{'fraction_non_alphanumeric': 0.031130390405715743, 'fraction_numerical': 0.013141107425363613, 'mean_word_length': 5.306516492357201, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Shock and Diffuse ST-elevation in a Patient with Coronavirus Disease-2019 Disease

IntroductIon Cardiac involvement is a prominent feature in the novel coronavirus disease-2019 (COVID-19), a clinical syndrome caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.[1,2] Myocardial injury and heart failure contributed to 40% of COVID-19 deaths, either in conjunction or not with respiratory failure.[3,4] However, little is currently known about the incidence, clinical manifestations, and management of heart disease in patients with COVID-19. Here, we describe a case of a patient with COVID-19 disease admitted with shock and diffuse ST-elevation at the electrocardiogram.

a mass in the right lung suspected for cancer. Subsequently, an endobronchial ultrasound-guided transbronchial needle aspiration was planned.
On April 2, for the occurrence of severe hypotension and asthenia, the emergency service was called. At patients' home, he was found in shock, and the electrocardiogram revealed a diffuse ST-elevation [ Figure 1a]. Blood pressure was 80/40 mmHg, heart rate 110 bpm, oxygen saturation 88% on room air, and body temperature 37.5°C. He was directly moved to the catheterization laboratory, and any contact with other health-care workers was avoided. An emergency coronary angiography showed the absence of a coronary artery disease as well as a normal left ventricular function.
Afterward, the patient was admitted to the COVID-19 ward. At blood samples, high inflammatory markers, increased liver enzymes, and normal troponin values were observed (peak HS-troponin value 10.5 ng/L); arterial blood gas analysis showed respiratory alkalosis with hyperlactatemia (pH 7.5, paCO 2 27.1 mmHg, HCO 3 -24.1 mmol/dL, and lactates 5.5 mmol/dL). Table 1 shows the results of the blood samples and Figure 1b a control electrocardiogram. A bedside focused ultrasound was performed. The lung ultrasound showed an interstitial syndrome with bilateral B lines, small sub-pleural consolidations, and bilateral pleural effusion. The echocardiography highlighted the presence of diffuse pericardial effusion of 2.5 cm and a swinging heart, inferior caval vein of 2.2 cm with no respiratory excursion, and global left ventricular ejection fraction of 50% [ Figure 2]. Blood pressure values increased after fluid therapy, and pericardiocentesis was not performed due to the improved patient's hemodynamic conditions, instead oxygen saturation rapidly deteriorated with the need of high flow oxygen therapy.
A diagnosis of pericarditis was made; corticosteroids and colchicine were started. Heparin prophylaxis was started, and high dose aspirin was avoided. Empiric antibiotic therapy was administrated as a concomitant lung infection was suspected. A second and third (2 days after) nasopharyngeal swab tested negative for SARS-CoV-2 infection, whereas an enzyme-linked immunosorbent assay based test resulted positive for IgM and IgG antibodies for SARS-CoV-2.
In the next days, the patient remained hemodynamically stable but severe respiratory failure persisted. At this time, a total body CT was performed and confirmed the presence of a locally advanced lung cancer of 8.5 cm with subclavian artery and vein and thoracic lymph nodes involvement and confirmed the pleural and pericardial effusion [ Figure 3]. The histological examination confirmed the diagnosis of lung adenocarcinoma. Indeed, after oncologic evaluation, the patient was moved to the oncologic clinic, but 1 week later, he died for rapidly worsening of the respiratory failure.

dIscussIon
We report on the management of a man with shock, diffuse ST-elevation at the electrocardiogram, pericardial effusion, and concomitant SARS-CoV-2 infection. A diagnosis of locally advanced lung adenocarcinoma was done.
During COVID-19, a considerable proportion of patients may develop cardiac events with a subsequently increased risk of in-hospital mortality. [3][4][5][6] Those include acute coronary syndrome or venous thromboembolism but also pericarditis or myocarditis. Cardiac events require a quick diagnosis and management and should not be overlooked due to the presence of SARS-CoV-2 infection. In this view, a correct triage of the patient is essential for the right in-hospital allocation according to the infective state and allows the prompt adoption of protective measures. At the emergency service arrival, our patient had hemodynamic deterioration and electrocardiographic findings compatible with an ST-elevation myocardial infarction (STEMI). According to the triage protocol, an emergency angiography was  immediately performed, and a myocardial ischemia was excluded. Emergency coronary angiography is recommended in patients with heart failure or shock (Class I, Level A) irrespective of COVID-19 status. [7,8] In our patient, the bedside echocardiogram was performed after the coronary angiography. Recent guidance suggests that focused cardiac ultrasound study and critical care echocardiography should be performed and focused only to answer clinical questions to reduce patient contact during COVID-19 pandemic. [8,9] Indeed, a differential diagnosis with "STEMI-mimicker" such as focal myocarditis or stress cardiomyopathy known to be associated with COVID-19 should be considered in these patients since the prehospital setting. However, in this case, a focused cardiac ultrasound study performed before moving the patient to the catheterization laboratory would have led to a quicker correct diagnosis of pericardial effusion.
A second electrocardiogram better underlined the PR depression and the diffuse concave upward ST-segment elevation suggesting a probable diagnosis of acute pericarditis ultimately confirmed by focus echocardiography. Thus, a multidisciplinary evaluation is essential in these patients.
The hemodynamic deterioration in our patient should be related to both a cardiogenic and a septic component. Since pericardiocentesis was not performed, the etiology of the pericardial effusion remains to be defined (infective or neoplastic). Finally, the diagnostic tests for SARS-CoV-2 infection should be correctly interpreted. [9] In our patient, the infection of SARS-CoV-2 was confirmed by the positive of nasopharyngeal swab on the real-time reverse transcriptase-polymerase chain reaction assay before admission. However, while the patient had positive IgM and IgG antibodies for SARS-CoV-2 infection, a second and a third, at 48 hours nasopharyngeal swabs during hospital stay were negative. This suggests even according to symptoms onset, that SARS-CoV-2 infection occurred 2 weeks before. [10] In conclusion, our case highlights a complex diagnostic and therapeutic management in a patient with SARS-CoV-2 infection, hemodynamic compromise, and important comorbidities (locally advanced lung cancer). In this view, not delayed primary PCI remains the standard of care for patients with suspected STEMI in the COVID-19 era. The use of the established management protocols and multidisciplinary approach is essential in daily clinical practice, especially in critically ill patients with SARS-CoV-2 infection.

Statement of consent
The authors confirm that consent for submission and publication of this case report, including images, has been obtained according to the Local Institutional Review board.

Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.