Myocarditis after Covid-19 mRNA Vaccination

U.S, 30 September 2021, Verma et al., New England Journal of Medicine

Summary

Here, we report two cases of histologically confirmed myocarditis after Covid-19 mRNA vaccination.

Patient 1, a 45-year-old woman without a viral prodrome, presented with dyspnea and dizziness 10 days after BNT162b2 vaccination (first dose). At presentation, she had tachycardia; ST-segment depression detected on electrocardiography, which was most prominent in the lateral leads (Fig. S1); and a troponin I level of 6.14 ng per milliliter (reference range, 0 to 0.30). A transthoracic echocardiogram showed severe global left ventricular systolic dysfunction (ejection fraction, 15 to 20%) and normal left ventricular dimensions. Right heart catheterization revealed elevated right- and left-sided filling pressures and a cardiac index of 1.66 liters per minute per square meter of body-surface area as measured by the Fick method. Coronary angiography revealed no obstructive coronary artery disease. An endomyocardial biopsy specimen showed an inflammatory infiltrate predominantly composed of T-cells and macrophages, admixed with eosinophils, B cells, and plasma cells. She received inotropic support, intravenous diuretics, methylprednisolone (1 g daily for 3 days), and, eventually, guideline-directed medical therapy for heart failure (lisinopril, spironolactone, and metoprolol succinate). Seven days after presentation, her ejection fraction was 60%, and she was discharged home.

Patient 2, a 42-year-old man, presented with dyspnea and chest pain 2 weeks after mRNA-1273 vaccination (second dose). He did not report a viral prodrome, and a PCR test was negative for SARS-CoV-2 (Table S1). He had tachycardia and a fever, and his electrocardiogram showed diffuse ST-segment elevation (Fig. S1). A transthoracic echocardiogram showed global biventricular dysfunction (ejection fraction, 15%), normal ventricular dimensions, and left ventricular hypertrophy. Coronary angiography revealed no coronary artery disease. Cardiogenic shock developed in the patient, and he died 3 days after presentation. An autopsy revealed biventricular myocarditis. An inflammatory infiltrate admixed with macrophages, T-cells, eosinophils, and B cells was observed, a finding similar to that in Patient 1.

Histopathological Findings from Endomyocardial Biopsy and Autopsy.

Download article: https://www.nejm.org/doi/10.1056/NEJMc2109975

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