SlideShare a Scribd company logo
CASE REPORT
CLINICAL CASE
Cardiac Tamponade Secondary
to COVID-19
Mohammed F. Dabbagh, MD,a
Lindsey Aurora, MD,a
Penny D’Souza, DO,a
Allison J. Weinmann, MBBS,b
Pallavi Bhargava, MD,b
Mir B. Basir, DOa
ABSTRACT
A 67-year-old woman presented with upper respiratory symptoms and was diagnosed with coronavirus disease-2019
(COVID-19). She was found to have a large hemorrhagic pericardial effusion with echocardiographic signs of tamponade
and mild left ventricular impairment. Clinical course was complicated by development of takotsubo cardiomyopathy.
She was treated with pericardiocentesis, colchicine, corticosteroids, and hydroxychloroquine, with improvement in
symptoms. (Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep 2020;-:-–-) © 2020 The Authors.
Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
HISTORY OF PRESENTATION
A 67-year-old woman presented to the emergency
department with cough, mild shortness of breath, and
left shoulder pain. Physical exam and radiographic
imaging of the chest were unremarkable (Figure 1). A
nasopharyngeal swab was positive for severe acute
respiratory syndrome-coronavirus-2 (SARS-CoV-2) by
reverse transcription polymerase chain reaction. She
was discharged home due to mild symptoms.
One week after her initial presentation, she
presented with worsening dyspnea and orthopnea.
Physical exam was pertinent for a blood pressure of
118/82 mm Hg, heart rate of 122 beats/min, respi-
ratory rate of 24 breaths/min, temperature of
36.8
C, normal oxygen saturation on room air,
distant heart sounds, and rales at the lung bases
bilaterally.
PAST MEDICAL HISTORY
The patient had a history of nonischemic cardiomy-
opathy with left ventricular ejection fraction (LVEF)
of 15%, diagnosed in 2018 and managed with
guideline-directed medical therapy with improve-
ment in her LVEF to 40%. She had not been not pre-
scribed antiplatelet agents or anticoagulants and had
no history of malignancy or coagulopathy.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis included evolving corona-
virus disease-2019 (COVID-19) pneumonia, acute-on-
LEARNING OBJECTIVES
 To recognize that COVID-19 can have
extrapulmonary manifestations, which can
be readily identified with physical examina-
tion and simple diagnostic studies.
 To identify COVID-19 as a potential etiology
of hemorrhagic pericardial effusion.
ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2020.04.009
From the a
Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan; and the b
Department of Infectious Disease, Henry
Ford Hospital, Detroit, Michigan. The authors have reported that they have no relationships relevant to the contents of this paper
to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ in-
stitutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit
the JACC: Case Reports author instructions page.
Manuscript received April 14, 2020; accepted April 16, 2020.
J A C C : C A S E R E P O R T S V O L . - , N O . - , 2 0 2 0
ª 2 0 2 0 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A N
C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E R
T H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .
chronic heart failure exacerbation, acute
coronary syndrome, acute pulmonary embo-
lism, myocarditis, and pericardial disease.
INVESTIGATIONS
Chest x-ray film and computed tomography
angiogram obtained 1 week prior to admission
were negative for pneumonia or pulmonary
embolism. Upon representation to the hospi-
tal, chest x-ray film demonstrated an enlarged
cardiac silhouette and electrocardiography
(ECG) revealed low voltage in the limb
leads with nonspecific ST-segment changes
(Figure 2). Laboratory testing demonstrated
normal levels of high-sensitivity cardiac
troponin I (cTnI) (18 ng/l; reference range
[RR]: 19 ng/l) and mildly elevated brain
natriuretic peptide (54 pg/ml; RR: 50 pg/ml). Trans-
thoracic echocardiography (TTE) (Videos 1 and 2)
revealed a large pericardial effusion circumferentially
around the entire heart with signs of early right ven-
tricular diastolic collapse, dilated but collapsing infe-
rior vena cava, and mitral valve inflow variation of 31%
on pulsed wave Doppler. LVEF was mildly reduced at
40%, with no regional wall motion abnormalities,
similar to TTE 1 year prior.
MANAGEMENT
Given the patient’s worsening symptoms, rapid
expansion of the effusion over 1 week, and
early echocardiographic findings of tamponade, we
elected to proceed with pericardiocentesis. The
patient could not tolerate lying flat because of
severe coughing spells and emesis, so she under-
went elective intubation and was taken to the
cardiac catheterization laboratory. Pericardiocent-
esis yielded 800 ml of exudative bloody fluid
(fluid lactate dehydrogenase [LDH] 1,697 IU/l, peri-
cardial fluid LDH/serum LDH 0.6). Fluid cytology
was negative for malignant cells. Acid-fast bacilli
smear was negative, and there was no growth on
cultures. Samples of the fluid were frozen in an
effort to test the presence of SARS-CoV-2, which is
currently not available in our center. Serum auto-
immune work-up was negative. In the absence of a
history of malignancy, chest trauma, or coagulop-
athy, we suspected the hemorrhagic effusion to be
secondary to COVID-19. Treatment was started
with hydroxychloroquine along with colchicine
and glucocorticoids given elevated serum inflam-
matory markers: C-reactive protein (15.9 mg/dl;
RR: 0.5 mg/dl), ferritin (593 ng/ml; RR: 11 to
307 ng/ml), D-dimer (6.52 mg/ml; RR: 0.68 mg/ml),
and interlukin-6 (8 pg/ml; RR: #5 pg/ml). Serial TTE
demonstrated resolution of the pericardial effusion;
however, the patient was found to have new
hypokinesis of the apical and periapical walls con-
cerning for takotsubo cardiomyopathy (TTC) (Video
3). This coincided with a rise in cTnI levels to
2,410 (ng/l) and deep T-wave inversions in pre-
cordial leads (V2 to V6) (Figure 3). The patient did
not develop any chest pain or worsening dyspnea.
On the contrary, she reported improvement of
dyspnea and was subsequently discharged from the
hospital.
FIGURE 1 Imaging on Initial Presentation
Chest x-ray film (left) and chest computed tomography (right) showing no acute lung disease. Cardiac silhouette appears normal.
A B B R E V I A T I O N S
A N D A C R O N Y M S
COVID-19 = coronavirus
disease-2019
cTnI = cardiac troponin I
ECG = electrocardiography
LDH = lactate dehydrogenase
LVEF = left ventricular ejection
fraction
RR = reference range
SARS-CoV-2 = severe acute
respiratory syndrome-
coronavirus-2
TTE = transthoracic
echocardiography
TTC = takotsubo
cardiomyopathy
Dabbagh et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0
Cardiac Tamponade Secondary to COVID-19 - 2 0 2 0 : - – -
2
FIGURE 2 Chest X-Ray Film and Electrocardiography on Second Presentation
