Key result
Therapeutic plasma exchange resolved cardiogenic shock, normalized left ventricular function, and improved inflammatory markers in a patient with COVID-19 and reverse takotsubo cardiomyopathy.
Why the study?
Fulminant COVID-19 can be complicated by acute respiratory failure, multi-system organ failure, and cytokine release syndrome, but the presentation and management of associated reverse takotsubo cardiomyopathy remain poorly documented.
Does therapeutic plasma exchange improve clinical outcomes in a patient with fulminant COVID-19 complicated by cytokine release syndrome and reverse takotsubo cardiomyopathy?
Case Report (n=1)
No
Does therapeutic plasma exchange improve clinical outcomes in a patient with fulminant COVID-19 complicated by cytokine release syndrome and reverse takotsubo cardiomyopathy?
Therapeutic plasma exchange may serve as a rescue therapy for fulminant COVID-19 complicated by cytokine release syndrome and reverse takotsubo cardiomyopathy when inotropic therapy fails.
May support TPE consideration in refractory fulminant COVID-19; single case leaves efficacy unproven.
BACKGROUND: Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). CASE PRESENTATION: A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. CONCLUSION: Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.
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Faqihi et al. (2020) conducted a case report in Fulminant COVID-19 with cytokine release syndrome and reverse takotsubo cardiomyopathy (n=1). Therapeutic plasma exchange was evaluated on Clinical and echocardiographic improvement (resolution of cardiogenic shock and LV function). Therapeutic plasma exchange resolved cardiogenic shock, normalized left ventricular function, and improved inflammatory markers in a patient with COVID-19 and reverse takotsubo cardiomyopathy.
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