Late cytokine storm following mild COVID-19 infection in three adult patients complicated with fulminant myocarditis

Introduction

Cytokine storm characterized by high concentration of inflammatory cytokines has been described as a serious complication of COVID-19 infection leading to ARDS, multi organ failure and death. Herein we report three cases of Late Cytokine storm , developed 4-6 weeks following mid COVID-19 infection, presenting with fulminant hyper inflammatory response complicated with fulminant myocarditis.

Results

A total of three male young patients at the age of 32, 39 and 46 years old admitted at our hospital due to fever and shortness of breath in addition to other symptoms involving gastrointestinal system. they were all confirmed with COVID-19 four to six weeks prior their admission. their symptoms due to acute phase of COVID-19 was described as mild weakness and fever from which they fully recovered. few hours after admission they all had a rapid deterioration requiring intubation and admission in intensive care unit.Initial workup revealed high inflammatory markers and with elevated troponin levels. echocardiography proved severely reduced biventricular function. one patient was transferred to the catheterization laboratory and connected to Extracorporeal membrane oxygenation (ECMO) after ventricular arrhythmia and prolonged resuscitation. The second patient had to be intubated and went through coronary catheterization with no intervention.A myocardial biopsy proving severe myocarditis with necrosis and macrophage infiltrates was conducted. The third patient needed inotropes support and MRI suggested myocarditis. all patients received immusupprive treatment in different stages. it was noted that early aggressive immunosuppression treatment based on pulse solumedrol lead to early improvement and better outcomes. All three patients’ cardiac function improved few days following treatment. our ECMO patient died of anoxic brain damage and ECMO complications. The other two patients were fully recovered.

Conclusion

Myocarditis can complicate late cytokine reaction despite mild acute COVID-19 illness. Early supportive treatment based on aggressive immunotherapy is the treatment cornerstone.