Myocardial infarction with nonobstructive coronaries (MINOCA) following rabies postexposure prophylaxis: A case report

Abstract

Key clinical message: This case underscores the importance of considering myocardial infarction with nonobstructive coronary arteries (MINOCA) in patients experiencing acute chest pain following rabies vaccination, emphasizing the need for heightened awareness and further research into the association between MINOCA and Rabies vaccination.

Abstract: Rabies is a vaccine-preventable deadly viral disease prevalent in Asia and Africa that causes thousands of deaths annually. Rabies pre (PrEP) and postexposure prophylaxis (PEP) is highly effective in annulling rabies-associated deaths. The adverse reactions following rabies vaccination are typically mild. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare condition, and its association with rabies vaccination is unprecedented. We present a case of a 43-year-old male with MINOCA following Rabies PEP. A 43-year-old male, nonsmoker and nonalcoholic, presented to the ER with complaints of acute onset left sided chest pain following the completion of the third dose of intradermal rabies vaccine, whose clinical features, ECG changes and lab reports were suggestive of acute presentation of inferior wall MI. Coronary angiography was performed, which however revealed normal coronaries with only slow flow being noted in the left anterior descending (LAD) artery. Echocardiography later showed a normal study with no other relevant diagnosis unveiled on further investigations. Hence a diagnosis of vaccine-induced MINOCA was made. Treatment included antiplatelet therapy, statins, and beta-blockers. MINOCA following rabies vaccination is an unprecedented finding. The clear etiology behind this couldn't be ascertained. The patient's treatment was conventional, emphasizing the need for further research and clinical trials in MINOCA diagnosis and management. This case highlights the need for clinicians to consider MINOCA in patients with acute chest pain post-rabies vaccination. Further research is essential to unravel the association between MINOCA and rabies vaccination, paving the way for optimal management strategies.

Keywords: MINOCA; case reports; myocardial infarction; postexposure prophylaxis; rabies vaccines.

FIGURE 1

(A) ST elevation in leads II, III, and avF with reciprocal change in aVR in left sided ECG suggestive of inferior wall MI. (B) ST elevation in II, III, aVF, V1, and V2 in Right sided ECG suggestive of RCA involvement. (C) ST elevation in limb leads, no posterior wall involvement in posterior ECG.

FIGURE 2

(A) Coronary angiography showing nonobstructive RCA (right coronary artery). (B) Coronary angiography showing nonobstructive LAD (left anterior descending) and LCX (left circumflex) arteries.