The Imperfect Cytokine Storm

Abstract

As health systems worldwide grapple with the coronavirus disease-2019 (COVID-19) pandemic, patients with durable LVAD support represent a unique population at risk for the disease. This paper outlines the case of such a patient who developed COVID-19 complicated by a "cytokine storm" with severe acute respiratory distress syndrome and myocardial injury and describes the challenges that arose during management. (J Am Coll Cardiol Case Rep 2020;2:1315-20) open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). HISTORY OF PRESENTATION The patient was a 70-year-old male with a destination therapy HeartMate 3 (Abbott Laboratory, Lake Bluff, Illinois) left ventricular assist device (LVAD) implanted in 2016 who developed fever, flank pain, and hematu-ria 3 days after attending a party. He was evaluated for nephrolithiasis at a local emergency department by abdomen and pelvis computed tomography imaging, which incidentally found possible atypical or viral pneumonia. He was tested for coronavirus disease-2019 (COVID-19), but he left against medical advice. In the ensuing days, he continued to have fever, new onset myalgia, diarrhea, and dyspnea. He returned to the emergency department and was in acute hypoxic respiratory failure requiring supplemental oxygen to maintain peripheral oxygen saturation $94%. MEDICAL HISTORY His medical history included ischemic cardiomyopa-thy, stage 3 chronic kidney disease, and obesity. His post-LVAD complications include gastrointestinal bleeding, ventricular tachycardia, and right ventric-ular (RV) dysfunction but no infectious complications. He did not have diabetes or use tobacco. His blood group was type A positive. DIFFERENTIAL DIAGNOSIS Pretest probability for COVID-19 infection was moderate to high due to fever, dyspnea, and hypoxia as well as prior imaging showing peripheral ground-glass opacities. LEARNING OBJECTIVES To describe high-risk clinical features in a patient on durable LVAD support who developed COVID-19. To illustrate potential complications and clinical dilemmas in managing COVID-19 in a patient supported with a durable LVAD.