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Table 1 What is known and how to further proceed with COVID-19 post-infective myocarditis?

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]
Abdominal symptoms [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]
  1. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; CRP, C-reactive protein; BNP, brain natriuretic peptide; cluster of differentiation-8; IL-6, interleukin 6; COVID-19, coronavirus infection disease 2019; Ig, immunoglobulins; CD8, cluster of differentiation 8; IVIg, intravenous immunoglobulins
  2. aAutopsy and endomyocardial biopsy findings are issued from COVID-19 patients [7, 8]