COVID myocarditis in a collegiate athlete: Timeline and return to play

Studies in collegiate athletes have demonstrated a prevalence of cardiac involvement between 0.5 and 3 % after SARS-CoV-2 infection. When post-COVID cardiac involvement occurs in athletes, the ideal return to play timeline and many possible long-term sequela or complications are unknown. A 20 yo female collegiate athlete tested positive for SARS-CoV-2 and underwent routine cardiac screening prior to her return to play (RTP). Evaluation demonstrated an elevated high-sensitivity troponin-I and an ECG showed some mild T wave changes. She had a normal transthoracic echocardiogram, and her Cardiac magnetic imaging (CMR) met Lake Louise Criteria for acute myocarditis. She was diagnosed with acute myocarditis and restricted from sports. CMR was repeated at 3.5 months after normalization of troponin I HS and demonstrated continued active inflammation. She continued to be restricted from exertion. A third CMR was obtained at 6.5 months and showed resolution of active inflammation but a small area of fibrosis, and the remainder of her cardiac testing was normal. She was allowed to slowly progress back into sport and returned to competition at 9 months and successfully completed her season. CMR is not typically repeated prior to RTP after a diagnosis of myocarditis in athletes, but in this case, repeat CMR at 3.5 months initially demonstrated continued active inflammation, and a second repeat CMR at 6.5 months demonstrated abnormal cardiac fibrosis. This may suggest utility in repeating CMR and raises questions about possible long-term implications of cardiac fibrosis once the acute inflammation of myocarditis has resolved.