Maskophobia As A Cause Of Non-exertional Dyspnea In The Era Of Covid-19

INTRODUCTION: COVID-19 can cause dyspnea through many mechanisms, and uncovering the underlying etiology greatly affects management. Diagnostic examinations can help uncover pulmonary, cardiac, or hematologic conditions that can contribute to post-viral COVID dyspnea. HYPOTHESIS: Non-exertional dyspnea could be caused by maskophobia and not cardiopulmonary conditions. METHODS: A 59-year-old woman with no history of heart failure and a history of mild exercise-induced asthma, hyperlipidemia, anxiety, depression, and migraines was hospitalized for resting dyspnea. Three months prior, she tested positive for SARS-CoV-2, and a repeat test was positive a week prior to presentation. Upon exercise, oxygen saturation improves. The patient does not endorse dyspnea regularly, with shortness of breath only when wearing a mask. Orthopnea and paroxysmal nocturnal dyspnea were absent. Vital signs were normal. The patient was treated with antivirals, and because of her asthma history, was prescribed 10 days of oral steroids. Supplemental O(2) was given for initial mild hypoxia, and the patient was discharged with an oxygen prescription at 1 L/min throughout the day. Upon follow-up, diagnostic testing was performed to assess the etiology of her dyspnea symptoms. D-dimer, complete blood count and basic metabolic panel were unremarkable. Electrocardiogram (EKG) did not demonstrate any evidence of infarction or cardiomyopathy. Chest X-ray did not show pulmonary infiltrate or cardiomegaly. Transthoracic echocardiogram showed normal left ventricular ejection fraction. Nuclear stress testing did not demonstrate any cardiac ischemia. Pulmonary function testing showed mild reactive airway disease consistent with prior asthma history. The symptoms of dyspnea would resolve once the patient removes her mask. RESULTS: Dyspnea can be caused by dysfunction anywhere along the pathway from environment oxygen intake to oxygen delivery to the end organs. The most common organ systems involved are pulmonary, cardiac, or hematologic. Anxiety can also cause dyspnea in the absence of a physiologic mismatch between oxygen supply and demand. Cardiopulmonary evaluation is the initial step in the workup of exertional dyspnea. Chest X-ray can assess for the presence of pneumonia, and labs such as D dimer indicate the likelihood of blood clots and pulmonary embolism. Exertional symptoms are evaluated by cardiopulmonary exercise testing. Heart failure can be suspected with abnormal systolic or diastolic function on an echocardiogram. However, if the diagnostic exams do not show any exertional abnormalities of the heart related to dyspnea, and symptoms only occur with the use of a mask, this may reflect an unusual case of non-exertional dyspnea from maskophobia. CONCLUSIONS: Because masks are becoming a norm during the COVID-19 era, non-exertional dyspnea may represent maskophobia. In the absence of significant laboratory, imaging, and cardiopulmonary investigation, wearing masks could be a cause of non-exertional dyspnea during the era of COVID-19.