
include acute myocardial injury, arrhythmias, acute myocarditis and
severe left ventricular dysfunction.\textsuperscript{1} Conversely,
reports of pericarditis and pericardial effusion are rare.

A large pericardial effusion due COVID-19 has been reported in a 41
woman in Saudi Arabia.\textsuperscript{2} Besides, cardiac tamponade
secondary to COVID-19, \textsuperscript{3} life-threatening cardiac
tamponade complicating myopericarditis in COVID-19,
\textsuperscript{4}acute myopericarditis with pericardial effusion and
cardiac tamponade in a patient with COVID-19, \textsuperscript{5} and a
case of acute pericarditis and cardiac tamponade in a patient with
COVID-19 have all been reported. \textsuperscript{6}

Hereby, we describe a case of acute pericarditis and pericardial
effusion in a COVID-19 patient.

\textbf{Case presentation:}

A previously healthy 50-years old Sudanese man with no prior significant
medical history came to a university hospital, Sudan, complaining of
chest pain, stabbing in nature, increased in severity when supine
position and improved with leaning forward. He denied any history of
cough or shortness of breath.

During the physical examination, the patient preferred sitting leaning
forward, not dyspneic. Her BP was 160/80, pulse rate 96 regular,
temperature 38.1 and oxygen saturation 96 \% on room air. The JVP was
not raised. Pericardial friction rub was not heard. Cardiovascular and
chest examination was unremarkable.

Initial laboratory investigations revealed the following: WBCs 11.0 \selectlanguage{ngerman}×
109/L (4.0 -11.0 × 109/L), lymphopenia 5\%, ESR 50mm / hour, The liver
and kidney function were within normal values. D-dimer 350 ng / ml.
Serum quantitative troponin was 0.5 ng/ml (normal lab value 0-0.6
ng/ml). The ECG showed widespread ST-segment elevation.

The diagnosis was acute pericarditis as he fulfilled two items of ESC
diagnostic criteria for pericarditis (pericardiac chest pain and new
widespread ST-segment elevation) in addition to elevation in
inflammatory markers. The patient received I.V fluids and Ibuprofen
tabs. Due to the current COVID-19 pandemic and lymphopenia, a
nasopharyngeal swab for SARS-CoV-2 was taken to be tested by reverse
transcription-polymerase chain reaction(PCR) and the result came as
positive. The patient was admitted to the isolation centre of COVID-19
and received paracetamol infusion, low molecular weight heparin (LMWH)
75 IU / kg, dexamethasone 6 mg QID, and vitamins supplement.

On the fifth day of admission, the patient developed mild shortness of
breath and dry cough. On physical examination, he was dyspneic and
tachypnoeic, further assessment revealed that the apex beat is difficult
to locate with muffled first and second heart sound, there no added
sounds or murmurs. The ECG showed low voltage in all leads. (Figure 1)
The chest radiograph revealed an enlarged cardiac silhouette and with
the absence of pulmonary infiltrates, and no pleural effusion was
detected. (Figure 2). Subsequently, a transthoracic echocardiogram was
performed which showed a moderate pericardial effusion with no regional
wall motion abnormalities.(Figure 3) The LVEF was 55\%. The patient was
continued on LMWH 75 IU / kg, dexamethasone 6 mg QID, and vitamins
supplement.

\textbf{Discussion:}

The coronavirus infection 2019 (COVID-19), which is caused by
SARS-CoV-2, causes mainly respiratory tract symptoms. While much of the
focus has been on pulmonary complications, emergency clinicians need to
be aware of the cardiovascular complications as well, which can be a
significant contributor to the deaths associated with this disease.

Cardiovascular complications that are associated with COVID-19 include
arrhythmias, acute myocardial infarction, myocarditis, heart failure and
thromboembolic events.

These complications could be explained by many mechanisms such as;
plaque rupture and coronary thrombosis, exaggerated immune response,
direct myocardial injury, systemic inflammation, altered myocardial
demand-supply ratio, electrolyte imbalances or adverse effects of
therapies. \textsuperscript{7}

Acute pericarditis, which is an inflammation of the sac surrounding the
heart, is a rare extrapulmonary complication of COVID-19. Generally, the
aetiology of pericarditis could be classified into infectious and
non-infectious. \textsuperscript{8} They depend on the clinical context
and epidemiological framework. In developing countries, viral infections
represent the most common cause, whereas tuberculosis is the commonest
cause globally.

Generally, it is postulated that viruses can cause pericardial
inflammation via direct cytotoxic effects or immune-mediated
mechanisms.\textsuperscript{9} COVID-19 has been stated to trigger an
exaggerated systemic inflammatory response in certain patients.
\textsuperscript{10}likewise in other viral infections, this
inflammatory response could lead to pericarditis and the consequent
pericardial effusion; however, the exact mechanism is be explained.

According to European Society of Cardiology (ESC) guidelines, the
diagnosis of acute pericarditis depends on the presence of at least two
out of four criteria: pericarditic chest pain, pericardial rub, new
widespread ST-segment elevation or PR depression and new or worsening
pericardial effusion. Elevation of inflammatory markers (white blood
cell count, C-reactive protein and erythrocyte sedimentation rate), and
evidence of pericardial inflammation on computed tomography (CT),
cardiac magnetic resonance (CMR) can support the diagnosis of acute
pericarditis.

