Differentiating COVID-19-associated pericarditis from other diseases

• Normal limits in acute pericarditis.
• Enlarged cardiac silhouette in cardiac tamponade.

• ST elevation and PR depression are seen but these changes are not specific to COVID-19 pericarditis.
• Non-specific ST changes
• T wave inversion in the inferior leads (II, III and aVF)

• Small to moderate pericardial effusion.
• In the cases complicated by cardiac tamponade, findings included:
  • Large pericardial effusion
  • Right ventricular diastolic collapse
  • Increased respiratory variation in peak E-wave mitral inflow velocity
  • Dilated inferior vena cava

• CT: Pericardial effusion
• CMR: late gadolinium sequences done to rule out myocarditis showed extensive enhancement of the walls of the heart and the pericardium in two of the reported cases.

• On physical exam, Pericardial friction rub may be heard; tachycardia, hypotension and distant heart sounds seen in cardiac tamponade
• Increased cardiac troponin level, CK level; increase in inflammatory markers levels.

• Pericardial effusion may be detectable

• Non-specific:may show nonspecific ST-T abnormalities, sinus tachycardia and conduction abnormalities (such as bundle-branch blocks or atrioventricular conduction delays)

• Non-specific: In fulminant myocarditis, cardiac chamber sizes are usually normal with an increased septal thickness (secondary to acute myocardial edema), whereas in acute myocarditis marked left ventricular dilation and normal wall thickness might be seen.
• Pericardial effusion may be be seen.

• CMR: T2-weighted edema imaging shows the presence of “acute myocardial inflammation”. “Late gadolinium enhancement (LGE) imaging” can demonstrate myocardial damage.

• No specific X-ray findings

• ST elevation MI (STEMI)
• Non-ST elevation MI (NSTEMI) or Non Q wave

• Localized wall motion abnormalities
• Diffuse hypokinesia
• Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.

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• Cardiomegaly
• Pulmonary edema (interstitial, alveolar)

• Left ventricular hypertrophy
• Low-voltage QRS
• Non-specific ST-T change

• Systoloic dysfunction (in HFrEF)
• Diastoic dysfunction (in HFpEF)
• COVID-19-associated stress cardiomyopathy (apical ballooning)

• CT: Cardiomegaly, Pulmonary edema
• CMR: Signs of underlying myocarditis may be seen.

• Lobar Consolidation

• Prolonged PR interval
• Transient T wave inversions

• CT: Lobar Consolidation

• Bilateral ground-glass opacities

• Signs of RV dysfunction/RV dilatation may be seen.

• CT: Bilateral ground-glass opacities

• May show Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark’s sign

• Non-specific:may show S1Q3T3 pattern

• May show signs of RV strain, RV dilatation, RV dysfunction (if large PE)

• On CT angiography: Intra-luminal filling defect
• On MRI: Narrowing of involved vessel
• No contrast seen distal to obstruction
• Polo-mint sign (partial filling defect surrounded by contrast)

• Increased D-dimer, fibrinogen, and fibrin degradation products levels
• May have symptoms and/or signs of accompanying DVT