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  • „ CLINICAL VIGNETTE

Every rose has its thorns — acute myocarditis following COVID-19 vaccination

Justyna M Sokolska1, Jacek Kurcz2, Wojciech Kosmala1

1Department of Cardiovascular Imaging, Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland

2Department of General and Interventional Radiology and Neuroradiology, Chair of Radiology, Wroclaw Medical University, Wrocław, Poland

Correspondence to:

Justyna Sokolska, MD, PhD,

Department of Cardiovascular Imaging,

Institute of Heart Diseases,

Wroclaw Medical University,

Borowska 213, 50–556 Wrocław, Poland

phone: +48 71 736 42 00,

e-mail: justyna.sokolska@umw.edu.pl

Copyright by the Author(s), 2021

Kardiol Pol. 2021; 79 (10): 1153–1154; DOI: 10.33963/KP.a2021.0075

Received: July 14, 2021

Revision accepted: July 23, 2021

Published online: July 27, 2021

A 21-year-old man was admitted to the hospital with severe chest pain. Apart from atopic asthma in childhood, pollen and pet allergy, and appendectomy a few years ago, his past medical history was unremarkable, and he did not have a symptomatic COVID-19 infection in the past. He worked physically as a warehouse worker and trained regularly Brazilian Jiu-Jitsu without any health problems. The family history was negative for cardiovascular disease.

Three days before hospitalization, the patient received the first dose of mRNA COVID-19 vaccination (Comirnaty, Pfizer). Apart from mild muscle pain at the site of vaccine administration, he did not experience any other symptoms during the first two days. On admission day, he woke up at night due to a tight and squeezing sensation in his chest, which he rated as 8 points in the 010 Numeric Rating Scale used to estimate the intensity of pain. The chest discomfort lasted about 3 hours despite taking a painkiller; it resolved spontaneously and did not return later.

On admission to the hospital, the patient was hemodynamically stable. Electrocardiography showed sinus rhythm at a heart rate of 50 beats per minute, an incomplete right bundle branch block, Q wave and ST-segment elevation less than 1 mm in leads II, III and aVF, negative T-wave in lead V1 and patterns of precordial early repolarization (Figure 1A). Blood tests demonstrated elevated levels of high-sensitive cardiac troponin I (6490––6559 pg/ml; reference range <34 pg/ml), N-terminal fragment of the prohormone brain natriuretic peptide (337 pg/ml; reference range <125 pg/ml), and C-reactive protein (82 mg/l; reference range <5 mg/l).

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Echocardiography demonstrated a normal-sized, non-hypertrophic left ventricle with normal ejection fraction (biplane, 58%) and borderline global longitudinal deformation (–16.3%) with a regional heterogeneity (Figure 1B). Coronary computed tomography angiography demonstrated normal coronary arteries (Figure 1C). Cardiac magnetic resonance revealed imaging findings typical of active myocarditis [1], including increased signal intensity on T2-weighted images, increased values on both T1 and T2 mapping (Figure 1D), and the presence of diffuse subepicardial late gadolinium enhancement (Figure 1EF). During further laboratory workup, viral causes of myocarditis were excluded, i.e. COVID-19, influenza type A and B, hepatitis type B and C, EpsteinBarr-, human immunodeficiency- and cytomegalovirus infections. The vaccine-associated acute myocarditis was diagnosed.

Acute myocarditis following vaccination is a rare but serious complication, which has until now been recognized as associated almost exclusively with smallpox and influenza immunization [2]. Myocarditis in the course of COVID-19 infection was previously described [3, 4]; however, only recently have the first cases of acute myocarditis following administration of the mRNA-based anti-COVID-19 vaccines (Pfizer-BioNTech and Moderna) been reported [2, 5]. This complication typically occurs in young adult males within 4 days after administration of the second dose of the COVID-19 vaccine [2, 5]. Acute myocarditis diagnosed shortly after the first dose of mRNA vaccine, as in our case, is unusual and appears mainly in COVID-19 convalescents [5]. Longer follow-up is needed to assess the further course of the disease. Comprehensive imaging is helpful in establishing the diagnosis of myocarditis and should be included in the diagnostic workup in patients suspected of having myocardial complications of COVID-19 infection or COVID-19 vaccination.

Article information

REFERENCES

  1. 1. Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular magnetic resonance in nonischemic myocardial inflammation: expert recommendations. J Am Coll Cardiol. 2018; 72(24): 31583176, doi: 10.1016/j.jacc.2018.09.072, indexed in Pubmed: 30545455.
  2. 2. Shay DK, Shimabukuro TT, DeStefano F. Myocarditis occurring after immunization with mRNA-Based COVID-19 vaccines. JAMA Cardiol. 2021 [Epub ahead of print], doi: 10.1001/jamacardio.2021.2821, indexed in Pubmed: 34185047.
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  4. 4. Marcinkiewicz K, Petryka-Mazurkiewicz J, Nowicki MM, et al. Acute heart failure in the course of fulminant myocarditis requiring mechanical circulatory support in a healthy young patient after coronavirus disease 2019. Kardiol Pol. 2021; 79(5): 583584, doi: 10.33963/KP.15888, indexed in Pubmed: 34125938.
  5. 5. Montgomery J, Ryan M, Engler R, et al. Myocarditis following immunization with mRNA COVID-19 vaccines in members of the US military. JAMA Cardiol. 2021: e212833, doi: 10.1001/jamacardio.2021.2828, indexed in Pubmed: 34185045.

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