(Left) Chest x-ray film: enlarged cardiac silhouette. (Right) Electrocardiography: normal sinus rhythm with low-voltage QRS complex in limb leads and nonspecific ST-
segment changes in precordial leads.
FIGURE 3 Electrocardiogram After Pericardiocentesis
Electrocardiography: sinus rhythm with deep T-wave inversions in precordial leads V2 to V6.
J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Dabbagh et al.
- 2 0 2 0 : - – - Cardiac Tamponade Secondary to COVID-19
3
DISCUSSION
SARS-CoV-2 is the novel virus that causes COVID-19
(1). Early studies from Wuhan, China, demonstrated
that patients commonly develop fever, upper respi-
ratory symptoms, and pneumonia (2). As the disease
has spread globally, reports of extrapulmonary man-
ifestations have been frequently identified; however,
pericardial involvement has been rarely reported
(3,4). Here, we report the case of a patient who
developed large symptomatic hemorrhagic pericar-
dial effusion causing cardiac tamponade. There were
no initial signs of cardiac injury or myocardial
involvement, as demonstrated by the absence of cTnI
elevation or wall motion abnormalities on TTE. In
fact, her symptoms were relatively mild until the
development of pericardial effusion.
Viral infections are a common cause of pericarditis
and typically entail a benign clinical course (5). Hem-
orrhagic pericardial effusions have been less
commonly associated with viral infections but have
been reported in coxsackievirus (6). It is hypothesized
that viruses cause pericardial inflammation via direct
cytotoxic effects or via immune-mediated mecha-
nisms (5). COVID-19 has been reported to trigger an
exaggerated systemic inflammatory response in
certain patients; however, details of this response are
not fully understood (3). It is plausible that COVID-19,
similar to other viral infections, elicits an inflamma-
tory response, leading to pericarditis and subsequent
effusion; however, the exact mechanism is unclear.
Hemorrhagic effusions have also been reported in
other inflammatory states such as Dressler’s syn-
drome, which is thought to result from an immune
complex deposition and a subsequent inflammatory
cascade post–myocardial infarction (7,8).
After pericardiocentesis, our patient developed TTC
as evident by TTE, ECG findings, and cTnI elevation.
TTC is a stress-induced cardiomyopathy characterized
by transient apical ballooning with regional wall mo-
tion abnormalities that occur in association with
identifiable emotional or physical stressors including
infections (9). The Mayo Clinic proposed the following
diagnostic criteria for diagnosis of TTC: transient
segmental left ventricular systolic dysfunction,
absence of obstructive coronary artery disease, new
ECG abnormalities or modest cardiac troponin
elevation, and absence of pheochromocytoma or
myocarditis (9). Our patient met these diagnostic
criteria clinically and echocardiogram was consistent
with apical ballooning. Cardiac magnetic resonance
would have definitively ruled out the presence of
myocarditis. However, it was not performed, as the
patient’s condition continued to improve, and we
sought to further avoid nonessential medical testing to
minimize spread of the disease. Acute coronary syn-
drome was unlikely, as coronary angiography from 2
years prior showed no significant coronary artery
disease, and the patient demonstrated no symptoms
of acute coronary syndrome. Although TTC has
been widely reported in the setting of severe
bacterial infections, cases of TTC attributed to viral
infections such as influenza are rare (10). In our case,
troponin elevation and apical hypokinesis occurred
only after intubation and pericardiocentesis; there-
fore, stress from these procedures is also a possible
etiology.
FOLLOW-UP
Our patient received hydroxychloroquine and low-
dose glucocorticoids as per our institutional treat-
ment protocol; however, it is important to note that
currently there are no proven data for efficacy of this
regimen for COVID-19. We also treated our patient with
colchicine, given the elevated inflammatory makers.
The patient was continued on guideline-directed
medical therapy for nonischemic cardiomyopathy
including beta-blockers, angiotensin receptor
blockers, and spironolactone. Repeat TTE prior to
discharge demonstrated stable ejection fraction and
resolution of pericardial effusion.
CONCLUSIONS
We report a rare presentation of COVID-19
infection complicated by a large symptomatic hem-
orrhagic pericardial effusion and development of
TTC.
ADDRESS FOR CORRESPONDENCE: Dr. Mohammed
F. Dabbagh, Heart and Vascular Institute, Henry Ford
Hospital, 2799 West Grand Boulevard, K14, Detroit,
Michigan 48202. E-mail: mdabbag1@hfhs.org.
Twitter: @FerrasDabbagh1.
Dabbagh et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0
Cardiac Tamponade Secondary to COVID-19 - 2 0 2 0 : - – -
4
R E F E R E N C E S
1. WorldHealthOrganization.Namingthecoronavirus
disease (COVID-19) and the virus that causes it.
Available at: https://www.who.int/emergencies/
diseases/novel-coronavirus-2019/technical-guidance/
naming-the-coronavirus-disease-(covid-2019)-and-
the-virus-that-causes-it. Accessed March 31, 2020.
2. Guan WJ, Ni ZY, Hu Y, et al. Clinical charac-
teristics of coronavirus disease 2019 in China.
N Engl J Med 2020 Feb 28 [E-pub ahead of
print].
3. Inciardi RM, Lupi L, Zaccone G, et al. Cardiac
involvement in a patient with coronavirus disease
2019 (COVID-19). JAMA Cardiol 2020 Mar 27
[E-pub ahead of print].
4. Salehi S, Abedi A, Balakrishnan S,
Gholamrezanezhad A. Coronavirus disease 2019
(COVID-19): a systematic review of imaging
findings in 919 patients. AJR Am J Roentgenol
2020 Mar 14 [Epub ahead of print].
5. Adler Y, Charron P, Imazio M, et al. 2015 ESC
Guidelines for the diagnosis and management of
pericardial diseases: the Task Force for the Diag-
nosis 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;36:2921–64.
6. Hamasaki A, Uchida T, Yamashita A, et al. Car-
diac tamponade caused by acute coxsackievirus
infection related pericarditis complicated by aortic
stenosis in a hemodialysis patient: a case report.
Surg Case Rep 2018;4:141.
7. Hertzeanu H, Almog C, Algom M. Cardiac tam-
ponade in Dressler’s syndrome. Case report. Car-
diology 1983;70:31–6.
8. Paelinck B, Dendale PA. Images in clinical
medicine. Cardiac tamponade in Dressler’s syn-
drome. N Engl J Med 2003;348:e8.
9. Scantlebury DC, Prasad A. Diagnosis of takot-
subo cardiomyopathy. Circ J 2014;78:2129–39.
10. Cappelletti S, Ciallella C, Aromatario M, et al.
Takotsubo cardiomyopathy and sepsis. Angiology
2017;68:288–303.
KEY WORDS COVID-19, pericardial
effusion, takotsubo cardiomyopathy,
tamponade
APPENDIX For supplemental videos,
please see the online version of this paper.
J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Dabbagh et al.
- 2 0 2 0 : - – - Cardiac Tamponade Secondary to COVID-19
5

