*Purpose: COVID-19 infection involves entry of SARS-CoV-2 virus into cells via interaction between its spike protein and angiotensin converting enzyme resulting in an NF-κβ mediated inflammatory response. A cytokine storm may cause organ dysfunction. Cardiac manifestations without pulmonary symptoms is uncommon but has been described in the literature during an acute infection. We report a rare case of a potential late cardiac complication months after an acute COVID-19 infection.

*Methods: A 62-year-old male with hypertension and end stage renal disease on hemodialysis three times a week presented with fever, arthralgia and myalgia. He denied chest pain or respiratory symptoms. Patient tested positive for COVID-19 and received conservative management only. Over the next nine months he reported persistent fatigue and new onset of shortness of breath. He continued to be very compliant with dialysis. On presentation to the hospital, all laboratory investigations, including BUN (27mg/dL) were within normal limits. Chest X- ray revealed cardiomegaly. Echocardiogram showed a large circumferential pericardial effusion without tamponade. Pericardiocentesis was accomplished with removal of 1700 ml of bloody fluid. Cell count, LDH, protein and glucose was normal. Fungal, aerobic, and anaerobic cultures of the pericardial fluid was negative. No malignant cells were detected. Patient had gradual resolution of his symptoms. Serial echocardiograms at 1, 3 and 5 months revealed a persistent small pericardial effusion.

*Results: Cardiac manifestations of SARS-CoV-2 includes myocarditis, pericarditis and pericardial effusions. In case reports, the presence of the cardiac inflammatory state occurred simultaneously with an acute COVID-19 infection. In our case the COVID-19 infection occurred over nine months earlier yet remains a plausible explanation for his hemorrhagic pericardial effusion due to the absence of other identified causes. Further, COVID-19 molecular PCR testing of pericardial testing remains low yield due to its specific development for nasopharyngeal swab sampling.

*Conclusions: Cardiac manifestations of SARS-CoV-2 infection typically occur at the time of diagnosis. A late cardiac complication of COVID-19 may include pericardial inflammation with effusion. Further data and testing needs to be developed to confirm the diagnosis and guide therapy.

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