Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : OD04 - OD07 Full Version

Dilated Cardiomyopathy with Congestive Hepatopathy in Post COVID-19 Patient- A Case Report


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53273.16179
Mustaq Ahmed, Siva Ranganathan Green, Divya Sundar

1. Junior Resident, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 2. Professor, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 3. Junior Resident, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India.

Correspondence Address :
Dr. Siva Ranganathan Green,
Professor, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India.
E-mail: srgreen@mgmcri.ac.in

Abstract

In the current situation of pandemic, Coronavirus Disease 2019 (COVID-19), main organ involvement is of respiratory system ranging from mild symptoms to acute severe respiratory distress syndrome. Some studies are showing an increasing number of patients being hospitalised for COVID-19 with acute heart failure and multi-system inflammatory state. A 17-year-old male, with no known co-morbidities, presented with breathlessness and jaundice. He was diagnosed as a case of Dilated Cardiomyopathy (DCM) with congestive hepatopathy. He was treated with diuretics and supportive medications for which he showed symptomatic improvement, and there was a significant improvement in his ejection fraction during the course of treatment. The patient had Coronavirus Disease 2019 (COVID-19) infection 15 days prior to the onset of the above symptoms. The progression of COVID-19 complications seems potentially life-threatening, if associated with cardiac and hepatic manifestations. The present case illustrates the probable course of the ailment that has led to DCM. There was liver involvement too which was monitored and treated meticulously. These patients have high chances of deterioration even in simple situations of fever or pain, due to an increase in metabolic demands. It is a unique case which shows a strong association between COVID-19, acute heart failure, and congestive hepatopathy.

Keywords

Acute heart failure, Acute severe respiratory distress syndrome, Coronavirus disease 2019, Jaundice

Case Report

A 17-year-old male, with no known co-morbidities, came to causality in August 2021 with complaints of breathlessness on exertion for the past 45 days, yellowish discolouration of the sclera for 25 days, abdominal pain, vomiting, and swelling of both legs for three days. He was on medication from a native healer for jaundice 25 days back. In the month of June 2021, he was exposed to Coronavirus Disease 2019 (COVID-19) infection, treated as mild COVID-19, and advised supportive care and home quarantine.

At presentation, the patient’s pulse rate was 110 per minute, regular, no radio-radial delay with all peripheral pulses were felt equally, and his blood pressure was 100/70 mmHg. Patient’s room air saturation was 96% with a respiratory rate of 22 breaths per minute, and his body temperature was normal. General examination was suggestive of icterus, elevated jugular venous pressure, and bilateral pitting pedal oedema. The extremities were warm and well perfused with no pallor, cyanosis, clubbing. The abdomen was soft and distended. He had tenderness over the right hypochondrium, which on palpation showed tender hepatomegaly (liver span: 15 cm) also with shifting dullness on percussion. Cardiovascular examination showed soft S1 and a pansystolic murmur over the mitral area radiating to the back and entire precordium and axilla, apex beat was shifted out, downward and was hyperdynamic in character. Central nervous system examination and the respiratory system revealed bilateral basal crepitations.

Baseline investigation on Day 1 showed- thrombocytopenia (81,000/cumm), hyponatremia (126 mg/dL), Hyperbilirubemia (3.9 mg/dL) with elevated indirect bilirubin (2.8 mg/dL) and elevated enzymes (Aspartate aminotransferase: 584 U/L, Alanine transaminase: 462 U/L, Alkaline phosphatase: 95 U/L). The patient also had mild coagulopathy (prothrombin time: 23 sec, International normalised ratio: 1.8). The renal parameters were normal (urea: 31 mg/dL, creatinine: 1.15 mg/dL)
(Table/Fig 1).

Electrocardiogram (ECG) was suggestive of borderline right axis deviation (100°) with decreased amplitude in QRS complex in the frontal plane lead, poor R wave progression in the precordial leads (V1-V4), and incomplete Right Bundle Branch Block (RBBB). Chest x-ray was suggestive of cardiomegaly (Table/Fig 2). A 2D Echocardiography (Echo) showed enlargement of all four chambers, global hypokinesia of the left ventricle with severe Left Ventricle (LV) systolic dysfunction (Ejection Fraction: 23%). Mild to moderate mitral regurgitation and severe tricuspid regurgitation with (Pulmonary artery systolic pressure: 52 mmHg) and right ventricle dysfunction (Table/Fig 3). Ultrasonography (USG) abdomen showed hepatomegaly, mild to moderate ascites, mild right-sided pleural effusion. N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) was elevated (4894 pg/mL). Cardiac enzymes {Creatine phosphokinase (CPK) NAC :507 U/L, CPK MB: 25 U/L, troponin-I: 5.7 ng/L) were normal. Thyroid function test and lipid profile were normal. Immunoglobulin G (IgG) and Immunoglobulin M (IgM) for Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) was positive (Table/Fig 4).

