A Case of Myopericarditis After the Second Dose of mRNA COVID-19 Vaccine in a Patient With a History of Myopericarditis

Abstract

Vaccination is important for the prevention of coronavirus-induced disease 2019 (COVID-19) caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and to protect persons with a high risk for complications. There have been reports of myopericarditis following COVID-19 vaccination, especially in adolescent males and young adults. Breakthrough infections, such as the Delta or Omicron variant of SARS-CoV-2, have raised great concern about the necessity for repeated doses of the vaccine. A case of myopericarditis after the second dose of COVID-19 mRNA-1273 (Moderna) vaccine in a 23-year-old man with a prior episode of viral myopericarditis is presented. He received the second dose of the COVID-19 mRNA vaccine, after which he developed persistent midsternal chest pain and he was subsequently transferred to our emergency department. An echocardiogram showed a trivial inferior pericardial effusion with diffuse left ventricular systolic dysfunction. He was treated with colchicine from the first day of hospitalization with a diagnosis of myopericarditis. His chest pain had resolved by the third day, and left ventricular wall motion was dramatically improved by the seventh day of hospitalization. A strong response to the second vaccination in the present case suggests that the prior history of myopericarditis is evidence of strong congenital or acquired immunological features in this individual. Individuals with such a strong immune response may be more likely to develop myopericarditis after mRNA vaccination. Immunization against COVID-19 is currently recommended from a risk-benefit standpoint. We advised the patient to avoid additional COVID-19 mRNA vaccines because of this episode. The risk of COVID-19 weighed against myopericarditis associated with the mRNA vaccination should be considered on a case-by-case basis. This case may help us better understand the mechanism of myopericarditis following COVID-19 mRNA vaccination.

Keywords: COVID-19; Myocarditis; SARS-CoV-2; case report; mRNA vaccine; myopericarditis; pericarditis.

Figure 1.

Clinical course. Myocardial enzymes (TnT, CK-MB) and inflammatory markers (WBC, CRP) were transiently elevated. These findings, including pericardial effusion, improved over the clinical course. BNP transiently increased several days after these changes, and returned to the normal range at discharge. Colchicine was continued for 1 month after discharge and ACE-I for 6 months. WBC, white blood cell (cell count/μL, normal range 3300 -8600/μL); CRP, C-reactive protein (mg/dL, normal ⩽0.14 mg/dL); TnT, high-sensitivity troponin T (ng/mL, normal ⩽0.1 ng/mL); BNP, B-type natriuretic peptide (pg/mL, normal ⩽18.4 pg/mL); CK-MB, creatine kinase-isoenzyme MB (U/L, normal ⩽12 U/L).

Figure 2.

Contrast-enhanced cardiac magnetic resonance imaging performed on day 5, short-axis views (A), 4-chamber views (B). Linear midmyocardial late gadolinium enhancement is seen in the septal and apical walls of the left ventricle (red arrow).

Figure 3.

Endomyocardial biopsy specimens show no obvious lymphocytic infiltration of the myocardium and no cardiomyocyte damage. (Hematoxylin and eosin staining, original magnification ×40, The white bar indicates 200 μm).