More Related Content

What's hot

Controversies in the management of COVID-19
Controversies  in the management of COVID-19Controversies  in the management of COVID-19
Controversies in the management of COVID-19
PROFESSOR DR. MD. TOUFIQUR RAHMAN
 
Infective endocarditis pdf
Infective endocarditis pdfInfective endocarditis pdf
Infective endocarditis pdf
PGIMER,DR.RML HOSPITAL
 
ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASEACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
Dr. Murtaza Kamal MD,DNB,DrNB Ped Cardiology
 
Covid and heart
Covid and heartCovid and heart
Covid and heart
এ হক
 
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...
asclepiuspdfs
 
Rheumatic Fever and Rheumatic Heart Disease
Rheumatic Fever and Rheumatic Heart DiseaseRheumatic Fever and Rheumatic Heart Disease
Rheumatic Fever and Rheumatic Heart Disease
Kamran Afzal, PhD.
 
Endocarditis presentation to internal medicine2019
Endocarditis presentation to internal medicine2019Endocarditis presentation to internal medicine2019
Endocarditis presentation to internal medicine2019
hospital
 
A Case of Infective Endocarditis
A Case of Infective EndocarditisA Case of Infective Endocarditis
A Case of Infective Endocarditis
Stanley Medical College, Department of Medicine
 
Rheumatic heart disease: Acute Rheumatic Fever
Rheumatic heart disease: Acute Rheumatic FeverRheumatic heart disease: Acute Rheumatic Fever
Rheumatic heart disease: Acute Rheumatic Fever
Pratap Tiwari
 
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...
asclepiuspdfs
 
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...
asclepiuspdfs
 
rheumatic heart disease and fever INDIA
rheumatic heart disease and fever  INDIA rheumatic heart disease and fever  INDIA
rheumatic heart disease and fever INDIA
Karan Rawat
 
Mi and covid cne final
Mi and covid cne finalMi and covid cne final
Mi and covid cne final
Anand Manual
 
Rheumatic Fever by Adnan Bhutto
Rheumatic Fever by Adnan BhuttoRheumatic Fever by Adnan Bhutto
Rheumatic Fever by Adnan Bhutto
Adnan Bhutto
 
Recent literature in rheumatic heart disease
Recent literature in rheumatic heart diseaseRecent literature in rheumatic heart disease
Recent literature in rheumatic heart disease
abhay pota
 
Rheumatic heart disease
Rheumatic heart diseaseRheumatic heart disease
Rheumatic heart disease
https://aiimsbhubaneswar.nic.in/
 
(Acute) Cardiac Care in COVID era
(Acute) Cardiac Care in COVID era (Acute) Cardiac Care in COVID era
(Acute) Cardiac Care in COVID era
Praveen Nagula
 
Right sided valve infective endocarditis by dr adeel
Right sided valve infective endocarditis by dr adeelRight sided valve infective endocarditis by dr adeel
Right sided valve infective endocarditis by dr adeel
West Medicine Ward
 
Rhd 11 4-2016
Rhd 11 4-2016Rhd 11 4-2016
Rhd 11 4-2016
pathologydept
 
Endocarditis 2015
Endocarditis  2015Endocarditis  2015
Endocarditis 2015
samirelansary
 

What's hot (20)

Controversies in the management of COVID-19
Controversies  in the management of COVID-19Controversies  in the management of COVID-19
Controversies in the management of COVID-19
 
Infective endocarditis pdf
Infective endocarditis pdfInfective endocarditis pdf
Infective endocarditis pdf
 
ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASEACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
 
Covid and heart
Covid and heartCovid and heart
Covid and heart
 
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...
 
Rheumatic Fever and Rheumatic Heart Disease
Rheumatic Fever and Rheumatic Heart DiseaseRheumatic Fever and Rheumatic Heart Disease
Rheumatic Fever and Rheumatic Heart Disease
 
Endocarditis presentation to internal medicine2019
Endocarditis presentation to internal medicine2019Endocarditis presentation to internal medicine2019
Endocarditis presentation to internal medicine2019
 
A Case of Infective Endocarditis
A Case of Infective EndocarditisA Case of Infective Endocarditis
A Case of Infective Endocarditis
 
Rheumatic heart disease: Acute Rheumatic Fever
Rheumatic heart disease: Acute Rheumatic FeverRheumatic heart disease: Acute Rheumatic Fever
Rheumatic heart disease: Acute Rheumatic Fever
 
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...
 