In view of elevated indirect bilirubin, the patient was further worked up for haemolysis which showed- Lactate Dehydrogenase (LDH): 988 U/L, peripheral smear suggestive of moderate thrombocytopenia with an elevated reticulocyte count (3). The haptoglobin was low (22 mg/dL). Antinuclear Antibodies (ANA) was weakly positive. Direct and indirect Coomb’s tests were negative. Bile salts, bile pigments, and urobilinogen were negative. Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) were negative. The hepatitis panel was negative (Table/Fig 4).

Day 10 investigations showed, thrombocytopenia (1,38,000/cumm), liver function showed hyperbilirubemia (2.4 mg/dL) direct bilirubin (1 mg/dL), and indirect bilirubin (1.4 mg/dL) with reducing enzymes (AST: 43 U/L, ALT: 101 U/L, ALP: 86 U/L) and (Prothrombin time: 18.3, INR: 1.4) (Table/Fig 1).

Following the investigative findings, the diagnosis was established as DCM with congestive hepatopathy probably due to post COVID-19. On day 1, patient was decongested using frusemide (40 mg BD), and spironolactone (25 mg OD), while ensuring that his blood pressure was normal. Inj. Vitamin K (10 mg OD) was also started in view of coagulopathy. Prothrombin time-INR was monitored on daily basis.

On the third day of hospitalisation, the patient went into hypotension following the decongestion probably due to the diuretic effect (2,400 mL urine output compared to 750 mL of oral fluid intake). Hence, the diuretic was withheld, and he was started on inotropic support (dopamine) along with causation usage of intravenous (i.v.) fluid which was slowly tapered and stopped (36 hours).

Following haemodynamic stability of 48 hours, on 7th day patient was initiated on Angiotensin-Converting Enzyme 2 (ACE 2) inhibitors (Enalapril 2.5 mg BD), low diuretics (Spironolactone 25 mg OD, Furosemide 20 mg OD) and Digoxin 0.25 mg OD. On the 10th day of admission patient showed improvement clinically, his leg swelling, breathlessness and jaundice decreased, laboratory parameters liver function test, coagulopathy (INR: 1.40 and echocardiogram (ejection fraction 30%) showed an improving trend. Hence, the patient was discharged from the hospital on the 10th day of admission and was followed up on an Outpatient Department (OPD) basis.

After one week, the patient was reviewed in OPD. The leg swelling had resolved and breathlessness reduced. His platelets had improved (164000/cumm), and liver function showed hyperbilirubemia (2.3 mg/dL) direct bilirubin (1.0 mg/dL), and indirect bilirubin (1.3 mg/dL) with reducing enzymes (AST: 30 U/L, ALT: 60 U/L, ALP: 98 U/L) and (Prothrombin time: 18.1, INR: 1.38). His repeat ECHO showed ejection fraction of: 40%. So, he was advised to continue his ACE inhibitors, diuretics, digoxin and suggested regular monthly follow-up.

Following a three month review, the patient was asymptomatic and on regular medication for heart failure, and his laboratory parameters such as liver function test and thrombocytopenia resolved completely.

Discussion

Post COVID-19 Dilated Cardiomyopathy (DCM): In this pandemic of COVID-19, the hallmark of COVID-19 is respiratory involvement ranging from mild symptoms to acute severe respiratory distress syndrome. But some studies are showing an increasing number of patients being hospitalised for COVID with acute heart failure and multisystem inflammatory state (1),(2). Post COVID-19 cardiovascular sequelae are considered to be an involvement of the direct viral injury to the cardiac cells and host immune response against the virus (3). Cardiovascular sequelae associated with COVID-19 are myocardial injury, myocarditis, acute coronary syndrome, cardiac arrhythmias, cardiac arrest, cardiomyopathy, heart failure, and cardiogenic shock (4). Cardiomyopathies are the main cause of heart failure and sudden death in adolescents (5).

Though the aetiology of non hereditary DCM has not yet been elucidated, several viral genomes have been detected in myocardial tissue samples from patients diagnosed with DCM, even when infiltrating inflammatory cells are undetectable (6). A prolonged immune mechanism gets activated following a viral infection which causes a transition to DCM (7). COVID-19 infects the human heart especially, in case of heart failure as ACE 2 is upregulated because COVID-19 enters into human cells by binding its spike protein to the membrane protein Angiotensin-Converting Enzyme 2 (ACE 2) (8).

In the index case, the patient presented with DCM with elevated levels of NTPro-BNP (4894 pg/mL), which was similar to the case-series by Guo T et al., that analysed patients with COVID-19. Among 187 patients, 66 (35.3%) had cardiomyopathy out of which 27.8% of patients had myocardial injury. This study also reported that 8 (4.3%) of the study populace had cardiomyopathy with significant rise in troponin levels (p-value <0.001) (9). but there was no significant rise in troponin levels in the present case probably due to late presentation.

