From: SARS-CoV-2 post-infective myocarditis: the tip of COVID-19 immune complications?
What is known? | What need to be clarified? | |
---|---|---|
Diagnosis | ||
Post-infective COVID-19 acute myocarditis diagnosis | Positive SARS-CoV-2 serology [1, 2] SARS-CoV-2 virus detection in nasopharynx may be negative [1, 2] Elevated D-Dimer, ferritin, fibrinogen, and CRP (IL-6), troponins, NT-proBNP [1, 2] Lung CT scan may be suggestive of COVID-19 [1, 2] Clinical signs and symptoms compatible with Kawasaki disease [1, 2] | SARS-CoV-2 virus detection in feces may be prolonged Systemic organ involvement: heart, kidney, liver, polyserositis |
Investigations | ||
Circulating cell phenotyping | No available data on post-infective COVID-19 | Multiple phenotypic signatures have been suggested in COVID-19, but currently there is a significant requirement of data and correlation with prognosis |
Circulating immunoglobulins (quantitative and subclasses) | No available data on post-infective COVID-19 | Normal Ig level is seen in COVID-19, although some report suggest elevated circulating immunoglobulins |
Cardiac imaging | Sub-epicardial edema (T1 gadolinium, T2-weighted) is seen on cardiac magnetic resonance | Defining cardiac magnetic resonance semiology (2018 Lake Louise Criteria) and kinetics |
Autopsy—myocardial biopsy | Presence of lymphocytic myocarditisa Vascularitis and microangiopathy may be presenta | Coronary microangiopathy Immuno-histochemical analysis of coronary arteries, incl. cells phenotypes (neutrophils, cytotoxic CD8 + Lymphocytes, dendritic cells, macrophages) |
Therapy | ||
Intravenous immunoglobulins | Similarly to Kawasaki disease, COVID-19 post-infective acute myocarditis respond to IVIg in most cases unless heart failure may not support important volume transfusion [1, 2] | Controlled trials comparing hemodynamic tolerance of IVIg and IL-1 receptor antagonist is warranted |
IL-1 receptor antagonist | Limited experience suggests that use of Anakinra is well tolerated and clinical response rapid. It may be an alternative to IVIg in depressed myocardial function or in addition if symptoms are refractory to IVIg [1, 2] |