A case report of long COVID-19 and chronic active myocarditis

Background Post-acute sequelae of SARS-CoV-2 infection (PASC), commonly known as ‘Long COVID-19’, are progressively emerging in the population. While it was clear from the pandemic outbreak that pre-existing cardiac conditions were exacerbated by the infection even after its resolution, little is known about the rare cases of de novo heart failure onset, whose mechanisms are still not fully understood. Case summary A 74-year-old man was admitted to the emergency department with SARS-CoV-2 bilateral interstitial pneumonia at the computed tomography scan. A few months after, he developed acute myocarditis that slowly led to progressive myocardial fibrosis, systolic dysfunction, and a pro-arrhythmic state. Furthermore, these manifestations were associated with growing ‘mental dullness’ and chronic psychophysical asthenia. The patient underwent two cardiac MRI over 3 years witnessing the worsening of cardiac involvement and started full pharmacological therapy for heart failure. We report here the initial presentation, medical care, and clinical course of this patient. Discussion In SARS-CoV-2 patients, long COVID-19-related myocarditis is one of the more severe complications. A thorough multimodal evaluation of these patients should be conducted, as presentation symptoms can appear subtle or misleading. Early identification of a chronic process of myocardial damage is crucial to implement early therapeutic strategies and prevent the potential worsening of heart failure.