Similarly, a study of 416 hospitalised COVID-19 patients, showed evidence of myocardial injury which manifested with elevated high-sensitivity troponin-I levels. It was found that severe systemic inflammation was associated with greater leucocyte counts, C-reactive protein and procalcitonin. Other biomarkers such as creatine kinase, myoglin and NT-proBNP were elevated as well (1).

The patient’s 2D Echo was suggestive of enlargement of all four chambers, global hypokinesia of the left ventricle with severe LV systolic dysfunction (EF: 23%). This was similar to a study conducted by Inciardi RM et al., in which a 53-year-old female presented with elevated NT-proBNP levels and cardiac MRI showed increased wall thickness with diffuse biventricular hypokinesis in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%) (10).

In all the cases reported so far, the troponin levels were elevated but in the index case, the troponin levels were within normal limits. This emphasises better prognosis for the patient compared to patients with cardiovascular disease with elevated troponin levels that leads to significant morbidity and mortality rates. Though the patient had chief complaints of breathlessness and jaundice; bedside clinical examination revealed congestive heart failure, and the echocardiography, suggestive of DCM. The patient was not vaccinated and had a COVID-19 infection (COVID-19 IgG and IgM: positive) 15 days prior to onset of the above symptoms. The patient would have still been having a persistent immune mediated activation due to the COVID-19, which could have led to haemolytic pictures as well as the DCM.

Dilated Cardiomyopathy (DCM) with congestive hepatopathy: Any cause of elevated central venous pressure such as right-side heart failure, biventricular dysfunction, severe pulmonary hypertension or cor-pulmonale, constrictive pericarditis leads to the development of hepatic congestion, which is also referred to as congestive hepatopathy (11).

Ascites is also clinically present in up to 20% of patients with congestive hepatopathy (12), while cases presenting with pleural effusion and pericardial effusion were also reported (11). Congestive heart failure shows a broad range of liver abnormalities, a hepatocellular pattern with predominantly elevated transaminases is seen in hypoxic hepatitis. In cardiac hepatopathy, hyperbilirubinemia is reported with a mild increase in unconjugated bilirubin (<3 mg/dL) in 70% of patients (13).

In congestive hepatopathy, the common laboratory abnormalities are hyperbilirubinemia, which is reported with a mild increase in unconjugated bilirubin (<4.5 mg/dL); out of which 50-60% are unconjugated because of mild haemolysis, reduced uptake, and decreased conjugation by hepatocytes. INR derangement in acute congestion may rise up to twice the normal and it is not responsive for the vitamin K, and may return normal after successful decongestion. Aminotransferases are elevated 3-4 times the UNL, and AST >ALT as the AST is rich in cardiac myocytes. And these enzymes return to normal in 3-7 days after improving cardiac function. Albumin is decreased to 30-50%, it takes more than a month to improve following the resolution of the heart failure (14).

In the present case, patient had the characteristic laboratory abnormalities congestive hepatopathy of such as predominant unconjugated hyperbilirubinemia and elevation of aminotransferases with which became normal after successful treatment with the ACE inhibitors (enalapril), low diuretics (spironolactone, furosemide), and digoxin. And also features of mild haemolysis such as mild coagulopathy, with low haptoglobin level, elevated LDH, and a weakly positive ANA report which may probably be due to the immune-mediated effect of the COVID-19 or because of the native medication which the patient had during the event of jaundice.

Conclusion

Many studies have been reported on coronavirus-related DCM, but due to a rapid deterioration in such patients it is difficult to extend the process of research among these patients. This patient was asymptomatic without any cardiac symptoms until the event of COVID-19 illnesses. However, immediately 15 days post COVID-19 infection, he started to have acute symptoms of breathlessness, pedal oedema, and abdominal pain. Further evaluation confirmed presence of DCM with congestive hepatopathy. These symptoms might have shown due to the persistent immune mediated activation, seen in post COVID-19 infection. Still future research is needed to determine the cause of myocardial injury and adverse cardiac outcome after this viral infection.

References

1.
Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalised patients with COVID-19 in Wuhan, China. JAMA Cardiology. 2020;5(7):802-10. [crossref] [PubMed]
2.
Garg N, McClafferty B, Ramgobin D, Golamari R, Jain R, Jain R. Cardiology and covid-19: Do we have sufficient information? Future Cardiology. 2021;17(4):705-11. [crossref] [PubMed]
3.
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DOI and Others

DOI: 10.7860/JCDR/2022/53273.16179

Date of Submission: Nov 12, 2021
Date of Peer Review: Jan 03, 2022
Date of Acceptance: Feb 12, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 16, 2021
• Manual Googling: Jan 03, 2022
• iThenticate Software: Feb 21, 2022 (9%)

ETYMOLOGY: Author Origin

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