Myopericarditis with hemorrhagic pericardial effusion following BNT162b2 mRNA COVID-19 vaccine

Abstract

Since the onset of the COVID-19 pandemic, to date, around 385 million cases have been diagnosed worldwide leading to an estimated 5.7 million death toll. Mass vaccination campaigns have been conducted to control the spread of infection with the most commonly used vaccines being Pfizer-BioNTech and Moderna. However, the adverse effects of vaccination have not yet been fully investigated. Of concern are some serious cardiovascular events such as myocarditis, pericarditis, or perimyocarditis development post-vaccination. Hemorrhagic pericardial effusion has not been reported. However, we report a case of myopericarditis with a hemorrhagic pericardial effusion that developed two weeks following BNT162b2 mRNA COVID-19 vaccination. We performed a complete workup identifying the underlying cause that did not yield any significant findings. Our patient was treated with colchicine and ibuprofen, and he made a full recovery. A follow-up cardiovascular magnetic resonance imaging (CMR) showed no signs of active inflammation.

Keywords: COVID-19; COVID-19 vaccine; Hemorrhagic pericardial effusion; Myopericarditis; Pericardial effusion.

Fig. 1

Transesophageal echocardiogram (TTE): large circumferential pericardial effusion without tamponade physiology. Posteriorly, the effusion measure was 2.43 cm, and anteriorly, it was 1.43 cm.

Fig. 2

Three-chamber T2-weighted image of left ventricle (LV) and right ventricular outflow tract (RVOT) with T2-weighted TSE sequences: There was no significantly increased signal intensity in the T2-weighted images to suggest edema of active inflammation. The T2-weighted images made before contrast showed mildly increased signal in the septal and lateral free wall of the LV on 3-chamber view and in the mid to anteroapical LV wall in the 2-chamber view.

Fig. 3

Three-chamber (L) and basal short-axis slice (R) of small area of epicardial DE (arrows): A small area of epicardial delayed enhancement (DE) was seen on the 3-chamber view and a corresponding short-axis slice in the MAG and PSIR sequences, characteristic of myocarditis (marked by arrows in images). The remainder of the RV and LV myocardium appeared free of DE.