case_images: PMC10803410_01
case_images: Serial chest radiograph (CXR) and transthoracic echocardiography (TTE) after nosocomial infection of COVID-19. On day 3 after admission (1 day after nosocomial infection of SARS-CoV-2), CXR (A) and TTE (B, C) are unremarkable. On day 17 (15 days after nosocomial infection of SARS-CoV-2), the follow-up CXR reveals cardiac enlargement with bilateral pleural effusions (D), whereas the follow-up TTE reveals a moderate pericardial effusion with pericardial thickening (arrowheads) (E, F). Note the right ventricular collapse during early diastole (arrows). Ao, aorta; COVID-19, coronavirus disease; LA, left atrium; LV, left ventricle; PLAX, parasternal long-axis; PSAX, parasternal short-axis; RV, right ventricle; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
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case_images: F1
case_images: His physical examination and chest radiograph showed unremarkable findings (Figure 1A). Echocardiography showed mild concentric left ventricular (LV) hypertrophy with normal contraction and enlarged left atrium suggestive of diastolic dysfunction; however, pericardial effusion was not observed (Figures 1B,C and Supplementary Videos S1, S2). On day 17, the patient's condition exacerbated (Figure 1D). The follow-up echocardiography revealed a moderate pericardial effusion with tamponade physiology, suggestive of PT (Figures 1E,F and Supplementary Videos S3, S4).
case_images: The treatment effect on chest computed tomography (CT) and cardiac magnetic resonance (CMR) findings. Chest CT reveals moderate pericardial and bilateral pleural effusions with passive atelectasis (A) that resolves completely at the 6-month follow-up (D) Cine CMR reveals a moderate pericardial effusion at baseline (B) that resolves significantly at the 6-month follow-up (E) Note the entire thickening of epicardium (arrowheads) and pericardium (arrows). T2-weighted image (T2WI) shows active diffuse pericardial edema of the epicardium (arrowheads) and pericardium (arrows) observed at baseline (C) that resolves significantly at the 6-month follow-up (F). LV, left ventricle; RV, right ventricle.
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case_images: PMC10803410_01_fcvm-10-1329952-g002.jpg
case_images: F2
case_images: ECG showed sinus rhythm and concave ST-segment elevation in precordial leads, suggestive of early repolarization (Supplementary Figure S2A). Echocardiography showed mild concentric left ventricular (LV) hypertrophy with normal contraction and enlarged left atrium suggestive of diastolic dysfunction; however, pericardial effusion was not observed (Figures 1B,C and Supplementary Videos S1, S2). Chest computed tomography (CT) revealed moderate pericardial and bilateral pleural effusions (Figure 2A). The follow-up ECG showed ST-segment normalization (Supplementary Figure S2B). Cardiac MRI suggested active pericarditis (Figures 2B,C). Furthermore, a complete resolution of pericardial structural and functional abnormalities with concurrent pleural effusions was observed at the 6-month follow-up (Figures 2D-F).
case_images: Pericardial fluid and cytological findings and histological feature of resected lymph node. (A) Pericardial fluid shows hematogenous appearance. (B) Atypical cell nest is detected in the pericardial fluid and initially diagnosed as adenocarcinoma by Papanicolaou (PAP) staining (scale bar, 20 mum). (C) The resected lymph node shows multiple non-caseating granulomas (scale bar, 100 mum). (D) The same atypical cells observed in (B) are positive for anti-D2-40 antibody by immunocytochemistry (scale bar, 20 mum).
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case_images: PMC10803410_01_fcvm-10-1329952-g003.jpg
case_images: F3
case_images: The follow-up echocardiography revealed a moderate pericardial effusion with tamponade physiology, suggestive of PT (Figures 1E,F and Supplementary Videos S3, S4). S1). Subsequently, the patient underwent an urgent pericardiocentesis with a placement of pericardial drainage, showing 750 ml of hemorrhagic exudate fluid (Figure 3A). Notably, PF cytology suggested adenocarcinoma cells suspecting carcinomatous pericarditis (Figure 3B), for which ibuprofen (600 mg three times daily) and colchicine (0.5 mg twice daily) were initiated. Owing to the concern for malignancy, the patient underwent video-assisted thoracoscopic biopsy (VATS-biopsy) of the FDG-avid hilar lymph node, revealing multiple non-caseating granulomas suggestive of sarcoidosis (Figure 3C). Furthermore, re-examination of the PF cytological materials using immunohistochemistry revealed that the atypical cells were reactive mesothelial cells because they were positive for D2-40, a specific cell-marker for mesothelial cell (Figure 3D), which was unlikely due to malignancy.
case_images: Treatment effect on lymphadenopathy on chest computed tomography (CT) imaging. Chest CT on day 18 after admission reveals right paraesophageal (white arrow) and hilar (red arrow) slight lymphadenopathies (A, B). FDG/PET-CT on day 26 reveals slight hypermetabolic activities in the same ones (C, D). Post-treatment follow-up CT on day 90 reveals a significant improvement in size of the affected lymphadenopathies (E, F). FDG/PET, positron emission tomography with 2-[18F]-fluoro-2-deoxy-D-glucose.
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case_images: PMC10803410_01_fcvm-10-1329952-g004.jpg
case_images: F4
case_images: The follow-up echocardiography revealed a moderate pericardial effusion with tamponade physiology, suggestive of PT (Figures 1E,F and Supplementary Videos S3, S4). CT screening revealed right paraesophageal and hilar lymph nodes swelling (Figures 4A,B). On day 26, positron emission tomography (PET)/CT with the glucose analog 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) disclosed the slight hypermetabolic activities in the same lesions (Figures 4C,D). A significant improvement in size of the affected lymphadenopathies was also observed on day 90 (Figures 4E,F).
case_images: Timeline of the diagnostics, therapeutic interventions, and disease status of the present case. CEZ, cephazolin; CMR, cardiac magnetic resonance; CT, computed tomography; CXR, chest radiograph; COVID-19, coronavirus disease; Dx, diagnosis; ECG, electrocardiogram; FDG/PET, glucose analog 2-[18F]-fluoro-2-deoxy-d-glucose positron emission tomography; iv, intravenous; JVD, jugular vein distention; MMSE, methicillin-sensitive Staphylococcus aureus; MRI, magnetic resonance imaging; NPS, nasopharyngeal swab; P/E, physical examination; PF, pericardial fluid; RT-PCR, reverse-transcriptase polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; SBT/ABPC, ampicillin-sulbactam; TTE, transthoracic echocardiography; VATS-biopsy, video-assisted thoracoscopic biopsy.
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case_images: PMC10803410_01_fcvm-10-1329952-g005.jpg
case_images: F5
case_images: We present a summarized illustration of the case presentation in Figure 5.