SARS-COV-2 AND INFECTIVE ENDOCARDITIS: A CAUSE OF NON-ISCHEMIC ST-SEGMENT ELEVATION
Omar Leonards, MD and Martin Marak, MD
ABSTRACT: Acute substernal chest pain with diffuse ST-segment elevation and PR-segment depression is a peculiar presentation of both infective endocarditis and SARS-CoV-2 infection. This case presentation of inferior and anterolateral ST-segment elevation with PR-depression was initially concerning for an acute obstructive coronary thrombus. Subsequently, a diagnosis of COVID-19 myopericarditis with coexistent infective endocarditis was made. We therefore will review the pathophysiology of SARS-CoV-2 and infective endocarditis as a cause of cardiac injury along with mimickers of an acute myocardial infarction.
CASE REPORT: In July of 2020, a 66-year-old male with a past medical history of type 2 diabetes mellitus, hypertension, and prostate cancer, status-post recent prostatectomy, presented with a chief complaint of acute onset, non- radiating, substernal chest discomfort associated with diaphoresis and dyspnea. He denied recent fevers, cough, anosmia, ageusia, malaise, gastrointestinal symptoms, recent illness, ill contacts, and had a negative SARS-CoV-2 screen seven days before presentation. on presentation were a temperature of 36.8 °C, a heart rate of 120 beats per minute, a blood pressure of 138/86 mmHg, and oxygen saturation of 97% on room air. Physical examination was notable for an ill appearance and tachycardia. An electrocardiogram obtained during triage demonstrated inferior and anterolateral ST-segment elevation with PR-depression (Figure 1). Emergency cardiac catheterization was performed and demonstrated no significant coronary disease or ventriculardysfunction.Labevaluation, which returned during cardiac The patient’s vital signs catheterization, was remarkable for a leukocytosis of 31.1 x 1000/uL, acute renal injury with a creatinine of 3.73 mg/dL, peak troponin of 0.12 ng/ ml, and hyperkalemia of 5.6 mmol/L. SARS-CoV-2 PCR returned positive six hours later. Clinically the patient
appeared septic and vancomycin with ceftriaxone was initiated after blood cultures were obtained. The following day the blood cultures grew gram-positive cocci. A transthoracic echocardiogram was performed revealing a circumferential pericardial effusion without evidence of cardiac tamponade or valvular vegetations. Speciation of the blood cultures revealed Group G Streptococcus and antibiotic coverage was narrowed to intravenous ceftriaxone. The patient’s blood cultures cleared at 48 hours and he was discharged five days after presentation. He returned 11 days after discharge with worsening lower extremity weakness, generalized malaise, and severe lumbar pain. Magnetic resonance imaging of the lumbar spine revealed osteomyelitis
and discitis at L3-S1 and a small L5 paraspinal epidural abscess. Repeat transthoracic echocardiogram was performed and revealed a tricuspid valve vegetation. Review of the patient’s prior echocardiogram revealed a vegetation on the tricuspid valve that was not initially detected. Subsequent transesophageal echocardiogram found large mobile vegetations on multiple tricuspid leaflets and features concerning for old vegetations involving the anterior and posterior leaflets of the mitral valve. After multispecialty collaboration, the patient was treated with outpatient intravenous antibiotic therapy. ■
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Figure 1. Diffuse PR-segment depression and ST-segment elevation appreciated throughout the inferior and anterolateral leads.
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J LA MED SOC | VOL 173 | SPRING 2021
J LA MED SOC | VOL 173 | SPRING 2021
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