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...
 
rheumatic heart disease and fever INDIA
rheumatic heart disease and fever  INDIA rheumatic heart disease and fever  INDIA
rheumatic heart disease and fever INDIA
 
Mi and covid cne final
Mi and covid cne finalMi and covid cne final
Mi and covid cne final
 
Rheumatic Fever by Adnan Bhutto
Rheumatic Fever by Adnan BhuttoRheumatic Fever by Adnan Bhutto
Rheumatic Fever by Adnan Bhutto
 
Recent literature in rheumatic heart disease
Recent literature in rheumatic heart diseaseRecent literature in rheumatic heart disease
Recent literature in rheumatic heart disease
 
Rheumatic heart disease
Rheumatic heart diseaseRheumatic heart disease
Rheumatic heart disease
 
(Acute) Cardiac Care in COVID era
(Acute) Cardiac Care in COVID era (Acute) Cardiac Care in COVID era
(Acute) Cardiac Care in COVID era
 
Right sided valve infective endocarditis by dr adeel
Right sided valve infective endocarditis by dr adeelRight sided valve infective endocarditis by dr adeel
Right sided valve infective endocarditis by dr adeel
 
Rhd 11 4-2016
Rhd 11 4-2016Rhd 11 4-2016
Rhd 11 4-2016
 
Endocarditis 2015
Endocarditis  2015Endocarditis  2015
Endocarditis 2015
 

Similar to Taponamiento cardica covid

A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...
A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...
A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...
Pubrica
 
cardiology template.pptx
cardiology template.pptxcardiology template.pptx
cardiology template.pptx
PusapatiChaitanya
 
Case Presentation
Case PresentationCase Presentation
Case Presentation
Waleed El-Refaey
 
Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...
Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...
Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...
komalicarol
 
Covid and Cardia arrhytmias.pptx
Covid and Cardia arrhytmias.pptxCovid and Cardia arrhytmias.pptx
Covid and Cardia arrhytmias.pptx
WELCINOVIDA1
 
A04500103
A04500103A04500103
A04500103
iosrphr_editor
 
Superior vena cava syndrome
Superior vena cava syndromeSuperior vena cava syndrome
Superior vena cava syndrome
Ranjita Pallavi
 
Med jdy patiluniv_2016_9_4_541_186077
Med jdy patiluniv_2016_9_4_541_186077Med jdy patiluniv_2016_9_4_541_186077
Med jdy patiluniv_2016_9_4_541_186077
Keshri Yadav
 
pulmo HTN.pptx
pulmo HTN.pptxpulmo HTN.pptx
pulmo HTN.pptx
Kemi Adaramola
 
COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...
COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...
COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...
YasserMohammedHassan1
 
Covid 19
Covid 19Covid 19
COVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case Series
COVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case SeriesCOVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case Series
COVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case Series
mahendrareddychirra
 
Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...
Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...
Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...
DrHeena tiwari
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
semualkaira
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
semualkaira
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
semualkaira
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
semualkaira
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
semualkaira
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
semualkaira
 
Transverse Myelitis in a Patient with COVID-19: A Case Report
Transverse Myelitis in a Patient with COVID-19: A Case ReportTransverse Myelitis in a Patient with COVID-19: A Case Report
Transverse Myelitis in a Patient with COVID-19: A Case Report
komalicarol
 

Similar to Taponamiento cardica covid (20)

A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...
A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...
A-CASE-REPORT-OF-ARTERIAL-AND-VENOUS-THROMBOEMBOLIC-ILLNESS-IN-A-COVID-19-PAT...
 
cardiology template.pptx
cardiology template.pptxcardiology template.pptx
cardiology template.pptx
 
Case Presentation
Case PresentationCase Presentation
Case Presentation
 
Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...
Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...
Thrombophylia and COVID-19. A case report of young man 53 years old whith acu...
 
Covid and Cardia arrhytmias.pptx
Covid and Cardia arrhytmias.pptxCovid and Cardia arrhytmias.pptx
Covid and Cardia arrhytmias.pptx
 
A04500103
A04500103A04500103
A04500103
 
Superior vena cava syndrome
Superior vena cava syndromeSuperior vena cava syndrome
Superior vena cava syndrome
 
Med jdy patiluniv_2016_9_4_541_186077
Med jdy patiluniv_2016_9_4_541_186077Med jdy patiluniv_2016_9_4_541_186077
Med jdy patiluniv_2016_9_4_541_186077
 
pulmo HTN.pptx
pulmo HTN.pptxpulmo HTN.pptx
pulmo HTN.pptx
 
COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...
COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...
COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple ...
 
Covid 19
Covid 19Covid 19
Covid 19
 
COVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case Series
COVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case SeriesCOVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case Series
COVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case Series
 
Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...
Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...
Evaluation of Cardiac Complications in Pateint Undergoing COVID 19 Treatment:...
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
 
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower LimbMeadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
Meadows Syndrome as Manifested by Displaced Ischemia of the Lower Limb
 
Transverse Myelitis in a Patient with COVID-19: A Case Report
Transverse Myelitis in a Patient with COVID-19: A Case ReportTransverse Myelitis in a Patient with COVID-19: A Case Report
Transverse Myelitis in a Patient with COVID-19: A Case Report
 

More from Freddy Flores Malpartida

Pronunciamiento cmvp ivermectina
Pronunciamiento cmvp ivermectinaPronunciamiento cmvp ivermectina
Pronunciamiento cmvp ivermectina
Freddy Flores Malpartida
 
Por una nueva convivencia
Por una nueva convivenciaPor una nueva convivencia
Por una nueva convivencia
Freddy Flores Malpartida
 
Open safely nhs
Open safely nhsOpen safely nhs
Open safely nhs
Freddy Flores Malpartida
 
Observacional de ivermectina
Observacional de ivermectinaObservacional de ivermectina
Observacional de ivermectina
Freddy Flores Malpartida
 
covid 19 Fair allocation - Nejm
covid 19 Fair allocation - Nejmcovid 19 Fair allocation - Nejm
covid 19 Fair allocation - Nejm
Freddy Flores Malpartida
 
HIDROXICLOROQUINA nejm
HIDROXICLOROQUINA nejmHIDROXICLOROQUINA nejm
HIDROXICLOROQUINA nejm
Freddy Flores Malpartida
 
MECANISMO DE ACCIÓN covid 19
MECANISMO DE ACCIÓN covid 19MECANISMO DE ACCIÓN covid 19
MECANISMO DE ACCIÓN covid 19
Freddy Flores Malpartida
 
Jama sanders 2020 tto
Jama sanders 2020 ttoJama sanders 2020 tto
Jama sanders 2020 tto
Freddy Flores Malpartida
 
Jama covid19 ieca
Jama covid19 iecaJama covid19 ieca
Jama covid19 ieca
Freddy Flores Malpartida
 
Gastro wuhan 15 abril
Gastro wuhan 15 abrilGastro wuhan 15 abril
Gastro wuhan 15 abril
Freddy Flores Malpartida
 
protección de sars cov2
protección de sars cov2 protección de sars cov2
protección de sars cov2
Freddy Flores Malpartida
 
salud mental COVID dr. bocanegra.pdf
salud mental COVID dr. bocanegra.pdfsalud mental COVID dr. bocanegra.pdf
salud mental COVID dr. bocanegra.pdf
Freddy Flores Malpartida
 
