Fulminant myocarditis and systemic hyperinflammation temporally associated with BNT162b2 mRNA COVID-19 vaccination in two patients

12 August 2021, International Journal of Cardiology


We herein report two cases of fulminant myocarditis following BNT162b2 mRNA Covid-19 vaccination.

A 27-year-old male with trisomy 21 complicated by speech impairment without history of cardiovascular disease presented in cardiogenic shock 2 days after his second vaccine dose. Transthoracic echocardiogram showed severe left ventricular systolic dysfunction (LVEF 20%) and a small circumferential pericardial effusion without tamponade. Approximately 21 h after admission, patient died due to recurrent cardiac arrest and refractory shock. Family declined request for autopsy.

A 34-year-old female without prior medical history presented 9 days after her first vaccine dose. On day 4 after vaccine, she developed fevers, cough, chest pain, nausea, and vomiting. She presented to another
institution with hypotension and sinus tachycardia, an echocardiogram showed severely reduced LVEF of 15%. She was transferred for initiation of VA-ECMO. On admission, she was in severe shock requiring multiple vasopressors. An endomyocardial biopsy performed on day 13 of hospital admission, after recovery of cardiac function and near resolution of the systemic hyperinflammation, showed cardiomyocytes with minute foci of cytoplasmic vacuolization and rare interstitial lymphocytic infiltrate, which is consistent with healing myocarditis, but did not meet conventional diagnostic criteria for acute myocarditis. A cardiac catheterization at the same time showed preservation of cardiac output and normal filling pressures. A cardiac magnetic resonance, performed 45 days after the initial presentation, showed LVEF of 35%, diffuse elevation of native T1 values, small pericardial effusion with enhancement of the pericardium anterior and anterolaterally and small patchy areas of enhancement following delayed imaging after gadolinium in the mid-wall of the anterior wall, consistent with myopericarditis.

In summary, both cases presented features of fulminant myocarditis with a temporal association with the BNT162b2 mRNA Covid-19 vaccination, in absence of other apparent causes, and with unique features of systemic hyperinflammation associated with refractory shock.

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