Background Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). Case presentation A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. Conclusion Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.
【저자키워드】 COVID-19, Cytokine release syndrome, echocardiography, Cardiogenic shock, Therapeutic plasma exchange, Reverse takotsubo cardiomyopathy, Case-report, 【초록키워드】 therapy, Respiratory failure, anticoagulation, intensive care, Antiviral, mechanical ventilation, fatigue, variant, Home isolation, interleukin-6, C-reactive protein, ferritin, oxygen, Prophylactic, RT-PCR, lactate dehydrogenase, ICU, electrocardiogram, Shock, protective antibodies, Critically ill, male, Patient, chest X-ray, USA, change, non-specific, Protective antibody, CRS, Lactate, infusion, Concentration, chest pain, myalgia, Organ failure, Oxygenation, dry cough, help, life-threatening, vasopressors, fraction, fulminant, over, apheresis, System, interstitial, IMPROVE, Course, healthy, elevated, was performed, demonstrated, suggested, discharged, ARF, complicate, Inc., inflammation marker, normalized, progressed, TPE, ventricular, 【제목키워드】 therapeutic, plasma, Cardiomyopathy,