Covid reference01 book
Covid reference01 bookCovid reference01 book
Covid reference01 book
Freddy Flores Malpartida
 
Covid19 Hemoglobina
Covid19 HemoglobinaCovid19 Hemoglobina
Covid19 Hemoglobina
Freddy Flores Malpartida
 
Covid19 mgh treatment guidance 031820
Covid19 mgh treatment guidance 031820Covid19 mgh treatment guidance 031820
Covid19 mgh treatment guidance 031820
Freddy Flores Malpartida
 
Covid 19 jama
Covid 19 jamaCovid 19 jama
Covid 19 and diabetes mellitus what we know how our patients
Covid 19 and diabetes mellitus  what we know how our patientsCovid 19 and diabetes mellitus  what we know how our patients
Covid 19 and diabetes mellitus what we know how our patients
Freddy Flores Malpartida
 
Prediccion covid19 peru mar 24.pdf
Prediccion covid19 peru mar 24.pdfPrediccion covid19 peru mar 24.pdf
Prediccion covid19 peru mar 24.pdf
Freddy Flores Malpartida
 
Manejo del iam covid
Manejo del iam covidManejo del iam covid
Manejo del iam covid
Freddy Flores Malpartida
 
Ivermectina y covid disminuye mortalidad
Ivermectina y covid disminuye mortalidadIvermectina y covid disminuye mortalidad
Ivermectina y covid disminuye mortalidad
Freddy Flores Malpartida
 

More from Freddy Flores Malpartida (20)

Pronunciamiento cmvp ivermectina
Pronunciamiento cmvp ivermectinaPronunciamiento cmvp ivermectina
Pronunciamiento cmvp ivermectina
 
Por una nueva convivencia
Por una nueva convivenciaPor una nueva convivencia
Por una nueva convivencia
 
Open safely nhs
Open safely nhsOpen safely nhs
Open safely nhs
 
Observacional de ivermectina
Observacional de ivermectinaObservacional de ivermectina
Observacional de ivermectina
 
covid 19 Fair allocation - Nejm
covid 19 Fair allocation - Nejmcovid 19 Fair allocation - Nejm
covid 19 Fair allocation - Nejm
 
HIDROXICLOROQUINA nejm
HIDROXICLOROQUINA nejmHIDROXICLOROQUINA nejm
HIDROXICLOROQUINA nejm
 
MECANISMO DE ACCIÓN covid 19
MECANISMO DE ACCIÓN covid 19MECANISMO DE ACCIÓN covid 19
MECANISMO DE ACCIÓN covid 19
 
Jama sanders 2020 tto
Jama sanders 2020 ttoJama sanders 2020 tto
Jama sanders 2020 tto
 
Jama covid19 ieca
Jama covid19 iecaJama covid19 ieca
Jama covid19 ieca
 
Gastro wuhan 15 abril
Gastro wuhan 15 abrilGastro wuhan 15 abril
Gastro wuhan 15 abril
 
protección de sars cov2
protección de sars cov2 protección de sars cov2
protección de sars cov2
 
salud mental COVID dr. bocanegra.pdf
salud mental COVID dr. bocanegra.pdfsalud mental COVID dr. bocanegra.pdf
salud mental COVID dr. bocanegra.pdf
 
Covid reference01 book
Covid reference01 bookCovid reference01 book
Covid reference01 book
 
Covid19 Hemoglobina
Covid19 HemoglobinaCovid19 Hemoglobina
Covid19 Hemoglobina
 
Covid19 mgh treatment guidance 031820
Covid19 mgh treatment guidance 031820Covid19 mgh treatment guidance 031820
Covid19 mgh treatment guidance 031820
 
Covid 19 jama
Covid 19 jamaCovid 19 jama
Covid 19 jama
 
Covid 19 and diabetes mellitus what we know how our patients
Covid 19 and diabetes mellitus  what we know how our patientsCovid 19 and diabetes mellitus  what we know how our patients
Covid 19 and diabetes mellitus what we know how our patients
 
Prediccion covid19 peru mar 24.pdf
Prediccion covid19 peru mar 24.pdfPrediccion covid19 peru mar 24.pdf
Prediccion covid19 peru mar 24.pdf
 
Manejo del iam covid
Manejo del iam covidManejo del iam covid
Manejo del iam covid
 
Ivermectina y covid disminuye mortalidad
Ivermectina y covid disminuye mortalidadIvermectina y covid disminuye mortalidad
Ivermectina y covid disminuye mortalidad
 

Recently uploaded

buy oxycodone online at chemworldstore.net
buy oxycodone online at chemworldstore.netbuy oxycodone online at chemworldstore.net
buy oxycodone online at chemworldstore.net
luciatcupups
 
Acute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdfAcute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdf
RawanAlakwaa
 
Girls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in CityGirls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in City
snehamittal#G05
 
Diagnosis and treatment planning in complete denture.pptx
Diagnosis and treatment planning in complete denture.pptxDiagnosis and treatment planning in complete denture.pptx
Diagnosis and treatment planning in complete denture.pptx
SatvikaPrasad
 
How Virtual Medical Assistants Improve Patient Engagement.pdf
How Virtual Medical Assistants Improve Patient Engagement.pdfHow Virtual Medical Assistants Improve Patient Engagement.pdf
How Virtual Medical Assistants Improve Patient Engagement.pdf
johnmark49490
 
The Connection Between Physical and Mental Well-Being.pptx
The Connection Between Physical and Mental Well-Being.pptxThe Connection Between Physical and Mental Well-Being.pptx
The Connection Between Physical and Mental Well-Being.pptx
MartaLoveguard
 
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
saroni night girls
 
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
pinkichadda23 #v08
 
nhs fpx 4000 assessment 2 applying research skills.pdf
nhs fpx 4000 assessment 2 applying research skills.pdfnhs fpx 4000 assessment 2 applying research skills.pdf
nhs fpx 4000 assessment 2 applying research skills.pdf
aleyna0069
 
SMET (Self-Management of Excessive Tension) Cyclic Meditation.pptxv.pptx
SMET (Self-Management of Excessive Tension)  Cyclic Meditation.pptxv.pptxSMET (Self-Management of Excessive Tension)  Cyclic Meditation.pptxv.pptx
SMET (Self-Management of Excessive Tension) Cyclic Meditation.pptxv.pptx
Karuna Yoga Vidya Peetham
 
