Myocarditis After SARS-CoV-2 Vaccination: A Vaccine-Induced Reaction?

Canada, 8 June 2021, D’Angelo et al, Canadian Journal of Cardiology


A 30-year-old man presented at the emergency department complaining dyspnea, constrictive retrosternal pain, nausea, and profuse sweating. Of note, the patient had suffered from fever (38.8°C) and arthralgia 72 hours earlier when he received his second dose of SARS-CoV-2 vaccine (mRNA BNT162b2), which was injected 21 days after the first dose.The patient tested negative at nasopharyngeal swab testing for SARS-CoV-2, as required before hospital admission.Anamnesis was negative for cardiovascular or metabolic disorders and recent infectious diseases.At physical examination he was afebrile, with moderate tachycardia (heart rate 93 beats/min) and normal blood pressure (115/58 mm Hg). At auscultation, neither lung alterations nor heart murmurs were identified; oxygen saturation was of 99% on room air.Laboratory data revealed elevated cardiac troponin I (12,564.80 pg/mL; normal < 34.2 pg/mL), creatine kinase-MB (53.8 ng/mL; normal 0-5.2), lactate dehydrogenase (228 U/L; normal 125-220), activated partial thromboplastin time (75.2 seconds; normal 20-40), and C-reactive protein (39.6 mg/L; normal 0-5). White blood cells were 10.4 103/µL (normal 4.0-10.0), with mild eosinophilia (0.9 × 103/µL, normal 0.0-0.5 × 103). Serum levels of cardiac troponin I, creatine kinase-MB, and C-reactive protein during the first 72 hours from hospital admission are shown in Fig 1.

Electrocardiography (ECG) showed subtle ST-segment elevation suggestive of potential myocardial injury or pericarditis in V2-V4 and nonspecific T-wave changes in V5 and V6. Transthoracic echocardiography revealed preserved ejection fraction, mild pericardial effusion, and segmental wall motion abnormality of the apical portion of interventricular septum. No coronary artery disease was found at coronary angiography. Cardiac magnetic resonance imaging (MRI), performed 72 hours after hospital admission, revealed good systolic function and increased myocardial and pericardial signal intensity on T2-weighted short tau inversion recovery sequences (T2 ratio 2.1; normal < 2). T1-weigheted phase-sensitive inversion recovery sequences, performed 15 minutes after intravenous injection of gadolinium, showed subepicardial enhancement of the myocardium, suggesting a provisional diagnosis of myopericarditis (Fig. 2).

(A, B) Twelve-lead electrocardiography on admission showing subtle ST-segment elevation suggestive of potential myocardial injury or pericarditis in V2-V4 and nonspecific T-wave changes in V5 and V6. (C) Cardiac magnetic resonance imaging T2-weighted short tau inversion recovery sequence acquired along the basal short-axis view shows increased subepicardial signal intensity of the inferolateral myocardial segments (arrows). Increased thickness and signal intensity of pericardium is also shown (arrowheads). T1-weighted phase-sensitive inversion recovery sequences performed along (D) basal short-axis view, (E) 3-chamber view, and (F) 4-chamber view show diffuse myocardial late gadolinium enhancement with subepicardial distribution (arrows) and sparing of the basal and mid-septal segments; thickening and enhancement of pericardium can also be seen (arrowheads).

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