Introduction: Myocarditis is an inflammatory disease involving the myocardium, resulting in myocardial injury without any ischemic cause. The most common etiology of myocarditis remains viral, and the pathophysiology of COVID-19 viral myocarditis results from direct cell injury. We present an interesting case of COVID-19 induced myocarditis leading to cardiogenic shock with management complicated by the patient’s anatomy.

Case Presentation: A 19-year-old female with no known past medical history presented to the ED with complaints of nausea, vomiting, diarrhea, and subjective fever of 5-day duration. The patient’s vitals were significant for tachycardia and hypotension. Her oxygen saturation was 87% on room air. Her physical exam revealed no acute findings. Initial workup revealed a WBC 7.2 K/uL, hemoglobin 16.8 g/dL, platelets 119 K/uL, and lactic acid 7.9 mmol/L. Her high-sensitivity troponin was 1,228 ng/L, and BNP was 4,725 pg/mL. Her COVID-19 test was positive. Transthoracic echocardiogram showed an ejection fraction of 25 to 30%, severely reduced left ventricular systolic function, and a moderate to large pericardial effusion. The patient’s condition declined, and she became hemodynamically unstable. She was started on pressor support with norepinephrine infusion. Interventional cardiology was consulted, given her cardiogenic shock, and coronary angiogram was negative for coronary artery disease. The patient underwent intra-aortic balloon pump placement as her anatomy would not allow for Impella placement, given the small diameter of her femoral artery. The patient’s condition continued to deteriorate, and she required intubation in addition to the escalation of vasopressors. After a multidisciplinary collaboration, the decision was made to cannulate for venoarterial extracorporeal membrane oxygenation. During the procedure, the patient was noted to be coagulopathic with profuse bleeding necessitating transfusion with packed red blood cells, platelets, and fresh frozen plasma. Despite multiple interventions, she went into asystole and passed away.

Final Diagnosis: Ultimately this patient was diagnosed with cardiogenic shock in the setting of myocarditis from COVID-19 infection.

Management: Management of COVID-19 viral myocarditis is supportive, and if cardiogenic shock is present, then liberal use of inotropes and vasopressors is recommended. Patients may also require mechanical circulatory support if cardiogenic shock continues to deteriorate.