Case Report: Acute Fulminant Myocarditis and Cardiogenic Shock After Messenger RNA Coronavirus Disease 2019 Vaccination Requiring Extracorporeal Cardiopulmonary Resuscitation

Abstract

Recently, myocarditis following messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccination has become an important social issue worldwide. According to the reports so far, myocarditis related to mRNA COVID-19 vaccination is rare and usually associated with a benign clinical course without intensive care or any sequelae of fulminant myocarditis. Here, we report a case of acute fulminant myocarditis and cardiogenic shock after the mRNA COVID-19 vaccination, requiring extracorporeal cardiopulmonary resuscitation. Clinicians should keep in mind the possibility of progression to fulminant myocarditis in patients who presented with suggestive symptoms or signs of myocarditis after the COVID-19 vaccination.

Keywords: COVID-19; case report; extracorporeal membrane oxygenation; fulminant myocarditis; vaccination.

Figure 1

Serial changes of electrocardiography (ECG). (A) Extensive ST elevation with bizarrely wide QRS complexes immediately after extracorporeal membrane oxygenation (ECMO) application. (B) Ventricular and atrial electrical standstill during ECMO management. (C) Decreased but remained extensive ST elevation with narrowing and low voltage of QRS complexes on ECG on the third hospital day. (D) Normalization of ST segment elevation and QRS width; an increased but remained low voltage QRS complex on pre-discharge ECG.

Figure 2

Serial changes of echocardiography. (A,B) Global akinesia with severe left ventricular (LV) dysfunction and marked edematous left ventricular wall thickening on portable echocardiography performed just after extracorporeal membrane oxygenation application. (C,D) Normalized LV function and wall thickness on pre-discharge echocardiography.

Figure 3

Histopathologic examination of endomyocardial biopsy revealed marked and diffused infiltration of lymphocytes (thick arrow) within the myocardium (thin arrow) (×40, Hematoxylin-eosin stain).

Figure 4

Cardiac magnetic resonance imaging (MRI) findings. (A) T2-weighted short TI inversion recovery MRI at 3T in a short-axis view shows multifocal high signal intensities at the mid anterior and lateral wall (arrow) indicating myocardial edema. (B) Late gadolinium enhancement imaging in a four-chamber view displays multifocal mid wall enhancement (arrow) indicating inflammatory myocardial necrosis. (C) T1 mapping and T2 mapping in a short-axis view show elevated T1 and T2 relaxation times at the mid ventricular level, indicating an acute myocardial injury (regional T1 relaxation time-1,418 ms at the anterolateral wall and 1,461 ms at the septal wall, regional T2 relaxation time-45 ms at the anterolateral wall and 47 ms at the septal wall; institution-specific cutoff values for acute myocarditis- T1 global: ≥1,230 ms and T2 global: ≥36 ms).