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TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus-19 (COVID-19) myocarditis showed increased mortality despite team work of experts. We present a case of a middle-aged male with COVID-19 related myocarditis leading to cardiogenic shock. CASE PRESENTATION: 64-year-old male with history of hypertension, hyperlipidemia, hypothyroidism and positive COVID-19 infection with related stroke presented with 2 weeks of myalgias, malaise, and dyspnea. He was tachycardic on exam with bibasilar crackles and mild pedal edema. Labs revealed elevated inflammatory markers, cardiac biomarkers and leukocytosis with peripheral eosinophilia. Pulse dose steroids were initiated for suspected vasculitis. Transthoracic echocardiogram (TTE) revealed global hypokinesis and cardiac catheterization revealed LVEDP of 28 mmHg, LVEF of 10%, and cardiac index of 1.7 L/min/m2 without ischemic disease. Inotropes were started, and the patient was transferred to the center for advanced heart failure and cardiac transplant evaluation. Cardiac MRI (CMRI) revealed late enhancing subendocardial myocardial scarring of anteroseptal segments and endomyocardial biopsy revealed focal ischemic injury suggestive of COVID-19 related myocarditis in the setting of multisystem inflammatory syndrome (MIS-A). DISCUSSION: MIS-A is a rare subacute complication of COVID-19, thought to be caused by direct cell injury from ACE2 upregulation and a dysregulated immune response resulting in acute myocarditis. Elevated troponins have been reported in these patients due to ventricular dilation and direct myocardial injury. Electrocardiograms have poor sensitivity for myocarditis, thus TTE is performed which reveals wall abnormalities with reduced ventricular function and has been reported in 60% of COVID-19 related myocarditis cases. CMRI is preferred to evaluate myocarditis and may reveal hyperemia, edema, and myocardial necrosis. Endomyocardial biopsy (EMB) is the gold standard for diagnosing myocarditis, but should be a shared decision due to lack of studies to support EMB diagnosis in suspected COVID-19 myocarditis. Patients with cardiogenic shock need vasopressors and inotropes, and mechanical circulatory support via extracorporeal membrane oxygenation or intra-aortic balloon pumps if needed. It is unclear if intravenous immunoglobulins or steroids have benefit treating COVID-19-related myocarditis and requires further evaluation. CONCLUSIONS: Myocarditis should be suspected in patients with COVID-19 infection presenting with acute heart failure. Given limited data for COVID-19 related myocarditis, we need more studies to better treat these patients. REFERENCE #1: Morris SB, Schwartz NG, Patel P, et al. Case series of multisystem inflammatory syndrome in adults associated with sars-cov-2 infection — united kingdom and united states, march–august 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1450–1456. REFERENCE #2: Sawalha K, Abozenah M, Kadado AJ, et al. Systematic review of COVID-19 related myocarditis: insights on management and outcome. Cardiovasc Revasc Med. 2021;23,107-113. REFERENCE #3: Siripanthong B, Nazarian S, Muser D, et al. Recognizing covid-19-related myocarditis: the possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm. 2020;17(9):1463-1471. DISCLOSURES: No relevant relationships by Suong Nguyen, source=Web Response No relevant relationships by Nikola Perosevic, source=Web Response No relevant relationships by Evan Wasserman, source=Web Response