Shampoo - cosmetics B.pharm mpharam.pptx
Shampoo - cosmetics B.pharm mpharam.pptxShampoo - cosmetics B.pharm mpharam.pptx
Shampoo - cosmetics B.pharm mpharam.pptx
G.M.R ACADEMY G.M.R
 
Live Like Aubreigh Wings Hat Live Like Aubreigh Wings Hat
Live Like Aubreigh Wings Hat Live Like Aubreigh Wings HatLive Like Aubreigh Wings Hat Live Like Aubreigh Wings Hat
Live Like Aubreigh Wings Hat Live Like Aubreigh Wings Hat
exgf28
 
Cyberattacks on Healthcare Systemss.pptx
Cyberattacks on Healthcare Systemss.pptxCyberattacks on Healthcare Systemss.pptx
Cyberattacks on Healthcare Systemss.pptx
JoeOrlando16
 
ppt on National health mission copy - pptx
ppt on National health mission copy - pptxppt on National health mission copy - pptx
ppt on National health mission copy - pptx
AbinanthanLekhashree
 
Yoga Philosophy Lifestyle , ethics Teacher Training Certificate Course
Yoga Philosophy Lifestyle , ethics Teacher Training Certificate CourseYoga Philosophy Lifestyle , ethics Teacher Training Certificate Course
Yoga Philosophy Lifestyle , ethics Teacher Training Certificate Course
Karuna Yoga Vidya Peetham
 
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdfVisual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
Occupational Therapist
 
Apcalis Sx 20 Mg Oral Jelly July 2024.pdf
Apcalis Sx 20 Mg Oral Jelly July 2024.pdfApcalis Sx 20 Mg Oral Jelly July 2024.pdf
Apcalis Sx 20 Mg Oral Jelly July 2024.pdf
cenforceonlinestoreu
 
Girls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in CityGirls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in City
snehamittal#G05
 
Extraction Vs non exraction in orthodontics.pptx
Extraction Vs  non exraction in orthodontics.pptxExtraction Vs  non exraction in orthodontics.pptx
Extraction Vs non exraction in orthodontics.pptx
Anagha Prasad
 
Therapeutic Diets Applied Nutrition and Dietics in BSc Nursing
Therapeutic Diets Applied Nutrition and Dietics in BSc NursingTherapeutic Diets Applied Nutrition and Dietics in BSc Nursing
Therapeutic Diets Applied Nutrition and Dietics in BSc Nursing
MKSSS BTINE
 

Recently uploaded (20)

buy oxycodone online at chemworldstore.net
buy oxycodone online at chemworldstore.netbuy oxycodone online at chemworldstore.net
buy oxycodone online at chemworldstore.net
 
Acute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdfAcute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdf
 
Girls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in CityGirls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Thane 000XX00000 Provide Best And Top Girl Service And No1 in City
 
Diagnosis and treatment planning in complete denture.pptx
Diagnosis and treatment planning in complete denture.pptxDiagnosis and treatment planning in complete denture.pptx
Diagnosis and treatment planning in complete denture.pptx
 
How Virtual Medical Assistants Improve Patient Engagement.pdf
How Virtual Medical Assistants Improve Patient Engagement.pdfHow Virtual Medical Assistants Improve Patient Engagement.pdf
How Virtual Medical Assistants Improve Patient Engagement.pdf
 
The Connection Between Physical and Mental Well-Being.pptx
The Connection Between Physical and Mental Well-Being.pptxThe Connection Between Physical and Mental Well-Being.pptx
The Connection Between Physical and Mental Well-Being.pptx
 
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
 
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
 
nhs fpx 4000 assessment 2 applying research skills.pdf
nhs fpx 4000 assessment 2 applying research skills.pdfnhs fpx 4000 assessment 2 applying research skills.pdf
nhs fpx 4000 assessment 2 applying research skills.pdf
 
SMET (Self-Management of Excessive Tension) Cyclic Meditation.pptxv.pptx
SMET (Self-Management of Excessive Tension)  Cyclic Meditation.pptxv.pptxSMET (Self-Management of Excessive Tension)  Cyclic Meditation.pptxv.pptx
SMET (Self-Management of Excessive Tension) Cyclic Meditation.pptxv.pptx
 
Shampoo - cosmetics B.pharm mpharam.pptx
Shampoo - cosmetics B.pharm mpharam.pptxShampoo - cosmetics B.pharm mpharam.pptx
Shampoo - cosmetics B.pharm mpharam.pptx
 
Live Like Aubreigh Wings Hat Live Like Aubreigh Wings Hat
Live Like Aubreigh Wings Hat Live Like Aubreigh Wings HatLive Like Aubreigh Wings Hat Live Like Aubreigh Wings Hat
Live Like Aubreigh Wings Hat Live Like Aubreigh Wings Hat
 
Cyberattacks on Healthcare Systemss.pptx
Cyberattacks on Healthcare Systemss.pptxCyberattacks on Healthcare Systemss.pptx
Cyberattacks on Healthcare Systemss.pptx
 
ppt on National health mission copy - pptx
ppt on National health mission copy - pptxppt on National health mission copy - pptx
ppt on National health mission copy - pptx
 
Yoga Philosophy Lifestyle , ethics Teacher Training Certificate Course
Yoga Philosophy Lifestyle , ethics Teacher Training Certificate CourseYoga Philosophy Lifestyle , ethics Teacher Training Certificate Course
Yoga Philosophy Lifestyle , ethics Teacher Training Certificate Course
 
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdfVisual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
 
Apcalis Sx 20 Mg Oral Jelly July 2024.pdf
Apcalis Sx 20 Mg Oral Jelly July 2024.pdfApcalis Sx 20 Mg Oral Jelly July 2024.pdf
Apcalis Sx 20 Mg Oral Jelly July 2024.pdf
 
Girls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in CityGirls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in City
Girls Call Delhi 000XX00000 Provide Best And Top Girl Service And No1 in City
 
Extraction Vs non exraction in orthodontics.pptx
Extraction Vs  non exraction in orthodontics.pptxExtraction Vs  non exraction in orthodontics.pptx
Extraction Vs non exraction in orthodontics.pptx
 
Therapeutic Diets Applied Nutrition and Dietics in BSc Nursing
Therapeutic Diets Applied Nutrition and Dietics in BSc NursingTherapeutic Diets Applied Nutrition and Dietics in BSc Nursing
Therapeutic Diets Applied Nutrition and Dietics in BSc Nursing
 

