Pericarditis as the Main Clinical Manifestation of COVID-19 in Adolescents.

Children and adolescents with severe acute respiratory syndrome coronavirus 2 infection usually have a milder illness, lower mortality rates and may manifest different clinical entities compared with adults. Acute effusive pericarditis is a rare clinical manifestation in patients with COVID-19, especially among those without concurrent pulmonary disease or myocardial injury. We present 2 cases of acute pericarditis, in the absence of initial respiratory or other symptoms, in adolescents with COVID-19.

Molecular characterization and pathogenicity of a fowl adenovirus serotype 4 isolated from peacocks associated with hydropericardium hepatitis syndrome.

In September 2019, a highly prevalent infectious disease caused severe hydropericardium hepatitis syndrome (HHS) in a peacock farm in Central China. The disease showed high mortality of 78.6% in 28-42 day-old peacocks. In this study, one strain of highly pathogenic fowl adenovirus serotype 4 (FAdV-4) was isolated from peacocks and designated as HN19. Molecular characterization of amino acid revealed that HN19 contains the same deletions as the dominate strains in chickens in China recently. Phylogenetic analyses revealed that HN19 showed higher homology with other FAdV-4 strains isolated from China, indicating that HN19 might originate from previously FAdV-4 predecessor in China. Experimental infection of the HN19 strain via intramuscular injection led to 100% mortality rate in 21-day-old specific pathogenic-free (SPF) chickens. To our knowledge, this represents the first report on the prevalence of FAdV-4 in peacocks. These results suggested that the potential risk of cross-species transmission of FAdV-4 from chickens to peacocks, highlighting the need for implementing strict biosecurity measures to avoid the mixing of different bird species.

A Pediatric Case Report of Epstein-Barr Virus-associated Hemophagocytic Lymphohistiocytosis With Pericardial Effusion and Multiple Coronary Artery Aneurysms.

Pediatric coronary artery aneurysms (CAAs) are mainly detected in Kawasaki disease and in chronic active Epstein-Barr virus (EBV) infection sometimes, and cardiac complications are rare in viral-associated hemophagocytic lymphohistiocytosis (HLH) patients. Here, we report a pediatric case of EBV-associated HLH with pericardial effusion and multiple CAAs, whereas the patient did not fulfill the diagnostic criteria of Kawasaki disease or chronic active EBV. The case indicates that CAAs may occur in EBV-HLH. Specifically, in a patient with a long-term fever and a high EBV DNA copy number, the detection of cardiac complications may help signal the possible occurrence of HLH, and CAAs may affect the prognosis for high risk of cardiac events.

Maternal SARS-CoV-2 Infection Associated to Systemic Inflammatory Response and Pericardial Effusion in the Newborn: A Case Report.

Vertical transmission of SARS-CoV-2 has already been described, while clinical consequences to the fetus are still under investigation. This article reports a case of systemic fetal inflammatory response and pericardial effusion. As far as is known, this is the first case of fetal/neonatal cardiac complications related to SARS-CoV-2 infection.

Pericardial effusion and cardiac tamponade requiring pericardial window in an otherwise healthy 30-year-old patient with COVID-19: a case report.

BACKGROUND: This case report demonstrates pericardial effusion, acute pericarditis, and cardiac tamponade in an otherwise healthy woman who had a positive test result for coronavirus disease 2019. Few case reports have been documented on patients with this presentation, and it is important to share novel presentations of the disease as they are discovered. CASE PRESENTATION: A Caucasian patient with coronavirus disease 2019 returned to the emergency department of our hospital 2 days after her initial visit with worsening chest pain and shortness of breath. Imaging revealed new pericardial effusion since the previous visit. The patient became hypotensive, was taken for pericardial window for cardiac tamponade with a drain placed, and was treated for acute pericarditis. CONCLUSION: Much is still unknown about the implications of coronavirus disease 2019. With the novel coronavirus disease 2019 pandemic, research is still in process, and we are slowly learning about new signs and symptoms of the disease. This case report documents a lesser-known presentation of a patient with coronavirus disease 2019 and will help to further understanding of a rare presentation.

Myocarditis in Multisystem Inflammatory Syndrome in Children Associated With Coronavirus Disease 2019.

Cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 infection in children is a relatively new entity. We present our initial experience managing children with coronavirus disease 2019-related acute myocardial injury. The 3 patients presented here represent a spectrum of the cardiac involvement noted in children with coronavirus disease 2019-related multisystem inflammatory syndrome, including myocarditis presenting as cardiogenic shock or heart failure with biventricular dysfunction, valvulitis, coronary artery changes, and pericardial effusion.

Cardiac tamponade in COVID-19 patients: Management and outcomes.

