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.