CASE 16883 Published on 14.07.2020

COVID-19 infection with new onset atrial fibrillation

Section

Chest imaging

Case Type

Clinical Cases

Authors

Eric Han, MS1; Thanh-Lan Bui, MS4; Joseph Carbone, MS3; Justin Glavis-Bloom, MD; Roozbeh Houshyar, MD

University of California Irvine, Orange, CA USA

Patient

71 years, male

Categories
Area of Interest Respiratory system ; Imaging Technique CT
Clinical History

A 71-year-old male with no known past medical history presented to the emergency department with fever (39.1°C), cough, shortness of breath, and myalgias for one week. Laboratory studies were remarkable for lymphopenia (0.4´103/mL, normal range 0.9´103/mL – 3.3´103/mL), elevated c-reactive protein, elevated ferritin, elevated interleukin-6, elevated d-dimer, and elevated procalcitonin.

Imaging Findings

AP chest x-ray on admission demonstrated bilateral perihilar and peribronchial thickening with perihilar opacities (Fig. 1).

Non-contrast chest CT on admission demonstrated multiple patchy, peripheral-predominant ground-glass and consolidative opacities. A “crazy-paving” appearance associated with interlobular septal thickening was noted.
There was no significant intrathoracic or axillary lymphadenopathy (Figs. 2a-d).

Discussion

Background
Coronavirus disease-19 is a novel viral pandemic that primarily affects the lungs, causing respiratory symptoms including dry cough and shortness of breath [1]. However, recently there has been an increasing number of cardiac complications reported in patients with COVID-19 infection [2, 3]. The mechanism of myocardial injury in these patients is hypothesized to be the onset of cytokine storm in response to infection [4–6]. In addition, hydroxychloroquine, an antimalarial drug used to treat some severe cases of COVID-19, has been shown to increase atrioventricular depolarization length, potentially leading to drug-induced atrial and ventricular arrhythmias [7–9].

Clinical Perspective
Typical COVID-19 symptoms include fever, dry cough, myalgia, and lymphopenia [10]. Recent cases suggest that myocardial disease and injury may be a consequence of a COVID-19 induced cytokine storm [11, 12]. Elevated ferritin levels are associated with cytokine storm onset, which may predict myocardial damage related to severe inflammatory responses [13].

Imaging Perspective
Characteristic computed tomography (CT) findings for COVID-19 become more apparent as the disease progresses and may include multilobar ground-glass opacities and a crazy-paving pattern [14, 15]. CT may be more sensitive than chest x-ray for detection of classic COVID-19 findings, including ground-glass opacities [14–16].

Outcome
COVID-19 RT-PCR returned positive. On day two of admission, the patient was started on hydroxychloroquine. On day six of admission, he developed new-onset atrial fibrillation with rapid ventricular rate, requiring initiation of a beta-blocker for rate control.

Teaching Points
Potential cardiac complications should be monitored in patients with COVID-19 infection. Hydroxychloroquine has been associated with arrhythmias and should be administered with caution.

Differential Diagnosis List
Coronavirus disease-19 (COVID-19)
Influenza pneumonia
Multifocal bacterial pneumonia
Cryptogenic Organizing Pneumonia
Acute Respiratory Distress Syndrome (ARDS)
Final Diagnosis
Coronavirus disease-19 (COVID-19)
Case information
URL: https://www.eurorad.org/case/16883
ISSN: 1563-4086