It all began with a bad rash that wouldn’t go away, then a cough, a loss of taste and smell, a COVID-19 diagnosis and a quarantine that nearly ruined Christmas.
Cayden Puckett wears jersey #12 for the Shelbyville Central High School football team in Tennessee, where he plays wide receiver and sometimes safety for his dad, the coach. He couldn’t wait to get back into the weight room.
As he lifted weights after the holidays, though, he knew something was still wrong. He felt off-kilter, saying later: “I just wasn’t normal.” Suddenly, his heart began to race and flutter, and he struggled to breathe.
Changed by COVID: Doctors are worried about kids who don't get better
He’d had double pneumonia before, so when he got home, his mom pulled out the nebulizer for a treatment. He still felt jittery. He was making a snack when he ended up cutting his hand badly enough to need stitches – six of them.
In retrospect, his mom realized she hadn’t put two and two together. As she would soon learn, her teenage son was a COVID-19 long-hauler, and it had affected his heart.
“We’re very fortunate his heart didn’t stop that day,” Erin Puckett said.
One of the biggest identified risks for young athletes who have had COVID-19 is heart damage from myocarditis – an inflammation of the heart muscle that can lead to death.
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For Cayden, it would take weeks of medical appointments and tests to reach a diagnosis of myocarditis and multisystem inflammatory syndrome in children. At the children’s hospital at Vanderbilt University, doctors gave him strict orders not to do anything to make his heart beat faster for fear it would stop altogether.
New post-COVID-19 “return-to-play” guidelines for youth, college and professional athletes include cardiac screenings – screenings some sports medicine experts recommend for many COVID-19 patients who do vigorous exercise.
The Tennessee Secondary School Athletic Association required a medical doctor to clear Cayden to return to the field.
The stakes were high. Cayden had set his sights on playing football in college. He’d just come off a junior year as Shelbyville’s defensive MVP and as a member of an all-region team. The coming fall would be his last chance to prove himself on the field with the Golden Eagles.
He tried to stay positive. On March 12 he took to Twitter for an update, thanking people for their support and calling his illness “just another bump in the road.”
“My heart is inflamed and it will be a long process to healing,” he wrote, “but that is what I am determined to do.”
Protecting youth athletes' hearts has never been more urgent
Athletes often seem superhuman, among the fittest of their high school classmates. Yet regular news stories of their hearts stopping on the field or court provide tragic reminders that extreme activity can accentuate any illness or flaw.
That’s one reason why cardiac health is part of the sports physicals commonly required for the millions of Americans under 18 who participate in youth sports at the high school and club levels. COVID-19 has put an even greater emphasis on the heart.
Programs at underprivileged schools have long worked to overcome testing access issues through liaisons with local medical providers. The physicals can cost up to $150 –more if they lead to a referral to a cardiologist or other specialist – although they are typically covered by insurance if the athlete is insured.
Sports medicine also recommends that people with a fever of 101.5 or higher avoid exercise and find the cause, according to Dr. Steven Erickson, chief of primary care sports medicine for Phoenix-based Banner Health and team physician for the Phoenix Suns basketball team.
A viral infection could lead to myocarditis, which can leave patients with scarring that affects them later in life, said Erickson, who also is the medical consultant for Major League Umpires and a member of the medical advisory board for the Arizona Interscholastic Association. Viruses like flu and coxsackie can cause myocarditis, but not as often as COVID-19.
High schools, colleges and independent sporting organizations all have adopted their own return-to-play policies and protocols for athletes who have had COVID-19, typically adapted from national guidelines.
The American Medical Society for Sports Medicine, along with the National Federation of State High School Associations, released updated guidelines for young athletes returning to play on Aug. 20. The American Academy of Pediatrics also recently updated its recommendations.
The guidelines have to be continually reviewed and adjusted based on new information and studies, said Dr. Keri Denay, a family and sports medicine physician and associate professor in the Department of Family Medicine at the University of Michigan. That can be confusing for athletes, coaches, parents – even medical professionals.
“It’s this ever-evolving process that, literally by the hour, we get new information,” Denay said. “It’s frustrating for everybody, our profession included.”
Generally, national guidelines say any young athlete who was sick with moderate COVID-19 symptoms should get a medical evaluation and that providers should consider cardiac screening. Moderate symptoms can include significant coughing, several days of fever, chest pain, malaise, fatigue and shortness of breath.
Cayden’s case was moderate, but the aftermath was not. He had suffered with gastrointestinal problems for years before he had COVID-19. Afterward, they became worse. Some days, he could barely eat. He continued to struggle with fatigue, cramps and inflammation. The rash he’d had since November also persisted.
Shelbyville rallied behind him, creating a hashtags like #COVIDCantStopCayden and #WeGotYou12 and raising money to help the family with medical expenses. The community would even host a fishing tournament to raise money.
On April 1, Cayden told a local TV reporter: “This is not a life any kid or teenager wants to live, being in that room every day for half a year.”
While he waited to get better, his mom said Cayden just did “a whole lot of nothing.” He studied football videos to keep himself sharp. His mom also stuck close to home, scared to leave her son’s side.
“That was part of the sadness of it all,” Erin Puckett said. “The fatigue lasted so long. Months and months. He was really too tired to try and do anything anyway.”
An outing in May to accompany his brother on an overnight trip – the first time he’d ventured out since January – became a cautionary tale. Even though they took it easy, Cayden ended up violently vomiting, with so much gut pain he couldn’t stand up straight. He was hospitalized for two days as doctors treated inflammation in his bowels and appendix.