Taponamiento cardica covid

  • 1. CASE REPORT CLINICAL CASE Cardiac Tamponade Secondary to COVID-19 Mohammed F. Dabbagh, MD,a Lindsey Aurora, MD,a Penny D’Souza, DO,a Allison J. Weinmann, MBBS,b Pallavi Bhargava, MD,b Mir B. Basir, DOa ABSTRACT A 67-year-old woman presented with upper respiratory symptoms and was diagnosed with coronavirus disease-2019 (COVID-19). She was found to have a large hemorrhagic pericardial effusion with echocardiographic signs of tamponade and mild left ventricular impairment. Clinical course was complicated by development of takotsubo cardiomyopathy. She was treated with pericardiocentesis, colchicine, corticosteroids, and hydroxychloroquine, with improvement in symptoms. (Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep 2020;-:-–-) © 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). HISTORY OF PRESENTATION A 67-year-old woman presented to the emergency department with cough, mild shortness of breath, and left shoulder pain. Physical exam and radiographic imaging of the chest were unremarkable (Figure 1). A nasopharyngeal swab was positive for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) by reverse transcription polymerase chain reaction. She was discharged home due to mild symptoms. One week after her initial presentation, she presented with worsening dyspnea and orthopnea. Physical exam was pertinent for a blood pressure of 118/82 mm Hg, heart rate of 122 beats/min, respi- ratory rate of 24 breaths/min, temperature of 36.8 C, normal oxygen saturation on room air, distant heart sounds, and rales at the lung bases bilaterally. PAST MEDICAL HISTORY The patient had a history of nonischemic cardiomy- opathy with left ventricular ejection fraction (LVEF) of 15%, diagnosed in 2018 and managed with guideline-directed medical therapy with improve- ment in her LVEF to 40%. She had not been not pre- scribed antiplatelet agents or anticoagulants and had no history of malignancy or coagulopathy. DIFFERENTIAL DIAGNOSIS The differential diagnosis included evolving corona- virus disease-2019 (COVID-19) pneumonia, acute-on- LEARNING OBJECTIVES To recognize that COVID-19 can have extrapulmonary manifestations, which can be readily identified with physical examina- tion and simple diagnostic studies. To identify COVID-19 as a potential etiology of hemorrhagic pericardial effusion. ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2020.04.009 From the a Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan; and the b Department of Infectious Disease, Henry Ford Hospital, Detroit, Michigan. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ in- stitutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page. Manuscript received April 14, 2020; accepted April 16, 2020. J A C C : C A S E R E P O R T S V O L . - , N O . - , 2 0 2 0 ª 2 0 2 0 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E R T H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .
  • 2. chronic heart failure exacerbation, acute coronary syndrome, acute pulmonary embo- lism, myocarditis, and pericardial disease. INVESTIGATIONS Chest x-ray film and computed tomography angiogram obtained 1 week prior to admission were negative for pneumonia or pulmonary embolism. Upon representation to the hospi- tal, chest x-ray film demonstrated an enlarged cardiac silhouette and electrocardiography (ECG) revealed low voltage in the limb leads with nonspecific ST-segment changes (Figure 2). Laboratory testing demonstrated normal levels of high-sensitivity cardiac troponin I (cTnI) (18 ng/l; reference range [RR]: 19 ng/l) and mildly elevated brain natriuretic peptide (54 pg/ml; RR: 50 pg/ml). Trans- thoracic echocardiography (TTE) (Videos 1 and 2) revealed a large pericardial effusion circumferentially around the entire heart with signs of early right ven- tricular diastolic collapse, dilated but collapsing infe- rior vena cava, and mitral valve inflow variation of 31% on pulsed wave Doppler. LVEF was mildly reduced at 40%, with no regional wall motion abnormalities, similar to TTE 1 year prior. MANAGEMENT Given the patient’s worsening symptoms, rapid expansion of the effusion over 1 week, and early echocardiographic findings of tamponade, we elected to proceed with pericardiocentesis. The patient could not tolerate lying flat because of severe coughing spells and emesis, so she under- went elective intubation and was taken to the cardiac catheterization laboratory. Pericardiocent- esis yielded 800 ml of exudative bloody fluid (fluid lactate dehydrogenase [LDH] 1,697 IU/l, peri- cardial fluid LDH/serum LDH 0.6). Fluid cytology was negative for malignant cells. Acid-fast bacilli smear was negative, and there was no growth on cultures. Samples of the fluid were frozen in an effort to test the presence of SARS-CoV-2, which is currently not available in our center. Serum auto- immune work-up was negative. In the absence of a history of malignancy, chest trauma, or coagulop- athy, we suspected the hemorrhagic effusion to be secondary to COVID-19. Treatment was started with hydroxychloroquine along with colchicine and glucocorticoids given elevated serum inflam- matory markers: C-reactive protein (15.9 mg/dl; RR: 0.5 mg/dl), ferritin (593 ng/ml; RR: 11 to 307 ng/ml), D-dimer (6.52 mg/ml; RR: 0.68 mg/ml), and interlukin-6 (8 pg/ml; RR: #5 pg/ml). Serial TTE demonstrated resolution of the pericardial effusion; however, the patient was found to have new hypokinesis of the apical and periapical walls con- cerning for takotsubo cardiomyopathy (TTC) (Video 3). This coincided with a rise in cTnI levels to 2,410 (ng/l) and deep T-wave inversions in pre- cordial leads (V2 to V6) (Figure 3). The patient did not develop any chest pain or worsening dyspnea. On the contrary, she reported improvement of dyspnea and was subsequently discharged from the hospital. FIGURE 1 Imaging on Initial Presentation Chest x-ray film (left) and chest computed tomography (right) showing no acute lung disease. Cardiac silhouette appears normal. A B B R E V I A T I O N S A N D A C R O N Y M S COVID-19 = coronavirus disease-2019 cTnI = cardiac troponin I ECG = electrocardiography LDH = lactate dehydrogenase LVEF = left ventricular ejection fraction RR = reference range SARS-CoV-2 = severe acute respiratory syndrome- coronavirus-2 TTE = transthoracic echocardiography TTC = takotsubo cardiomyopathy Dabbagh et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Cardiac Tamponade Secondary to COVID-19 - 2 0 2 0 : - – - 2