IMPORTANCE: Cardiac tamponade requiring emergent intervention is a possible complication of coronavirus disease 2019 (COVID-19) infection. Favorable clinical outcomes are possible if timely management and drainage are performed unless ventricular failure develops. OBSERVATION: Cardiac tamponade in COVID-19, based on the limited reported cases, seems to be more common among middle-aged men with observed complications in black and ethnic minorities. Prognosis is worse amongst patients with concomitant ventricular failure. DESIGN AND METHODS: This is a case series of three COVID-19 patients complicated by cardiac tamponade, requiring surgical intervention at a single institution in New York. INTERVENTION: Pericardial window, Pericardiocentesis. OUTCOME: One patient had recurrence of cardiac tamponade with hemorrhagic component but fully recovered and was discharged home. Two patients developed cardiac tamponade with concomitant biventricular failure, resulting in death. CONCLUSION AND RELEVANCE: Cardiac tamponade with possible concomitant biventricular failure can develop in COVID-19 patients; incidence seems to be highest at the point of marked inflammatory response. Concomitant ventricular failure seems to be a predictor of poor prognosis.

Short report - Usefulness of point-of-care ultrasound in pediatric SARS-CoV-2 infection.

SARS-CoV-2 infection in children is uncommon compared to adult population. However, some children required hospital and/or PICU admission. The aim of this short communication is to share our experience with Point-of-Care Ultrasound (POCUS) when managing these patients. Remarkably, all cases presented pleural and pericardial effusions, detected by POCUS, despite showing an adequate urinary output and prior to receiving any kind of fluid resuscitation. Effusions have been described as rare among SARS-CoV-2 infection in adult population. By performing portable chest X-Ray they would have gone unnoticed in our patients. Other POCUS findings consisted of all types of consolidations and coalescent B-line patterns. POCUS was also performed in order to optimize PEEP, checking adequate endotracheal intubation positioning (avoiding the risk of contagiousness related to auscultation in this framework), and to assess volemia status, cardiac performance, and brain neuro-monitoring. There was not cross-infection. In pediatric SARS-CoV-19 effusions are frequent but easily unnoticed unless lung and echo POCUS are performed.

CT imaging features of COVID-19 pneumonia: initial experience from Turkey.

PURPOSE: We aimed to demonstrate the computed tomography (CT) findings observed at the initial presentation of coronavirus disease 2019 (COVID-19) pneumonia and reveal the most frequent infiltration and distribution patterns of the disease. METHODS: One hundred and eighty-five patients (87 men, 98 women; mean age, 48.7 years), who underwent RT-PCR sampling and high-resolution CT examination in our hospital between March 15, 2020, and April 15, 2020, and got a definitive diagnosis of COVID-19 disease via initial or follow-up RT-PCR test, were included in the study. We comprehensively analyzed the most common and relatively rare CT imaging features (e.g., distribution pattern, density of the lesions, additional CT signs) in patients diagnosed with COVID-19 pneumonia. RESULTS: Thirty-eight patients (20.6%) had no evidence of pneumonia on their initial high-resolution CT images. Among 147 patients (79.4%) who had parenchymal infiltration consistent with pneumonia, 10 (6.8%) had a negative baseline RT-PCR test, and positivity was detected as a result of repeated tests. Most of the patients had multifocal (89.1%) and bilateral (86.4%) lesions. The most common location, right lower lobe, was affected in 87.8% of the patients. Lesions were distributed predominantly at peripheral (87.1%) and posterior (46.3%) areas of lung parenchyma. Most of the patients had pure ground glass opacity (GGO) (82.3%) followed by GGO with consolidation (32.7%) and crazy paving pattern (21.8%). Pure consolidation, solid nodules, halo sign, reverse halo sign, vascular enlargement, subpleural line, air-bronchogram, and bronchiectasis were the other findings observed in at least 15% of the cases. Halo sign, acinar nodules, air-bubble sign, pleural thickening and effusion, mediastinal and/or hilar lymphadenopathy were seen rarely (2%-12.9%). Pericardial effusion, pneumothorax, cavitation, and tree-in-bud pattern were not detected in our study group. CONCLUSION: Multifocal and bilateral GGO infiltration predominantly distributed in peripheral, posterior, and lower lung areas was the most common infiltration pattern.

Respiratory syncytial virus-associated mortality in a healthy 3-year-old child: a case report.

