Multidisciplinary Rehabilitation Approach of COVID Myocarditis and Triple Extremity Amputation: A Case Report

Case Diagnosis: A 25 year-old female with COVID-19 myocarditis and triple limb amputation.

Case Description or Program Description: A 25-year-old female with a history of COVID-19 myocarditis, which necessitated veno-arterial extracorporeal membrane oxygenation (VA-ECMO) due to severe cardiac dysfunction, subsequently developed limb necrosis in both lower extremities and her right upper extremity, leading to bilateral transfemoral amputation and right transhumeral amputation.

Setting: Acute Inpatient Rehabilitation Unit

Assessment/Results: The patient presented to inpatient rehabilitation with multi-limb amputation, critical illness myopathy in the sound limb, renal failure requiring a hemodialysis catheter, and a wound vacuum over the left medial thigh. The patient’s rehabilitation course was interrupted due to medical complications including heart failure exacerbation and acute lymphocytic myocarditis. Over a 119-day course, including 34 days of acute rehabilitation, the patient achieved significant improvements in mobility and independence. The patient demonstrated progress in bed mobility, power wheelchair mobility, standing balance with foreshortened prostheses, and performing activities of daily living (ADLs). Additionally, she gained the capability to perform lateral slide board transfers with standby assistance. Medical management was comprehensive and involved a holistic team, including a physiatrist, pulmonologist, nephrologist, infectious disease specialist, wound care team, and dietician. This multidisciplinary approach facilitated improvements in cardiorespiratory and renal function, pain management, and infection treatment.

Discussion (relevance): Amputation involving an upper and lower limb is uncommon, while triple amputation is exceedingly rare, with limited documented cases. The rehabilitation process in a patient with cardiomyopathy and triple amputation poses unique challenges that are exacerbated in comparison to patients with single extremity amputations or cardiac rehabilitation alone. Her inpatient rehabilitation focused on (1) Functional mobility training, (2) ADL Training, (3) Power mobility and prosthetic evaluations, (4) Medical management, and (5) Psychosocial support facilitated significant functional recovery.

Conclusions: Intensive inpatient rehabilitation with a multidisciplinary approach provided significant benefit to this patient recovering from COVID-19 myocarditis and triple amputations.