  • 3. FIGURE 2 Chest X-Ray Film and Electrocardiography on Second Presentation (Left) Chest x-ray film: enlarged cardiac silhouette. (Right) Electrocardiography: normal sinus rhythm with low-voltage QRS complex in limb leads and nonspecific ST- segment changes in precordial leads. FIGURE 3 Electrocardiogram After Pericardiocentesis Electrocardiography: sinus rhythm with deep T-wave inversions in precordial leads V2 to V6. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Dabbagh et al. - 2 0 2 0 : - – - Cardiac Tamponade Secondary to COVID-19 3
  • 4. DISCUSSION SARS-CoV-2 is the novel virus that causes COVID-19 (1). Early studies from Wuhan, China, demonstrated that patients commonly develop fever, upper respi- ratory symptoms, and pneumonia (2). As the disease has spread globally, reports of extrapulmonary man- ifestations have been frequently identified; however, pericardial involvement has been rarely reported (3,4). Here, we report the case of a patient who developed large symptomatic hemorrhagic pericar- dial effusion causing cardiac tamponade. There were no initial signs of cardiac injury or myocardial involvement, as demonstrated by the absence of cTnI elevation or wall motion abnormalities on TTE. In fact, her symptoms were relatively mild until the development of pericardial effusion. Viral infections are a common cause of pericarditis and typically entail a benign clinical course (5). Hem- orrhagic pericardial effusions have been less commonly associated with viral infections but have been reported in coxsackievirus (6). It is hypothesized that viruses cause pericardial inflammation via direct cytotoxic effects or via immune-mediated mecha- nisms (5). COVID-19 has been reported to trigger an exaggerated systemic inflammatory response in certain patients; however, details of this response are not fully understood (3). It is plausible that COVID-19, similar to other viral infections, elicits an inflamma- tory response, leading to pericarditis and subsequent effusion; however, the exact mechanism is unclear. Hemorrhagic effusions have also been reported in other inflammatory states such as Dressler’s syn- drome, which is thought to result from an immune complex deposition and a subsequent inflammatory cascade post–myocardial infarction (7,8). After pericardiocentesis, our patient developed TTC as evident by TTE, ECG findings, and cTnI elevation. TTC is a stress-induced cardiomyopathy characterized by transient apical ballooning with regional wall mo- tion abnormalities that occur in association with identifiable emotional or physical stressors including infections (9). The Mayo Clinic proposed the following diagnostic criteria for diagnosis of TTC: transient segmental left ventricular systolic dysfunction, absence of obstructive coronary artery disease, new ECG abnormalities or modest cardiac troponin elevation, and absence of pheochromocytoma or myocarditis (9). Our patient met these diagnostic criteria clinically and echocardiogram was consistent with apical ballooning. Cardiac magnetic resonance would have definitively ruled out the presence of myocarditis. However, it was not performed, as the patient’s condition continued to improve, and we sought to further avoid nonessential medical testing to minimize spread of the disease. Acute coronary syn- drome was unlikely, as coronary angiography from 2 years prior showed no significant coronary artery disease, and the patient demonstrated no symptoms of acute coronary syndrome. Although TTC has been widely reported in the setting of severe bacterial infections, cases of TTC attributed to viral infections such as influenza are rare (10). In our case, troponin elevation and apical hypokinesis occurred only after intubation and pericardiocentesis; there- fore, stress from these procedures is also a possible etiology. FOLLOW-UP Our patient received hydroxychloroquine and low- dose glucocorticoids as per our institutional treat- ment protocol; however, it is important to note that currently there are no proven data for efficacy of this regimen for COVID-19. We also treated our patient with colchicine, given the elevated inflammatory makers. The patient was continued on guideline-directed medical therapy for nonischemic cardiomyopathy including beta-blockers, angiotensin receptor blockers, and spironolactone. Repeat TTE prior to discharge demonstrated stable ejection fraction and resolution of pericardial effusion. CONCLUSIONS We report a rare presentation of COVID-19 infection complicated by a large symptomatic hem- orrhagic pericardial effusion and development of TTC. ADDRESS FOR CORRESPONDENCE: Dr. Mohammed F. Dabbagh, Heart and Vascular Institute, Henry Ford Hospital, 2799 West Grand Boulevard, K14, Detroit, Michigan 48202. E-mail: mdabbag1@hfhs.org. Twitter: @FerrasDabbagh1. Dabbagh et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Cardiac Tamponade Secondary to COVID-19 - 2 0 2 0 : - – - 4
  • 5. R E F E R E N C E S 1. WorldHealthOrganization.Namingthecoronavirus disease (COVID-19) and the virus that causes it. Available at: https://www.who.int/emergencies/ diseases/novel-coronavirus-2019/technical-guidance/ naming-the-coronavirus-disease-(covid-2019)-and- the-virus-that-causes-it. Accessed March 31, 2020. 2. Guan WJ, Ni ZY, Hu Y, et al. Clinical charac- teristics of coronavirus disease 2019 in China. N Engl J Med 2020 Feb 28 [E-pub ahead of print]. 3. Inciardi RM, Lupi L, Zaccone G, et al. Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020 Mar 27 [E-pub ahead of print]. 4. Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID-19): a systematic review of imaging findings in 919 patients. AJR Am J Roentgenol 2020 Mar 14 [Epub ahead of print]. 5. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: the Task Force for the Diag- nosis 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;36:2921–64. 6. Hamasaki A, Uchida T, Yamashita A, et al. Car- diac tamponade caused by acute coxsackievirus infection related pericarditis complicated by aortic stenosis in a hemodialysis patient: a case report. Surg Case Rep 2018;4:141. 7. Hertzeanu H, Almog C, Algom M. Cardiac tam- ponade in Dressler’s syndrome. Case report. Car- diology 1983;70:31–6. 8. Paelinck B, Dendale PA. Images in clinical medicine. Cardiac tamponade in Dressler’s syn- drome. N Engl J Med 2003;348:e8. 9. Scantlebury DC, Prasad A. Diagnosis of takot- subo cardiomyopathy. Circ J 2014;78:2129–39. 10. Cappelletti S, Ciallella C, Aromatario M, et al. Takotsubo cardiomyopathy and sepsis. Angiology 2017;68:288–303. KEY WORDS COVID-19, pericardial effusion, takotsubo cardiomyopathy, tamponade APPENDIX For supplemental videos, please see the online version of this paper. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Dabbagh et al. - 2 0 2 0 : - – - Cardiac Tamponade Secondary to COVID-19 5