Case Presentation:
A 38-year-old man with a history of URI 10 days before admission and no risk factor for cardiac disease was presented with pleuritic chest pain that radiates to the scapula and shoulders, exacerbated by deep inspiration and in supine position, nausea, diarrhea and cough starting three days prior to admission.
Physical examinations; vital signs included blood pressure of 110/70 mmHg, pulse rate of 87 beats/min, respiratory rate of 23/min, oximetry of 90% on room air, and a temperature of 38.5 °C (101 °F).
The patient’s chest pain improved on the first day of admission and electrocardiography revealed diffuse ST-segment elevation (Figure 1).
Echocardiography showed a reduced ejection fraction (LVEF=45%) and the serum troponin (hsTn) was equal to 36 (normal range: 34). An initial plan for medical treatment of acute pericarditis was in place when the patient was admitted to the hospital.
Infectious diseases consultant added Vancomycin 2gr twice a day and Meropenem 1gr three times a day to the treatment.
A spiral lung CT scan showed no evidence in favor of covid and infectious diseases.
Laboratory evaluations such as viral, inflammatory, and coagulation markers were normal. All hypercoagulability tests (activated protein C resistance, beta-2 glycoprotein antibodies, protein S activity, and homocysteine) were normal.
On the next day of admission, the patient’s pleuritic chest pain changed to typical pain and felt as a feeling of pressure. In addition, serum troponin reached 27185, and SARS-CoV-2 PCR became positive.
ECG showed diffuse ST-segment elevation and increased ST elevation in precordial leads (Figure 2).
Echocardiography indicated a large left ventricle (LV) apical clot size (3.1cm*1.5cm) and moderate LV systolic dysfunction (LVEF 35%).
Due to the rise of serum troponin and LV clots, an intravenous injection of unfractionated heparin was started and the patient underwent angiography. The results disclosed a heavy thrombotic lesion on the left anterior descending artery (Figure 3).
On the 7th day of admission; the patient’s symptoms disappeared gradually, Anticoagulation was switched to Rivaroxaban, and the patient was discharged with aspirin 80 mg, clopidogrel 75mg, and rivaroxaban 15 mg once a day.
During a one-month follow-up, electrocardiography showed T wave inversion in anterior and lateral leads, ST elevation in inferior leads, and Q wave in lateral leads (Figure 4). CTA revealed reduction of thrombus burden in left anterior descending artery (Figure 5).
Based on clinical status and echocardiographic findings, continuation of rivaroxaban 15 mg daily for three months was prescribed.
Additionally, after three months, echocardiography detected a reduced-sized LV clot (2.2cm*0.7cm) with an increased LV systolic function (Figure 6).
In addition, the patient had a favorable evolution and showed stable vital signs, pain improvement, no angina, no dyspnea, and good work ability.