Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Transient Third-degree Heart Block Secondary to Asymptomatic COVID-19 Infection

Aleem Azal Ali*, Naji Maaliki, Michael Omar, Amy Roemer, Jose Ruiz, Khadeeja Esmail

Internal Medicine, University of Florida College of Medicine- Jacksonville

Abstract: COVID-19 predominantly affects the lungs manifesting as respiratory illnesses including pneumonia and acute respiratory distress syndrome. Cardiac manifestations are also being increasingly reported such as pericardial disease, myocardial injury and dysfunction, arrhythmias and conduction abnormalities. A 70-year-old male with asymptomatic COVID-19 infection developed a transient episode of complete heart block just prior to his planned discharge from hospital. There are only few case reports purporting the development of a transient complete heart block in patients with moderate to severe COVID-19 infection. However, to date, this is the first report of incidentally detected, asymptomatic COVID-19 infection manifesting as third degree heart block.

Keywords: Coronavirus, complete heart block, arrhythmia, COVID-19 myocardial injury

Received January 13, 2021; Revised January 24, 2021; Accepted February 04, 2021

Citation: Aleem Azal Ali, Naji Maaliki, Michael Omar, Amy Roemer, Jose Ruiz, Khadeeja Esmail, Transient Third-degree Heart Block Secondary to Asymptomatic COVID-19 Infection. American Journal of Medical Case Reports, 9 (4). 259-260. January 2021. doi:10.12691/ajmcr-9-4-13

1. Introduction

Novel Coronavirus was declared a pandemic by World Health Organization in March 2020. COVID-19 infection typically affects the lungs, manifesting with respiratory diseases ranging from atypical pneumonia to severe respiratory distress syndrome. There are emerging reports of COVID-19 affecting the heart and presenting with pericardial disease, myocardial injury and dysfunction, arrhythmias and conduction abnormalities. This case adds to the growing literature of the cardiac effects of COVID-19 infection and presents an interesting perspective of an asymptomatic COVID-19 infection manifesting as a third-degree AV Block.

2. Case Report

A 70-year-old male with no prior comorbidities was hospitalized for treatment of Streptococcus pyogenes bacteremia from intravenous drug use. He had initially presented with fevers for 2 days and apart from positive blood cultures, the infectious workup including chest radiography was unremarkable. On admission, a COVID-19 molecular test was negative. ECG revealed sinus rhythm without evidence of conduction disease and transthoracic echocardiography was unremarkable for pericardial, myocardial or valvular pathology, including the absence of vegetations. The patient was successfully treated with Ceftriaxone therapy with ensuing sterility of blood cultures and significant clinical improvement within 48 hours. His subsequent 14-day hospital course, although protracted in anticipation of a socially safe discharge disposition, had been grossly uneventful until the night prior to his planned discharge date.

The patient experienced sudden facial flushing followed by a transient loss of consciousness while watching television. He denied chest pain or palpitations and clinically there were no focal neurologic deficits. Telemetry revealed a 5 second complete heart block at the time of his symptoms, followed by a spontaneous return to normal sinus rhythm which was confirmed on subsequent ECG (Figure 1). Cardiac biomarkers were negative along with serum electrolyte panels and thyroid function tests within normal limits. The patient was transferred to the coronary care unit and underwent emergent transvenous pacing.

Figure 1. Telemetry with five second pause with spontaneous return to normal sinus rhythm

Prior to permanent pacemaker implantation, screening COVID-19 RT-PCR returned positive. He had remained asymptomatic, without elevation of inflammatory markers, hypoxia or abnormal chest radiography. In lieu of the absence of other causes of heart block, SARS-CoV-2 infection was deemed the inciting etiology of his acute onset third degree AV Block.

3. Discussion

With the WHO’s declaration of COVID-19 a global pandemic, there has been an emergence of case reports/series discussing the potential cardiovascular disease manifestations of COVID-19 infection.

Cardiovascular implications of COVID-19 include asymptomatic myocardial injury to acute coronary syndrome, mild to fulminant myocarditis, stress cardiomyopathy and cardiogenic shock [1]. Notably inflammatory cells and COVID-19 virus have been detected in the myocardium in autopsy studies, suggesting direct invasion of the heart [2]. COVID-19 viral RNA was detected in the hearts of 35% of patients with COVID-19 infection [3]. Wang et al reported that 7.2% of 138 patients hospitalized with COVID-19 infection had myocardial injury and 16.7% of the patients developed arrhythmias, although unspecified [4]. Deng et al noted 12.5% of patients with COVID-19 had evidence of myocardial injury with abnormalities suggestive of myocarditis [5].

COVID-19 related heart block is reported in only a few case studies thus far, although typically in patients with hypoxia or moderate to severe disease [6,7,8]. This phenomenon has been also reported in a patient without overt myocarditis [9], but this is the first reported case noted in asymptomatic COVID-19 infection devoid of hypoxia at rest. The mechanism of AV nodal involvement is yet uncertain, whether through direct viral invasion, viral inflammatory response, autoimmune sequelae or microthrombotic insults to the AV node from the hypercoagulable milieu of COVID-19 [6]. As a result, the prognosis is unpredictable and elucidation would unfortunately require the coveted long term prospective data. Until such a time, it may be safer to consider permanent pacemaker implantation, especially in patients with mild or asymptomatic COVID-19 infection such as in our case.

4. Conclusion

The cardiovascular implications of COVID-19 are incessantly being recognized as a myriad of events continue to occur. While the exact mechanism remains to be determined, the inflammatory and prothrombotic nature of the COVID-19 infection seems to contribute significantly. Even asymptomatic patients may be at risk for such cardiac manifestations, which can even initially go unnoticed. Thus, until there are high quality data on the risk and prognostic stratification of COVID-19 related cardiovascular complications such as complete heart block, even asymptomatic patients may warrant continuous telemetry monitoring and subsequent aggressive management strategies.

References

[1]   | Clerkin KJ, Fried JA, Raikhelkar J, et al. COVID-19 and Cardiovascular Disease. Circulation. 2020; 141(20): 1648-55.
[2]   | Bansal M. Cardiovascular disease and COVID-19. Diabetes Metab Syndr. 2020; 14(3): 247-50.
[3]   | Oudit GY, Kassiri Z, Jiang C, et al. SARS-coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS. Eur J Clin Invest. 2009; 39(7): 618-25.
[4]   | Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020; 323(11): 1061-69.
[5]   | Deng Q, Hu B, Zhang Y, et al. Suspected myocardial injury in patients with COVID-19: Evidence from front-line clinical observation in Wuhan, China. Int J Cardiol. 2020; 311: 116-21.
[6]   | Eneizat Mahdawi T, Wang H, Haddadin FI, Al-Qaysi D, Wylie JV. Heart block in patients with coronavirus disease 2019: A case series of 3 patients infected with SARS-CoV-2. HeartRhythm Case Rep. 2020; 6(9): 652-56.
[7]   | Azarkish M, Laleh Far V, Eslami M, Mollazadeh R. Transient complete heart block in a patient with critical COVID-19. Eur Heart J. 2020; 41(22): 2131.
[8]   | Kochav SM, Coromilas E, Nalbandian A, et al. Cardiac Arrhythmias in COVID-19 Infection. Circ Arrhythm Electrophysiol. 2020; 13(6): e008719.
[9]   | Kir D, Mohan C, Sancassani R. Heart Brake: An Unusual Cardiac Manifestation of COVID-19. JACC Case Rep. 2020; 2(9): 1252-55.