BACKGROUND: Respiratory syncytial virus (RSV) is the most frequently identified pathogen in children with acute lower respiratory tract infection. Fatal cases have mainly been reported during the first 6 months of life or in the presence of comorbidity. CASE PRESENTATION: A 47-month-old girl was admitted to the pediatric intensive care unit following sudden cardiopulmonary arrest occurring at home. The electrocardiogram showed cardiac asystole, which was refractory to prolonged resuscitation efforts. Postmortem analyses detected RSV by polymerase chain reaction in an abundant, exudative pericardial effusion. Histopathological examination was consistent with viral myoepicarditis, including an inflammatory process affecting cardiac nerves and ganglia. Molecular analysis of sudden unexplained death genes identified a heterozygous mutation in myosin light chain 2, which was also found in two other healthy members of the family. Additional expert interpretation of the cardiac histology confirmed the absence of arrhythmogenic right ventricular dysplasia or hypertrophic cardiomyopathy. CONCLUSIONS: RSV-related sudden death in a normally developing child of this age is exceptional. This case highlights the risk of extrapulmonary manifestations associated with this infection, particularly arrhythmia induced by inflammatory phenomena affecting the cardiac autonomic nervous system. The role of the mutation in this context is uncertain, and it is therefore necessary to continue to assess how this pathogenic variant contributes to unexpected sudden death in childhood.

Human Herpes-8 virus copy to cell ratio: A diagnostic tool in primary effusion lymphoma.

Primary effusion lymphoma (PEL) is a serious sequel to Human Herpes Virus 8 (HHV8) infection in the immunosuppressed host. Usually requiring a cytological diagnosis, body cavity effusions are often referred for investigation for possible PEL. Although absence of HHV8 effectively refutes this, the presence of HHV8 DNA, though indicative is not diagnostic. Referred effusion and plasma samples from 10 patients with HHV8-related pleural and pericardial effusions were submitted for quantitative investigations. HHV8 DNA and human DNA from unseparated effusion extracts have been quantified allowing estimation of virus-to-cell ratios in effusion fluid. These ratios varied widely between 0.003 and 700. Five fluids had in excess of 106 HHV-8 DNA genome equivalents per ML (GEq/ML), ranging between 18 and 300 million GEq/ML. Four of these five effusions were from patients with cytologically proven PEL and had virus to cell (V:C) ratios between 100 and 700 to 1. The remaining high load effusion exhibited a ratio of 1.6 to 1 and came from a patient with extensive thoracic Kaposi's sarcoma. Five effusion fluids with low viral loads exhibited virus to cell ratios between 0.003 and 0.5. High effusion HHV8 load, though supportive of a diagnosis of PEL is less accurate than using virus to cell ratios.

Pathogenicity of a fowl adenovirus serotype 4 isolated from chickens associated with hydropericardium-hepatitis syndrome in China.

Hydropericardium-hepatitis syndrome (HHS) is characterized by pericardial effusion and hepatitis and causes huge economic losses in the poultry industry in China. In this study, a strain of fowl adenoviruses (FAdV-4) (GX-1) was isolated from liver samples of diseased chickens with HHS. Phylogenetic analysis based on complete genome gene revealed that GX-1 clustered with the C-type fowl adenovirus and was serotyped as FAdV-4. Pathogenicity testing showed that the GX-1 strain caused 100% mortality in 10-day-old specific pathogen-free chickens at a dose of 104 tissue culture infective doses (TCID50) within 3 d post-infection. A viral dose of 103 TCID50 resulted in a 16% survival rate before day 9 and at 102 TCID50 an 80% rate before day 6. At necropsy, livers from infected chickens were swollen and yellow brown with necrotic foci. The hearts were flabby with amber-colored and jelly-like fluid in the pericardial sacs. The kidneys were swollen and congested. Histologically eosinophilic intranuclear inclusion body could be seen in the hepatic cell. The result of histopathological examination also revealed that heart muscle fibers were fractured with extensive congestion and hemorrhaging. Other tissues like kidney, bursa of Fabricius, thymus, and spleen were observed degeneration and necrosis. Virus-specific antibodies appeared in serum beginning at day 14 and reached statistically significant levels at 21, 28, 35, and 42 dpi (P < 0.001). In conclusion, we identified a highly virulent FAdV-4 virus as causative agent of the HHS outbreak reported here. The FAdV-4 GX-1 strain will be valuable for vaccine evaluation and development to prevent and reduce the spread of HHS in the poultry industry.

Influenza B virus infection complicated by life-threatening pericarditis: a unique case-report and literature review.

BACKGROUND: Acute pericarditis may occur frequently after viral infections. To our knowledge, influenza B virus infection complicated by pericarditis without myocardial involvement has never been reported. We report the first case of life-threatening pericarditis caused by influenza B virus infection. CASE PRESENTATION: A 48-years-old woman with trisomy 21 and ostium primum atrial septal defect was transferred from Cardiology to our Internal Medicine Department for severe pericardial effusion unresponsive to ibuprofen and colchicine. Based on the recent patient history of flu-like syndrome, and presence of pleuro-pericardial effusion, a viral etiology was suspected. Laboratory evaluation and molecular assay of tracheal aspirate identified influenza B virus. Therefore, the ongoing metilprednisolone and colchicine therapy was implemented with oseltamivir with progressive patient improvement and no evidence of pericardial effusion recurrence during follow-up. CONCLUSIONS: Especially in autumn and winter periods, clinicians should include Influenza B virus infection on differential diagnosis of pericarditis with large pericardial effusion.

