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Lack of efficacy: case report A 44-year-old woman exhibited lack of efficacy with dobutamine, while being treated for hypotension and with amiodarone, while being treated for atrial fibrillation with ventricular tachycardia. The woman was admitted with 3 day history of lethargy, febrile illness, muscle aches and two episodes of syncope at hospital in UK. Based on various investigations and clinical presentation, she was diagnosed with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) related fulminant myocarditis. Subsequently, she started receiving treatment with methylprednisolone. Additionally, she was receiving treatment with dobutamine infusion for hypotension and amiodarone infusion for atrial fibrillation with ventricular tachycardia [dosages not stated]. However, in the ICU despite treatment with dobutamine, she developed cardiogenic shock with a BP of 60/40 mm Hg. ECG showed an atrial fibrillation with ventricular rate of 140 bpm, and she had signs of peripheral hypoperfusion despite treatment with amiodarone and inotropic support (lack of efficacy). Thereafter, she was treated with milrinone and norepinephrine. Later, she developed typical SARS-CoV-2 pneumonia and renal failure. Within few days on milrinone and methylprednisolone treatment normal biventricular function was regained. By day 15 of hospitalisation an improvement in respiratory support was observed and tracheostomy was performed. Her condition improved, and she was discharged on day 41 following closure of her tracheostomy. She continues to recover at home. Naneishvili T, et al. Fulminant myocarditis as an early presentation of SARS-CoV-2. BMJ Case Reports 13: No. 9, 14 Sep 2020. Available from: URL: http://doi.org/10.1136/ 803508193 bcr-2020-237553

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Reactions 17 Oct 2020 No. 1826