P301 FULMINANT COVID–19 RELATED MYOCARDITIS: A CASE REPORT

The case

A 58–year–old man presented to ED because of fever, non–productive cough and worsening dyspnea. The patient’s medical history was unremarkable. On examination there was a hypoxic respiratory failure and the clinical picture rapidly evolved towards a cardiogenic shock characterized by altered mental status and cool extremities. Vital parameters: peripheral blood pressure was of 60/30 mmHg, pulse rate of 126 bpm, respiratory rate of 30 breaths/min, temperature of 38 °C. Two episodes of ventricular fibrillation were resolved by electrical shocks. The nasopharyngeal swab tested positive for COVID–19 on real–time reverse transcriptase–polymerase chain reaction assay. Arterial blood gas analysis showed a severe metabolic acidosis with hyperlactacidaemia (pH 7.26, excess basis–22 mEq/L, lactates 10 mmol/dL) and hypoxaemia. Situation evolved towards an end–organ hypoperfusion associated with multisystem organ failure (MOF). High resolution chest CT demonstrated bilateral ground glass opacities consisting of COVID–19 related interstitial pneumonia. 12–leads ECG demonstrated sinus rhythm with diffuse concave ST–segment elevation. T–T echocardiogram showed: 1) severely thickened LV walls; 2) decreased LV systolic function; 3) segmental wall motion abnormalities consisting of akinesis of the LV distal segments with relatively preserved function at the base; 4) LVEF) of 25%; 5) pericardial effusion. Thickened LV walls meant myocardial inflammatory infiltration/edema and the final diagnosis was FULMINANT COVID–19 related MYOCARDITIS. Patient underwent oro–tracheal intubation+invasive ventilation. An intra–aortic balloon pump (IABP) was placed on top of adrenaline (0.07μg/kg/min), and noradrenaline (0.1μg/kg/min) was added for worsening hypotension (systolic blood pressure: 80/67/60 mmHg). Additional therapy consisted of intravenous high dose diuretics, methyprednisolone, tucilizumab, immunoglobulin, ceftriaxone, remdesivir. After 3 weeks, patient recovered a good respiratory and haemodinamic status, LV wall thicknesses decreased and EF increased to normal values. The final outcome was favorable.

Discussion

The prevalence of fulminant myocarditis among COVID–19 patients is unclear. This simultaneous presentation of fulminant myocarditis and COVID–19 pneumonia favors an alternative pathogenetic pathway with possible acute replication and direct dissemination of the virus through the blood or the lymphatic system from the respiratory tract to the myocardium.

Morphometric comparison between contralateral sciatic nerves in the male and female rabbit

Some morphometrical parameters of the axons making up the contralateral sciatic nerves, both in the male and female rabbits were calculated and compared by means of a Zeiss Vidas image analyser (Ober Kochen, Germany). The results show that the fibres constituting the left nerve have a greater mean diameter but a lower mean density that those constitution the right nerve. This suggests that the diameter of the myelinated fibres and the density of both the myelinated and unmyelinated fibres do not vary from male to female. On the other hand, the G ratio and the diameter of the unmyelinated axons do, since the nerves on the right side (in both sexes) have higher morphometric values, on average, than the contralateral ones.

The three-dimensional architecture of the myosalpinx in mammals: an anatomical model for a functional hypothesis

Direct visualization of the three-dimensional architecture of the tubal musculature (myosalpinx) was made possible by a technique involving chemical digestion of interstitial connective tissue, followed by ultrasonic microdissection and final observations under the scanning electron microscope. The isthmic myosalpinx in the guinea pig, rabbit and in humans consists of muscular bundles that tend to lie longitudinally, circularly or oblique. The muscular bundles along the tubal wall change direction, branch and intermingle with one another, giving rise to an irregular network in which distinct layers are not readily distinguishable. In the ampulla, the muscle bundles form a very irregular three-dimensional network of fibres that follow different orientations. The authors suggest a primary role for such a structure in the random pendular transport of the gametes as well as in the denudation of the egg by deformation of the myotubal wall.