Fulminant Myocarditis and Acute Appendicitis after COVID-19 Vaccination

Abstract

A 19-year-old Japanese man was hospitalized for cardiogenic shock 28 days after receiving a second dose of the coronavirus disease 2019 (COVID-19) mRNA-1273 vaccine. He had had a high fever for three days with vomiting and abdominal pain before arriving at our hospital. The patient visited a local hospital and was diagnosed with heart failure and acute appendicitis. An endomyocardial biopsy specimen showed myocarditis. Thereafter, Impella CP left ventricular assist device implantation and venoarterial peripheral extracorporeal membranous oxygenation were initiated immediately along with inotropic support and steroid pulse therapy. Given these findings, he was finally diagnosed with multiple inflammatory syndrome and fulminant myocarditis.

Keywords: biopsy; cytokine; inflammation.

Figure 1.

Abdominal computed tomography revealed a swollen appendix (A: transverse view, B: coronal view)

Figure 2.

Chest radiography showed normal findings with a cardiothoracic ratio of 49.7% (A). Electrocardiography revealed sinus tachycardia, abnormal Q waves in leads V1-3, and slight ST-segment elevation in leads I, II, aVF, and V2-6 (B). Transthoracic echocardiography showing left ventricular hypokinesis with mild pericardial effusion (C: end-diastolic phase of parasternal long-axis view, D: end-systolic phase of the parasternal long-axis view).

Figure 3.

Cell infiltration in the myocardium (A, Hematoxylin and Eosin staining) with CD3+ cells (B), both CD4+ cells (C), CD8+ cells (D), more CD68+ cells (E), and fewer CD20+ cells (F) (×200).

Figure 4.

Immunostaining of the myocardium biopsy sample using antibodies for ACE2, SARS-CoV-2 (COVID-19) spike protein, and C4d. In the myocardium biopsy sample with myocarditis (A, Hematoxylin and Eosin staining, ×200), ACE2 (B, ×200), SARS-CoV-2 (COVID-19) spike protein (C, ×200), and C4d (D) were negative in myocytes. SARS-CoV-2: severe acute respiratory syndrome coronavirus 2, COVID-19: coronavirus disease 2019, ACE2: angiotensin-converting enzyme 2

Figure 5.

Time course of electrocardiography, echocardiographic data, and laboratory data. CRP: C-reactive protein, CK: creatinine kinase, NT-proBNP: N-terminal pro-brain natriuretic peptide, LVEF: left ventricular ejection fraction, IVST: interventricular septal thickness, LVPW: left ventricular posterior wall thickness