The mainstay treatment of acute pericarditis is a high-dose aspirin and
NSAIDs, other options include colchicines. A patient who has
contraindications or failed to respond to first-line therapy may get
benefit from corticosteroid. Using corticosteroid and NSAIDs could
worsen the general condition of COVID-19 patients, which has created a
management dilemma due to the concerns of the safety of using high-dose
aspirin safety in these patients. \textsuperscript{8} To date, there is
no convincing evidence for or against the use of high-dose aspirin in
Covid-19 patients.\textsuperscript{7} The matters were mainly regarding
the use of ibuprofen and there is no compelling evidence available
connecting worsening of COVID-19 patients status with aspirin or other
NSAIDs. To navigate this uncertainty, the Centre for Disease Control and
Prevention (CDC) and the US Food and Drug Administration (FDA) supported
the use of NSAIDs when clinically indicated. Dabbagh et al. reported the
successful use of corticosteroids and colchicine combination in a
patient with cardiac tamponade and COVID-19. \textsuperscript{3}

Predictors of poor prognosis in acute pericarditis include the
following, fever more than 38, large pericardial effusion, subacute
onset, cardiac tamponade and lack of response to NSAID or aspirin after
at least one week of therapy. Therefore, the presence of fever of 38.1 C
in this patient represents one of the poor prognostic features in this
attack of pericarditis.

\textbf{Conclusion:}

Acute pericarditis and pericardial effusion are rare extrapulmonary
presentations of COVID-19, especially without concomitant pulmonary
disease or myocardial injury. A high index of suspicion is necessary to
assure early diagnosis and treatment. Studies are needed to determine
the exact mechanism of acute pericarditis and pericardial effusion in
COVID-19 patients and the optimal therapeutic strategies.

\textbf{Declarations:~}

\textbf{Consent for publication:~}

Written consent for publication has been obtained from the patient.

\textbf{Availability of data and material:}

The data used in this report is available to readers.

\textbf{Conflict of interests:}

The authors declare that there is no conflict of interest.

\textbf{Funding} :

None

\textbf{Acknowledgement:~}

None

\textbf{Author Contribution :}

Waddah Osman: Diagnosed the case and participated in preparing the data.

Abdelmuniem Ahmed: ~Participated in preparing the data and writing the
article.

Omer Elawad:~ Participated in preparing the data and writing the
article.

Ahmed Albashir: Participated in preparing the data and writing the
article.

\textbf{References:}

1.Fried JA, Ramasubbu K, Bhatt R, Topkara VK, Clerkin KJ, Horn E, et al.
The variety of cardiovascular presentations of COVID-19. Circulation
2020 Apr 3. doi: 10.1161/CIRCULATIONAHA.120.047164 {[}Epub ahead of
print{]}.

2. Allam HH, Kinsara AJ, Tuaima T, Alfakih S. Pericardial Fluid in a
COVID-19 Patient: Is It Exudate or Transudate?.~\emph{Eur J Case Rep
Intern Med} . 2020;7(6):001703. Published 2020 May 12.
doi:10.12890/2020\_001703.

3.Dabbagh MF, Aurora L, D'Souza P, Weinmann AJ, Bhargava P, Basir MB.
Cardiac Tamponade Secondary to COVID-19 {[}published online ahead of
print, 2020 Apr 23{]}. JACC Case Rep. 2020;2(9):1326-1330.
doi:10.1016/j.jaccas.2020.04.009.

4.Hua A, O'Gallagher K, Sado D, Byrne J. Life-threatening cardiac
tamponade complicating myo-pericarditis in COVID-19. Eur Heart J.
2020;41(22):2130. doi:10.1093/eurheartj/ehaa253.

5.Purohit R, Kanwal A, Pandit A, et al. Acute Myopericarditis with
Pericardial Effusion and Cardiac Tamponade in a Patient with COVID-19.
Am J Case Rep. 2020;21:e925554. Published 2020 Jul 1.
doi:10.12659/AJCR.925554.

6.Asif T, Kassab K, Iskander F, Alyousef T. Acute Pericarditis and
Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge.
Eur J Case Rep Intern Med. 2020;7(6):001701. Published 2020 May 6.
doi:10.12890/2020\_001701.

7.Russell B, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment
with NSAIDs and corticosteroids: should we be limiting their use in the
clinical setting? Ecancermedicalscience 2020;14:1023.

8.Imazio M Spodick DH Brucato A Trinchero R Adler Y . Controversial
issues in the management of pericardial diseases.
Circulation2010;121:916--928.

9. Adler Y., Charron P., Imazio M. 2015 ESC Guidelines for the diagnosis
and management of pericardial diseases: the Task Force for the Diagnosis
and Management of Pericardial Diseases of the European Society of
Cardiology (ESC) Endorsed by: The European Association for
Cardio-Thoracic Surgery (EACTS) Eur Heart J. 2015;36:2921--2964.

10. Inciardi R.M., Lupi L., Zaccone G. Cardiac involvement in a patient
with coronavirus disease 2019 (COVID-19) JAMA Cardiol. 2020 Mar 27.

\textbf{Figure legends list:}

\textbf{Figure 1:} The electrocardiography (ECG): it showed low voltage
in all leads.\textbf{Figure 2} : Chest X-ray: it showed enlargement of
cardiac outline with the absence of pulmonary infiltrates.

\textbf{Figure 3} : The transthoracic echocardiogram: it showed a
moderate pericardial effusion with no regional wall motion
abnormalities.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1:} The electrocardiography (ECG): it showed low voltage
in all leads.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2} : Chest X-ray: it showed enlargement of cardiac
outline with the absence of pulmonary infiltrates.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 3} : The transthoracic echocardiogram: it showed a
moderate pericardial effusion with no regional wall motion abnormalities

\selectlanguage{english}
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\end{document}

