A 69-year-old male presented to an outside hospital with exertional chest pain of unknown duration. Vitals on admission: BP 99/71 HR 66 O2Sat: 97% on RA Physical examination: on general appearance he was in distress due to pain, JVD 2 cm above clavicle, chest were clear bilaterally, regular heart sounds, S1/S2 audible, no murmurs.
Extremities were warm with trace edema bilaterally.
Hypertension, hyperlipidemia, abdominal aortic aneurysm of 2.7 cm, uncontrolled diabetes and 1 pack-year tobacco use.
Acute coronary syndrome
Electrocardiogram revealed a posterior STEMI (Figure 1 ) for which he received tenecteplase, clopidogrel and aspirin. He was airlifted to our hospital for coronary angiography due to ongoing chest pain and persistent ST elevation. Angiography revealed a left-dominant system with a culprit 100% thrombotic occlusion of the left circumflex coronary artery and a non-culprit 90% proximally diseased left anterior descending artery (LAD) (Figure 2 and Figure 3 , Video 1 and Video 2). Although we were able to wire past the lesion, balloon angioplasty was unsuccessful due to extensive thrombus burden.
An intra-aortic balloon pump was inserted, and he was transfer to the coronary care unit (CCU) for medical management of STEMI. Transthoracic echocardiography revealed a left ventricular ejection fraction of 25% (Video 3) and a small circumferential pericardial effusion with visible thrombus (Figure 4 , Video 4). On further inquiry about the duration of symptoms, he admitted having chest pain for the last six days but had been avoiding seeking medical care due to ongoing pandemic. He was diagnosed with hemorrhagic pericarditis after treatment of MI with tenecteplase. For his STEMI he was managed with aspirin 81mg daily and ticagrelor 90mg twice daily. Anticoagulation was avoided and the intra-aortic balloon pump was removed next day. He tested negative for COVID-19.
Coronavirus disease 2019 (COVID-19) syndrome triggered a global pandemic with over three million confirmed cases to-date. Hospital systems worldwide have instituted emergency protocols to limit the spread of this pandemic, and some have transitioned to fibrinolytics for initial management of MI including STEMI (1). Although STEMI presentations are on the decline because patients are afraid of hospital contact (2-4), delayed revascularization poses a challenge due to reemergence of rare MI-related complications.
A study from China reported that patients with STEMI delayed seeking help from fear of COVID-19 (2) . Italy also revealed a decrease in MI admissions for the last several months when compared to the same timeframe in the prior year (3). Moroni et al (5), described complications of STEMI in three Italian patients who avoided the hospital because of COVID-19. One US study observed a 38% reduction of STEMI activations during the early phase of the pandemic (4) . Multiple studies corroborate that public fear of contracting SARS CoV-2 is leading to a decline in timely presentation of MI patients (2) (3) (4) . This phenomenon has been reported before in the SARS CoV-1, and H1N1 pandemics of 2003 and 2009, respectively (6). Our patient reported avoiding early medical care due to fear of acquiring COVID-19 in the hospital. One study suggests a significant increase in mortality during ongoing pandemic that is not fully explained by COVID-19 deaths alone (3) . This raise the question of whether some patients died from undiagnosed MI.
The incidence of MI related complications increases with delayed presentations and management (7) . In addition to the common sequalae of MI (i.e., arrhythmia and heart failure), rare complications such as papillary muscle rupture, ventricular septal rupture, and pericarditis can develop from delayed management. 8 Streptokinase trials from the early 1990s revealed that the incidence of early post-infarction pericarditis (first 2-5 days post MI) was 20%, with a decline to 6% after thrombolytics, and 4% after primary PCI; generally a pericardial effusion is not present in this group of patients (8) . Late pericarditis (i.e., Dressler's syndrome) develops 1 week after MI and has an incidence of 3% in the pre-revascularization era that has decreased to 0.1%; (8) in the current age. Diagnosis can be made from symptoms, diffuse ST elevations on electrocardiography, and a pericardial effusion on echocardiography (8) . The risk of Dressler's syndrome is increased after early post-MI pericarditis. 8 Risk factors include late presentation (>6 hours) and primary PCI failure (Odds ratio 2.8), both of which are expressions of reduced myocardial salvage or failed revascularization (8) . Our patient's course was complicated by hemorrhagic pericardial effusion likely from thrombolytics and an underlying inflamed pericardium. Hemorrhagic pericarditis has been described in case reports in patients with large transmural MI receiving thrombolytics as early as two hours after the institution of therapy (9). This complication usually evolves into tamponade with hemodynamic instability requiring pericardiocentesis (9) . Fortunately, our patient's small pericardial effusion did not require invasive therapy, and was managed with avoidance of anticoagulation during his CCU stay.
Prompt coronary vascular reperfusion has decreased the incidence of rare MI complications, and has improved mortality (7) . In pre COVID-19, ~13% of STEMIs in the US are managed with fibrinolytic-focused reperfusion strategies, mostly in geographically isolated areas (1). In the COVID-19 era, the American College of Cardiology still recommends PCI as the standard of care for STEMI (10) . However, emergency departments are facing delays in triaging patients, and similarly cardiac catheterization laboratory activations are slowed due to extra steps required to ensure safety of staff (2) . In PCI-capable centers, immediate fibrinolytic administration in the emergency department may mitigate systems-based delays. However, hemorrhagic pericarditis could represent a caveat to this eminent and needed strategy, especially in delayed MI cases.
Echocardiography after six days showed resolution of hemorrhagic pericardial effusion. He underwent successful staged percutaneous coronary intervention (PCI) of LAD lesion on the tenth day, and transferred to the cardiology wards before discharge on hospital day 19.
With the progression of this global pandemic, management of MI with thrombolytics or delayed reperfusion strategies may show a reemergence of rare complications such as post-MI pericarditis. This will be further exacerbated by patients who avoid medical care due to fear of contracting SARS-CoV-2. Hemorrhagic pericarditis is a rare entity precipitated by thrombolytics in late presenting MI which may lead to deleterious outcomes. Healthcare providers should continue educating patients to recognize life-threatening cardiovascular symptoms and seek timely care to avoid serious complications. 