Chest imagingCase Type
Eric Han, MS1; Thanh-Lan Bui, MS4; Joseph Carbone, MS3; Justin Glavis-Bloom, MD; Roozbeh Houshyar, MDPatient
71 years, male
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.
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).
Coronavirus disease-19 is a novel viral pandemic that primarily affects the lungs, causing respiratory symptoms including dry cough and shortness of breath . 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].
Typical COVID-19 symptoms include fever, dry cough, myalgia, and lymphopenia . 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 .
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].
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.
Potential cardiac complications should be monitored in patients with COVID-19 infection. Hydroxychloroquine has been associated with arrhythmias and should be administered with caution.
 Lake MA (2020) What we know so far: COVID-19 current clinical knowledge and
 research. Clinical Medicine (London) 20(2):124–127 (PMID: 32139372)
 Shi S, Qin M, Shen B (2020) Association of Cardiac Injury With Mortality in
 Hospitalized Patients With COVID-19 in Wuhan, China. JAMA (PMID: 32211816)
 Guo T, Fan Y, Chen M (2020) Cardiovascular Implications of Fatal Outcomes of
 Patients With Coronavirus Disease 2019 (COVID-19). JAMA (PMID: 32219356)
 Wong CK, Lam CW, Wu AK (2004) Plasma inflammatory cytokines and
 chemokines in severe acute respiratory syndrome. Clinical & Experimental Immunology
 136:95–103 (PMID: 15030519)
 Huang C, Wang Y, Li X (2020) Clinical features of patients infected with 2019
 novel coronavirus in Wuhan, China. Lancet 395:497–506 (PMID: 31986264)
 Cameron MJ, Bermejo-Martin JF, Danesh A, Muller MP, Kelvin DJ (2008) Human
 immunopathogenesis of severe acute respiratory syndrome (SARS). Virus Research
 133:13–9 (PMID: 17374415)
 Ratliff NB, Estes ML, McMahon JT, Myles JL (1988) Chloroquine-induced
 cardiomyopathy. Archives of Pathology & Laboratory Medicine 112(6):578 (PMID: 3377655)
 Fauchier JP, Fauchier L, Babuty D, Breuillac JC, Cosnay P, Rouesnel P (1993) Drug-
 induced ventricular tachycardia. Arch Mal Coeur Vaiss 86:757–67 (PMID: 8267504)
 Siqueira-Batista R, Ramos Júnior AN, Pessanha BS, Sforza-de-Almeida MP, Potsch DF (1998) Chloroquine and cardiac arrhythmia: case report. East African Medical Journal 75:117–119 (PMID: 9640837)
 Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395(10223):497–506 (PMID: 31986264)
 Hu H, Ma F, Wei X, Fang Y (2020) Coronavirus fulminant myocarditis saved with
 glucocorticoid and human immunoglobulin. European Heart Journal (PMID: 32176300)
 Wang D, Hu B, Hu C (2020) Clinical Characteristics of 138 Hospitalized Patients
 With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 323(11):1061–1069 (PMID: 32031570)
 Giemza-Stokłosa J, Islam MA, Kotyla PJ (2019) Hyperferritinaemia: An Iron Sword of
 Autoimmunity. Current Pharmaceutical Design 25(27):2909–2918 (PMID: 31686632)
 Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N, Diao K, Lin B, Zhu X, Li K, Li S, Shan H, Jacobi A, Chung M (2020) Chest CT Findings in Coronavirus
 Disease-19 (COVID-19): Relationship to Duration of Infection. Radiology (PMID: 32077789).
 Dai WC, Zhang HW, Yu J, Xu HJ, Chen H, Luo SP, Zhang H, Liang LH, Wu XL, Lei
 Y, Lin F (2020) CT Imaging and Differential Diagnosis of COVID-19. Canadian Association of Radiologists Journal 71(2):195–200 (PMID: 32129670)
 Kong W, Agarwal PP (2020) Chest Imaging Appearance of COVID-19 Infection. Radiol Cardiothorac Imaging 2:e200028.