Myocarditis following COVID-19 vaccination

Elsevier

IJC Heart & Vasculature

Volume 36, October 2021, 100872

IJC Heart & Vasculature

Myocarditis following COVID-19 vaccination

Author links open overlay panelRisheekKaulaJayakumarSreenivasanaAkshayGoelaAaqibMalikaDhrubajyotiBandyopadhyayaChengyueJinbMalaSharmaaAviLevineaStephenPanaAnthonFuiszaHoward A.CooperaJulio A.PanzaaShow moreAdd to MendeleyShareCitehttps://doi.org/10.1016/j.ijcha.2021.100872Get rights and contentUnder a Creative Commons licenseopen access

The messenger ribonucleic acid (mRNA) – based BNT162b2 (Pfizer, Inc) and mRNA-1273 vaccines (Moderna, Inc) were demonstrated in large randomized clinical trials to be highly effective in preventing severe illness from COVID-19 and to have acceptable safety profiles [1][2]. Given the short timeline between development and widespread utilization of this novel vaccine technology, however, careful investigation of possible unexpected adverse effects during real-world use is essential. In this report, we describe 2 cases of myocardial inflammation temporally associated with receipt of a COVID-19 mRNA vaccine in patients without evidence of concurrent or prior COVID-19 infection.

We describe 2 patients with acute myocarditis occurring within 72 h after the administration of mRNA-based COVID-19 vaccine. Clinical presentations, in-hospital events, treatments, and outcomes are presented in the Table 1. Cardiac magnetic resonance imaging findings and electrocardiograms of both patients with myocarditis are shown in Fig. 1. Both patients were young males without significant medical history, and presented 2–3 days after receiving the second vaccine dose. No patient had a history of prior or current COVID-19 infection, and all had negative RT-PCR nasopharyngeal swab testing for COVID-19 during their hospital course. With prompt recognition and treatment, all patients recovered quickly and were discharged from the hospital. The second patient followed up at 3 months after discharge and was completely asymptomatic without any other side effects.

Table 1. Patient clinical characteristics, in-hospital events and outcomes.

Patient 1Patient 2
Age (years)2821
SexMaleMale
EthnicityCaucasianCaucasian
Vaccine/DosemRNA-1273 (Moderna, Inc)/2nd doseBNT162b2 (Pfizer, Inc)/2nd dose
Time from vaccine administration to hospital presentation3 days2 days
Presenting complaintChest painSubsternal chest pain
Other symptomsFever, headache, neck pain, myalgiaFever, chills, headache
Medical historyNoneNone
Vitals on presentationT: 98.6F
HR: 75 beats/min
BP:118/60 mmHg
O2 sat: 98% on room air
T: 98.9F
HR: 83 beats/min
BP: 131/83 mmHg
O2 sat: 96% on room air
Physical examinationUnremarkableUnremarkable
ElectrocardiogramInfero-lateral ST elevation with no reciprocal changesDiffuse ST elevation
Peak troponin I (ng/mL)7.7517.0
Other pertinent labsESR: 15 mm/hr
CRP: 6 mg/dL
ESR: 20 mm/hr
CRP: 3.8 mg/dL
D-dimer: 509 ng/mL
RF: <10
ANA: 1:80
Coronary angiogramNormalNot performed
Initial echocardiogramLVEF 55%, mid inferolateral wall hypokinesis, normal RV systolic function, no pericardial effusionLVEF 25%, mildly dilated RV and reduced systolic function, moderate mitral regurgitation, no pericardial effusion
Repeat echocardiogramLVEF 55–60%, normal wall motion, normal RV systolic function, no pericardial effusionLVEF 50–55%, normal wall motion. RV mildly dilated with mildly reduced function, mild mitral regurgitation
Cardiac MRI PerformedYesYes
SARS-CoV-2 RT PCRNegativeNegative
SARS-CoV-2 IgG antibodyNegativeNot performed
Other testsRespiratory multiplex negative,
Coxsackie virus serology negative
Respiratory multiplex negative
Other clinical eventsNoneBrief episode of supraventricular tachycardia
TreatmentConservative careSolumedrol 1000 mg once daily for 3 days, colchicine 0.6 mg twice daily, losartan 25 mg daily and metoprolol succinate 25 mg daily
Length of stay3 days3 days
Clinical condition at the time of dischargeAsymptomaticAsymptomatic

Abbreviations: ANA: anti-nuclear antibody, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, LVEF: Left ventricular ejection fraction, MRI: magnetic resonance imaging, RF – rheumatoid factor, RV: right ventricle, RT-PCR: reverse transcriptase-polymerase chain reaction.

Normal laboratory range: BUN – < 20 mg/dL; CRP – <1.0 mg/dL; D-dimer – < 500 ng/mL; ESR – 0–15 mm/hr; Troponin – < 0.03 ng/mL.

This case series contributes to a limited body of literature describing acute myocardial and/or pericardial inflammatory illness occurring in close temporal association with the receipt of a mRNA COVID-19 vaccine. The possibility of a connection between COVID-19 vaccination and cardiac inflammatory illness was first suggested by a prelimary report from the the Israeli Health Ministry [3] which described a small number of cases of myopericarditis among young adults after receiving the BNT162b2 vaccine. Subsequently, 3 other case reports [4][5][6] and 3 case series [7][8][9] reporting myocarditis following COVID-19 vaccination have been published. Consistent with those recent reports, in our series all affected patients were males, and their illness was characterized by an uncomplicated hospital course and uneventful recovery with conventional treatment for myopericarditis.

In the published randomized clinical trials of these two COVID-19 mRNA vaccines, cardiovascular adverse events were exceedingly rare. Those that were reported included paroxysmal ventricular arrhythmiasarteriosclerosis and cardiac arrest, but there were no occurrences of myocarditis or pericarditis [1][2]. Myopericarditis has been reported in association with other vaccines, and the temporal relationship between the onset of symptoms and administration of the vaccine in our patients would suggest a possible causal association. Although mehanisms such as molecular mimicry between the viral spike protein and a cardiac protein or alternatively aberrant activation of the innate and acquired immune system leading to a non-specific inflammatory response have been suggested these potential mechanisms remain speculative.

It is important to consider these case reports within the broader context of the COVID-19 pandemic and the worldwide vaccination effort. COVID-19 has caused tremendous morbidity and mortality throughout the world, and the rapid development of safe and effective vaccines has provided hope that the pandemic can eventually be brought under control. Out of the more than 142 million Americans that have been vaccinated, fewer than 1000 cases of potential vaccine-associated myocarditis or pericarditis have been reported to Vaccine Adverse Event Reporting System (VAERS). An investigation by the US Centers for Disease Control (CDC) and their Advisory Committee on Immunization Practices (ACIP) is ongoing [10]. Even if a causal relationship between mRNA COVID-19 vaccination and myopericarditis is established, the incidence appears to be extremely low, the outcomes seem to be favorable, and the benefit of vaccination far outweighs any potential risk.

We report 2 cases of myocarditis occurring in close temporal relation to receipt of an mRNA COVID-19 vaccine. Clinicians should be alert to the possibility of myocarditis in patients presenting with compatible symptoms after vaccination, and appropriate diagnostic and therapeutic steps should be undertaken. Further basic and epidemiologic research is required to determine if a causal relationship exists and, if so, to elucidate the immunological basis of this aberrant inflammatory response.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

None.

References

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