When a local YouTube video series that covers Tennessee high school football interviewed Coach Puckett on May 15 about the upcoming season, the host began by asking about Cayden’s progress.
“Unfortunately, he’s still doing about the same,” Josh Puckett answered. “It’s very frustrating.”
The family was heading to Minnesota to the Mayo Clinic, he added, to “make sure what we’re doing is the best course.” Cayden’s case was severe enough that the clinic had pulled him off a waitlist.
Cayden Puckett heads to Mayo, hoping for answers
“Today is the day. I will be in Minnesota for the week, hoping for answers and relief. Thank you everyone for the prayers and support,” Cayden tweeted on June 14. He closed with a heart emoji.
At Mayo, Cayden underwent a battery of exams including an electrocardiogram, echocardiogram and stress test. The team of doctors there told him the inflammation in his heart had decreased enough that he could start working out again.
They also cautioned his improvement might only reflect several months of rest, and they urged him to take it slow. Even if a child or adolescent is cleared after a cardiac screening, the national guidelines say athletes who were sick with COVID-19 need to be monitored for new cardiopulmonary symptoms such as chest pain with exercise.
The Mayo team also relayed a harder truth: Cayden might not be able to play football his senior year – or ever again, for that matter. The thought of that was devastating to the entire family, but especially for Cayden, who, the family story goes, learned to read early so he could read the ESPN scrolls.
“He’s been an athlete since he was 4 years old,” Erin Puckett said. “That’s been one of the hardest parts for him emotionally and mentally. He has looked forward to this time literally since he was in elementary school.”
Cayden’s team of doctors sent him home with medications to help with his gastrointestinal ailments and set him up for a follow-up echocardiogram on July 30.
As summer dragged on, Cayden continued to post highlights from his last football season on social media, along with his ACT scores and GPA – 4.0. He cheered on teammates as they committed to play for colleges.
The Pucketts receive good news, with a caveat
Early in the pandemic, sports medicine physicians feared COVID-19 would cause a spike in sudden cardiac deaths in athletes. Luckily, so far that has not occurred.
A study published in the scientific journal JAMA Cardiology in March brought more good news based on data pooled from post-COVID-19 testing in athletes playing in professional sports leagues, including men's and women's National Basketball Association, the National Hockey League and Major League Baseball.
It found 0.6%, or five of the 789 professional athletes who were part of the study, had cardiac MRI findings that suggested inflammatory heart disease.
Two months later, another study of nearly 1,600 Big Ten college athletes who had tested positive for the coronavirus, published in JAMA Cardiology, found 2.3% showed signs of myocarditis.
Good news arrived for Cayden on Aug. 3 when the results of his latest echocardiogram showed his numbers were in a good range. He was cleared to play in the season opener of his senior year.
He tweeted jubilantly that day: “100% healthy. Nothing holding me back. I am fortunate to say after all of the months I was down I am finally back up and stronger. One more Year to prove myself. 12 is back.” He punctuated this one with a fire emoji.
His father retweeted it. His mother worried that he would push himself too far, too fast.
Cayden had been good about sticking to the rules when he was told to rest, she said. But after he got the all-clear to slowly begin to work out again, suddenly it was out of her hands.
“It is incredibly scary,” she said. “I’ve changed in a lot of ways and I don’t know how long some of those changes will stick with me.”
The team takes the field to open the 2021 season
The Golden Eagles exploded onto the field Aug. 19 to face the Tullahoma Wildcats. One of Cayden’s teammates led the Shelbyville squad through an inflatable tunnel, waving an American flag. Then, the players wove between rows of cheerleaders and the marching band. The crowd cheered.
The weather was mild, dropping into the 70s as the sun went down, but high humidity left the air heavy and sticky. Later, Cayden’s dad would say his son was heavier, too – slower and 10 pounds over the 204 he typically carries on his 6-foot frame.
Early in the game, Cayden looked up to find his mom in the stands – seated high above the 50-yard line – something he has done during games since he was a boy. Later he caught her eye again, this time making a funny face and making her laugh.
Josh Puckett played him during every offensive snap. Cayden caught a 7-yard pass.
Shelbyville lost 28-14 but Cayden had much to celebrate. Afterward, as his mom and girlfriend hugged him on the field, he said he had hoped to play even more.
“I’m still trying to get to 100%, but it feels good to play as much as I did, at least,” he said. “I was just so happy to be back. It’s hard to have a feeling like football. When you first get to the game and look around at the lights and take it in – I’ll probably always feel this when I play.”
Erin Puckett stood beside her son with tears in her eyes.
“I’ve been crying all night,” she said. “I’m just very grateful. Very grateful for this community and very grateful that he’s here to have this moment.”
Experts emphasize that the evidence so far shows that serious cardiac problems after COVID-19 are rare in young athletes, and that, in most cases, the fear of heart problems should not be a deterrent to being physically active.
“If you have myocarditis and you are participating in vigorous activity, then yes, you are putting yourself at higher risk of cardiac issues,” the University of Michigan’s Denay said. “However … we have really good evidence that physical activity is one of the best protectors against COVID infections. … The last thing we want is for people to sit on the couch and do nothing, because that's going to have a detrimental impact on their overall health.”
The inflammation that plagued Cayden’s body has largely subsided, and he’s regaining strength as he reconditions. The rash he first got in November finally cleared up in June. His digestive problems improved so much with the medication from Mayo that his mom can’t keep him fed. He’s working through lingering pain and a recent shin splint injury with a physical therapist.
Every day, he says, he pushes himself a little bit further.
As arduous as the journey behind him has been, out on the field after the season opener Cayden said he was focused on just one thing ahead of him: “Next week.”