Mechanism of fowl adenovirus serotype 4-induced heart damage and formation of pericardial effusion.

Fowl adenovirus serotype 4 (FAdV-4) is the causative agent of hydropericardium syndrome (HPS), which is characterized by the accumulation of a clear, straw-colored fluid in the pericardial sac, and high mortality rates. In order to explore the mechanism of FAdV-4-induced cardiac damage, dynamic pathology, apoptosis, and inflammatory reactions were analyzed in vivo. Moreover, we detected viral proliferation, and ultrastructure, inflammation and apoptosis of cardiomyocytes (CM) after FAdV-4 infection in vitro. The results showed that FAdV-4 impaired cardiac integrity and function by causing apoptosis and inflammation in vivo. Flow cytometry showed that CM infected with FAdV-4 did not show apoptosis in vitro. In addition, the mRNA expression of four inflammatory cytokines (interleukin (il)1B, il6, il8, and tumor necrosis factor), and activity of three myocardial enzymes were significantly different between FAdV-4 and control groups. However, in vitro, these indexes showed no significant difference between the groups. These observations collectively indicated that the heart was not the target organ of FAdV-4, and the virus may not directly lead to the occurrence of CM apoptosis and inflammation. To explore the source of pericardial effusion, we measured total protein, albumin, aspartate aminotransferase, creatine kinase isoenzyme, lactate dehydrogenase, potassium, sodium, and chloride ions in serum and pericardial effusion. Pericardial effusion was derived from vascular exudation rather than CM degeneration. Further studies are needed to investigate the exudation mechanism of vascular endothelial cells in FAdV-4 infection then weakened or eliminated pericardial effusion to minimize heart injury and/or restore damaged CM.

Fatal Myopericarditis Following an Influenza A (H3N2) Infection.

BACKGROUND Influenza viruses induce uncomplicated infections in most cases in individuals with no known predisposing factors. Acute febrile illness is generally limited to upper respiratory symptoms and several constitutional symptoms, including headache, lethargy, and myalgia. However, influenza A virus is a cause of severe morbidity and mortality worldwide. Some patients are at risk for serious and fatal complications. Cardiac involvement is a well-known condition, but, clinically apparent influenza myocarditis is not common. Few reports exist regarding recurrent fulminant influenza myocarditis. CASE REPORT We report here a fatal case of heart failure following myocarditis in a 14-year-old female who had seasonal flu symptoms but was otherwise healthy. H3N2 influenza virus infection was detected by molecular analyses of throat and nasal swabs, suggesting damage to myocardial cells caused directly by the virus. CONCLUSIONS Pericardial effusion myopericarditis may occur during influenza virus infection in young individuals, even those with no known predisposing factors. Physicians need to be aware that acute myopericarditis can be a fatal complication of recent influenza virus infection in all patients with instable hemodynamics. Early diagnosis and treatment could reduce, in some cases, the risk of severe cardiac events. However, this sudden and fatal outcome was difficult to predict in a healthy young female with no known risk factors.

Relevant pericardial effusion caused by cytomegalovirus infection in an immunocompetent patient: a case report.

BACKGROUND: Cytomegalovirus infection is known to cause symptomatic disease in immunocompromised patients, while an infection in immunocompetent individuals normally causes few or no symptoms. We present the case of an immunocompetent adult patient with unexpected severe evolution. CASE PRESENTATION: An otherwise healthy, 72-year-old Caucasian woman presented with complaints of progressive shoulder pain and dyspnoea on exertion. The blood test results showed elevated inflammation parameters and elevated hepatic transaminase levels. Radiologic examinations were carried out, and the computed tomography scan revealed a hepatomegaly and a chest X-ray showed evidence of a unilateral pleural effusion. A transthoracic echocardiography detected pericardial effusion with consecutive hemodynamic changes. Since it was considered that using ultrasound-guided pericardiocentesis could significantly increase the risk of liver injury due to hepatomegaly, a pericardial window was performed instead. Further investigation showed that our patient tested positive for an acute cytomegalovirus infection in the serologic tests. Laboratory findings included new evidence of immunoglobulin M seroconversion and high immunoglobulin G avidity, so we considered the possibility that a former cytomegalovirus infection may be coexisting with a new cytomegalovirus reinfection. CONCLUSIONS: In immunocompetent individuals, a symptomatic cytomegalovirus primary infection or reinfection should be considered in patients presenting with pericardial effusion and serositis.