Case Report - Volume 2 - Issue 6
Atrioventricular block: Circumstance of discovering of covid 19
I Kooli*1; A Aouam1; W Marrakchi1; H Denguir2; A Toumi1; C Loussaief1; M Chakroun1
1Department of Infectious Diseases CHU Fattouma Bourguiba, Monastir, Tunisia.
2Cardiology Department Gabes Regional Hospital, Tunisia.
Received Date : Nov 10, 2022
Accepted Date : Dec 09, 2022
Published Date: Dec 31, 2022
Copyright:© Ikbel kooli 2022
*Corresponding Author : Ikbel kooli, Department of Infectious Diseases CHU Fattouma Bourguiba, Monastir, Tunisia.
Email: Kooli.ikbel@gmail.com
DOI: Doi.org/10.55920/2771-019X/1336
Abstract
Background: In Tunisia the first case was diagnosed on march 2020. Several were the clinical manifestations. Cardiovascular system is frequently affected. In this article we describe the case of a patient that atrioventricular block was the circumstance of discovering of Covid 19.
Case: A 53-year-old woman, with a history of hypertension, was hospitalized for atrioventricular block. Covid 19 test was done and was positive. Patient was asymptomatic. ECG showed Type 2 AV block with junctional escape rhythm at 39 b.p.m. Biological tests were normal. The outcome was favorable and patient was discharged at home without any treatment.
Conclusion: This case demonstrates COVID-19 infection complicated by atrioventricular block. It notes the importance of electrogram in all patients covid 19 positives whether they are asymptomatic. Also cardiac involvement may be circumstance of discovering Covid19.
Keywords: Atrioventricular block; Covid19.
Introduction
Corona virus disease 2019 (COVID-19) is the clinical manifestation of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). COVID-19 was declared a pandemic in March 2020 [1]. In Tunisia the first case was diagnosed in March 2020. Several clinical manifestations were observed. Sincethe disease was discovered, many studies have been done to describe this disease and new symptoms are discovered frequently. The main sign is a respiratory syndrome associated with high rates of critical illness and mortality [1]. Actually, COVID-19 may affect all system. The cardiovascular system is frequently affected. So, it may cause embolic complication, myocardial affection, electrographic abnormalities and many other complications [1]. In this article we describe the case of a patient that presented with atrioventricular block which led to the discovery of COVID-19 infection.
Case report
A 53-year-old Tunisian woman, with a history of hypertension treated with captopril, was hospitalized on September 2020 for atrioventricular block. Because she was from Gabes, Tunisia, a region of high prevalence of COVID-19, and before pacemaker implantation, a Sars Cov 2 Polymerase chain reaction test was done and was positive. The patient was transferred to the Infectious Diseases department on Fattouma Bourguiba hospital Monastir Tunisia. On admission, vital signs were remarkable for blood pressure of 160/80 mmHg, heart rate of 40 bpm (beats per minute), and oxygen saturation at 98% on room air. An electrocardiogram (ECG) showed Type 2 Atrioventricular block with junctional escape rhythm at 39 bpm (Figure 1). Blood tests revealed c-reactive protein of 2 mg/L, normal electrolytes, normal thyroid function [thyroid-stimulating hormone (TSH) 2.13 mU/L], and no rise in troponin (<0,01). Transthoracic echocardiography showed normal left ventricle ejection fraction. She did not receive any specific treatment. She did not receive hydroxychloroquine and azithromycin because of cardiac condition. On her hospitalization her blood pressure was unstable so we changed her treatment from captopril to amlodipine with favorable outcome.
The patient was hospitalized for one month. Two others Sars Cov 2 Polymerase chain reaction tests were done, 1 month later, and were positive. Because she was asymptomatic, the patient was discharged. The last heart rate was 49 bpm. The patient did not require any pacemaker implantation. This case demonstrates atrioventricular block which led to the discovery of COVID-19 infection. These considerations were noted because of contact, no other cause of atrioventricular block was diagnosed and there was a favorable evolution when the infection was cured.
Figure 1: ECG demonstrating atrioventricular block
Discussion
SARS-CoV-2 causes respiratory, enteric, hepatic, and neurologic diseases. COVID-19 patients have complained of some prodromal symptoms including fever, malaise, myalgia, dizziness, cough, dyspnea, chest pain, expectoration, odynophagia, loss of smell/taste, diarrhea [2]. Cardiac rhythm disorder has not been noted as a circumstance for discovering the infection. To our knowledge, our case is the first one that notes discovering COVID-19 after discovering AV block. Cardiovascular complications are frequent in COVID-19. Specifically, COVID-19 has been associated with complete heart block, acute coronary syndromes, myocarditis, decompensated heart failure, and pulmonary embolisms [3]. Some studies have noted ECG abnormalities during SARS-CoV-2 infection [4]. These abnormalities may be acute coronary syndromes, rhythm disorders, ST segment and T waves ischemic changes, acute pericarditis, and pulmonary embolism [4]. Cardiac arrhythmias were reported in 23 (16.7%) of 138 hospitalized patients for covid 19 in a Chinese cohort. The exact nature of arrhythmias was not published [5]. All of cardiac arrhythmias were discovered during hospitalization. For our patient, admission for atrioventricular block was the circumstance for discovering COVID-19.
Atrioventricular block due to COVID-19 has not been widely reported. Some cases reports are described but in all of them, patients had respiratory symptoms [6-9]. In these cases, Atrioventricular block was discovered after hospitalization. The Atrioventricular block was due to myocarditis [5-8]. Our patient was asymptomatic and SARS-CoV-2 infection was discovered because of epidemiological conditions. Cardiac enzyme and transthoracic echocardiography were normal. Also, no others etiologies were noted. So, we presume that the Atriventricular block was due to COVID-19.
The 2018 American college of cardiology/ American heart association/ heart rythm society Guideline recommended ambulatory electrocardiographic monitoring (class IIb) for asymptomatic patients with extensive conducting system disease such as bifascicular block or trifascicular block. However, patients with documented second-degree Mobitz type II heart block arerecommended (class I) to receive permanent cardiac pacing [10].
For our patient, she had no atrioventricular block symptom, and she did not receive any treatment. However, in the others published cases, patients were symptomatic and consciousness. They have permanent cardiac pacing on intravenous treatment [6-9]. Outcome was favorable in all cases described. In our case, it was favorable evolution within treatment. It may be because the Atrioventricular was secondary to COVID-19 and it was ameliorated when SARS-CoV-2 viral load was decreased.
Conclusion
COVID-19 is a pandemic disease that clinical manifestations were various. There are many cardiac involvements caused by the virus or its sequelae. Atrioventricular block isn’t frequent. When diagnosed, Atrioventricular block was associated to respiratory features and secondary to myocarditis. For our case, the patient was asymptomatic and AV block was discovered via electrocardiogram. This rare case of asymptomatic AV block in the setting of COVID-19 infection adds more knowledge to the association between this virus and the cardiovascular system.
This case notes the importance of electrogram in all COVID-19 patients even if they are asymptomatic. Cardiac complication may be not different between patients with severe and non-severe COVID-19. Clinicians need to keep in mind potential proarrhythmic effects of antimalarial and antibiotic therapies currently being investigated as therapeutic agents against COVID-19.
Conflict of interest: No.
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