Post-Acute Sequelae of SARS-CoV2 Infection in a Collegiate Athlete: Evaluating the "Long-Hauler"

A 21-year-old female collegiate track and field athlete with a history of exercise-induced asthma and acute COVID-19 infection 4 months prior is referred to a sports cardiologist for evaluation of ongoing exercise intolerance, chest pain, shortness of breath, and lightheadedness with activity.

Her acute COVID-19 symptoms included fever for 2 days, congestion, myalgias, back pain, palpitations, chest pain, and anosmia and ageusia that lasted for 1 week. At the time, she had no shortness of breath or cough. She was not hospitalized and received no treatments. A trial of her albuterol inhaler, used previously for exercise-induced asthma, did not alleviate her symptoms.

Prior to developing COVID-19, she was exercising at least three times per week (running, rowing, and strength training) without limitation. After acute infection, she was unable to resume exercise due to ongoing symptoms and estimated that she could only exert herself to about 25-50% of her prior intensity. Her chest pain – initially constant – was exacerbated by activity and deep breathing. Her lightheadedness and sensation of heart racing worsened with activity/walking and positional change. She experienced lingering fatigue, difficulty sleeping, and impaired concentration. These symptoms persisted for 4 months, up to the time of evaluation by a sports cardiologist.

She has no significant family history, denying any history of sudden cardiac death, channelopathies, aortopathies, and cardiomyopathies. She denied use of illicit substances and performance enhancing drugs.

On physical exam, blood pressure was 106/70 mmHg and heart rate was 80 bpm. Orthostatic vital signs were negative. Heart rate after 10 minutes of quiet standing was 105 bpm. Physical exam was otherwise normal. Her resting 12-lead electrocardiogram (ECG, Image 1) showed normal sinus rhythm, normal axis and intervals, no ST-T wave abnormalities nor stigmata of channelopathies or pre-excitation. Chest X-ray showed no significant findings. Previous laboratory testing included a complete blood count, comprehensive chemistry panel, thyroid function tests, high-sensitivity troponin, sedimentation rate, C-reactive protein, and all values were within normal range. Cardiac biomarkers were repeated at the time of the evaluation and were still negative/normal.

Image 1: Resting 12-Lead Electrocardiogram

Image 1

An echocardiogram was performed and revealed normal size of all four chambers, normal left ventricular systolic and diastolic function (LVEF = 62%, global longitudinal strain = -21.8%), normal right ventricular systolic function, no regional wall motion abnormalities, no significant valvular abnormalities, normal pulmonary artery systolic pressure, and no pericardial enhancement or pericardial effusion.

Additional testing performed prior to her evaluation by a sports cardiologist included an ECG stress test (treadmill Bruce protocol) where she exercised for 12 minutes, achieving 95% of maximum predicted heart rate (MPHR), and 13.4 METS. She endorsed 6 out of 10 chest pain while exercising. However, her ECG showed normal sinus rhythm, sinus tachycardia, no ischemic ST-segment changes, and no exercise-induced arrhythmias.

Pulmonary function tests showed no evidence of obstructive or restrictive lung disease: forced expiratory volume (FEV1) was 85%, forced vital capacity (FVC) 89%, FEV1/FVC ratio 0.82, diffusing capacity/alveolar volume (DLCO/VA) 89%, and methacholine challenge was negative. Additionally, cardiac magnetic resonance imaging revealed preserved biventricular dimension and function, no regional wall motion abnormalities, and no evidence of late gadolinium enhancement or myocardial edema.

She proceeded with ambulatory rhythm monitoring (Zio Patch), which she wore for 8 days. Her average heart rate was 84 bpm (range 56-178 bpm), and there were no significant atrial or ventricular arrhythmias nor atrioventricular blocks or pauses. Symptoms of heart racing and dizziness at a low level of activity correlated to sinus tachycardia at 140-150 bpm.

She completed a maximal effort (respiratory exchange ratio >1.09) cardiopulmonary exercise test, exercising for 13:06 minutes (Bruce protocol), and achieving 10.9 METS with a maximum heart rate of 196 bpm (98% MPHR). Her ECG revealed sinus rhythm with no exercise-induced atrial or ventricular tachyarrhythmias, no increase in ventricular ectopy, and no atrioventricular conduction abnormalities. Exercise was terminated after the patient endorsed shortness of breath and fatigue, with a rating of perceived exertion of 9/10. Additionally, she reported 7/10 non-pleuritic chest pain with exercise. Pulmonary auscultation post-exercise was normal. Peak oxygen consumption (VO2) was 38.3 ml/kg/min (115% predicted based upon age- and gender-matched controls). Oxygen pulse achieved was 108% predicted. Blood pressure response was normal. Anaerobic threshold was reached at 45% of the peak VO2. Respiratory rate at anerobic threshold was 26, and 54 at peak. Parameters of gas exchange were normal and oxygen saturations remained within normal limits: 99% at rest and 97% at peak stress.

Image 2: Cardiopulmonary Exercise Test – Heart Rate & O2 Pulse Graph

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Image 3: Cardiopulmonary Exercise Test – Exercise Flow-Volume Loop at Peak

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Image 4: Cardiopulmonary Exercise Test: Post-Exercise Flow Volume Loop

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Tilt table test was also performed:

Time/Condition Blood Pressure Heart Rate Symptoms
Baseline 132/76 83 None
8 min 109/58 114 Dizzy, headache
18 min 110/65 96 Dizzy, lightheaded, nauseous
Nitroglycerin 94/52 130 Weak, lightheaded, no loss of consciousness

What is your diagnosis and proposed management?

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