Case 1
A 76-year-old man presented to the emergency room (ER) with a 10-day history of shortness of breath, fever and dry cough. He had a previous diagnosis of prostate cancer, currently in remittance. His baseline characteristics are shown in Table 1. He had leukopenia, elevated cardiac markers including creatine kinase (CK), creatine kinase myocardial band (CK-MB) and lactate dehydrogenase (LDH) and a severe acute respiratory distress syndrome (ARDS) with a PaO2/FiO2 ratio of 59, which was initially treated with a high-flow nasal cannula (HFNC) and supportive treatment. A TTE was performed during day 8 of his hospital stay. This revealed abnormal LV function with an LVEF of 35% and a GLS of -14%. Echocardiographic characteristics are shown in Table 2. He was intubated the next day and developed barotrauma with a right pneumothorax that required a pleural catheter for evacuation. Afterward, on his 10th day, he developed an acute kidney injury (AKI) with anuria, multiorgan failure and acidosis. He passed away on his 11th day.
Table 1  Baseline Clinical and Laboratory Characteristics
Variable  Case 1  Case 2  Case 3  Case 4
Gender  Male  Male  Male  Male
Age (years)  76  64  66  26
Comorbidities  Prostate cancer  HIV  None  None
White blood cell count, /µL  11.2  8.6  14.3  8.1
Lymphocytes, /µL  0.306  0.483  0.563  1.4
Serum creatinine, mg/dL  0.9  0.9  5.3  0.8
Aminotransferase
  Aspartate, U/L  44  96  99  68
  Alanine, U/L  40  108  43  85
  Albumin, g/dL  2.1  2  2.7  3.4
  hs-CRP, mg/dL  27  20.6  23.1  11.3
  ARDS  Yes  Yes  Yes  Yes
  PaO2/FiO2 ratio  59  66  180  258
Cardiac injury markers
  hs-TpnI, ng/L  2.8  5.4  5.6  1.4
  CK, U/L  721  868  517  50
  CK-MB, U/L  29  35.3  26.5  n/a
  LDH, U/L  312  259  424  317
hs-CRP: high-sensitivity C-reactive protein; ARDS: acute respiratory distress syndrome; hs-TpnI: high-sensitivity troponin I; CK: creatine kinase; CK-MB: creatine kinase myocardial band; LDH: lactate dehydrogenase.
Table 2  Echocardiographic characteristics and Recommended Reference Values
Variable  Case 1  Case 2  Case 3  Case 4  Reference value
LV septal thickness, cm  0.8  1.2  1.1  0.7  0.6 - 1
Posterior wall thickness, cm  0.8  1.1  0.8  0.9  0.6 - 1
LV indexed mass, g/m2  80.7  56.5  81.4  73.6  49 - 115
Relative wall thickness  0.31  0.47  0.32  0.37  0.24 - 0.42
VfdVI MOD BP  38  76  n/a  83  62 - 150
VfsVI MOD BP  25  26  n/a  56  21 - 61
LVEF, %  35  66  65  33  52 - 72
Left atrial indexed volume, mL/m2  21.8  15.4   11.1  < 34
Average GLS, %  -14  -18  n/a  -14  < -18.5%
Aplax GLS, %  -12  -18  n/a  -14  < -18.5%
a4C GLS, %  -13  -18  n/a  -13  < -18.5%
a2C GLS, %  -15  -19  n/a  -14  < -18.5%
TAPSE, mm  25  26  20  20  > 18
S wave, cm/s  0.18  0.7  0.18  0.12  > 0.095
RV basal diameter, mm  33  34  47  39  25 - 41
RV mid-cavity diameter, mm  29  22  45  34  19 - 35
MV E wave velocity, m/s  0.5  0.83  0.54  0.38  > 50
MV deceleration time, ms  210  218  185  147  > 200
E/A ratio  0.63  1.03  0.69  0.44  ≥ 0.8
Septal e′ velocity, m/s  0.05  0.08  0.07  0.1  > 7
Lateral e′ velocity, m/s  0.1  0.09  0.1  0.1  > 10
E/e′ ratio  6.6  9.66  6.27  3.78  < 10
Data are shown as frequencies (%) and median (min. - max.) or mean ± SD. LV: left ventricular; LVEF: LV ejection fraction; GLS: global longitudinal strain; a4C: apical four-chamber view; APLAX: apical long axis view; a2C: apical two-chamber view; TAPSE: tricuspid annulus plane systolic excursion; RV: right ventricular; MV: mitral valve; n/a: not available.