key: cord-0425982-7ubw5yz3 authors: Alizadeh, Leona S.; Koch, Vitali; Yel, Ibrahim; Grünewald, Leon D.; Mathies, Daniel; Martin, Simon; Vogl, Thomas J.; Rauschning, Dominic; Booz, Christian title: A case of Myocarditis after COVID-19 vaccination: Incidental or Consequential? date: 2022-05-28 journal: nan DOI: 10.1016/j.heliyon.2022.e09537 sha: b7fd6774b97da3d1cc4a45a4b434e44a8837c5c5 doc_id: 425982 cord_uid: 7ubw5yz3 Vaccination represents one of the fundamentals in the fight against SARS-CoV-2. Myocarditis has been reported as a rare but possible adverse consequence of different vaccines, and its clinical presentation can range from mild symptoms to acute heart failure. We report a case of a 29-year-old man who presented with fever and retrosternal pain after receiving SARS-CoV-2 vaccine. Cardiac magnetic resonance imaging and laboratory data revealed typical findings of acute myocarditis. Vaccination represents one of the fundamentals in the fight against SARS-CoV-2. Myocarditis has been reported as a rare but possible adverse consequence of different vaccines, and its clinical presentation can range from mild symptoms to acute heart failure. We report a case of a 29-year-old man who presented with fever and retrosternal pain after receiving SARS-CoV-2 vaccine. Cardiac magnetic resonance imaging and laboratory data revealed typical findings of acute myocarditis. Myocarditis; Vaccination; COVID-19; MRI Epicrisis Informed consent of the patient was obtained for the publication of this article. A 29- year-old male presented with fever and retrosternal pain to the emergency department after he had received a SARS-CoV-2-vaccination (Vaxzevria, Astra Zeneca) three days earlier. The patient had a medical history no known chronic illnesses or allergies and had not been using any medication. Vital signs were normal (blood pressure 125/85mmHg, heart rate 75bpm, respiratory rate 16/min, SpO2 99%). ECG showed STelevations of the posterolateral wall and depressions of the anterior wall ( Figure 1 , ECG leads II, III and aVF respectively V1-V3). In the initial laboratory testing (normal values in parenthesis) hscTroponin: 363pg (<14); CK-MB: 37U/l (<25) and nt-proBNP 347pg/ml (<125) as well as CRP: 2,2mg/dl (<0.50) were elevated. The remaining blood values including myoglobin were normal. Coronary heart disease was ruled out by an immediate invasive cardiac catheterization on the same day. Echocardiography The patient was transferred to a high care ward and a cardiac MRI was performed on the following day. The magnetic resonance imaging (MRI) on the 5th day post Astra Zeneca vaccination was acquired as a multiparametric functional MRI using refocusing gradient echo technique "steady-state free-precession" cinematic MRI sequences (CINE) and morphologic T1 and T2-weighted (MORPHO) sequences after intra-venous application of 25 ml Dotarem in early and late contrast-enhanced phase. Motion corrected T1 and T2 mapping sequences were acquired. These sequences were used to analyze functional and volumetric information. T1-and T2-weighted images as non-contrasted sequences and T1 after contrast agent injection. The sequences were acquired in short-axis transversal, 2-,3-,4-chamber view, as well as left ventricular outflow-tract view. MRI-images (Figure 2A Myocarditis is reported as being caused by SARS-CoV-2 but there have been a few cases reported after SARS-CoV-2 vaccination so far. Direct virus-induced cell damage to infected cardiomyocytes and T-cell-mediated cytotoxicity [1] , as well as immunological processes in response to viral components of the vaccine or immunogenic adjuvants [2, 3] , are suspected as a possible cause. These rare cases of myocarditis which were reported after SARS-CoV-2 vaccination mostly manifested over a short, self-limiting course without permanent impairment of cardiac function and predominantly affec young men with a mean age of 25 years [4, 5] . In this context, MRI is the diagnostic imaging modality of choice for patients with cardiac clinical symptoms, as it is non-invasive and causes no radiation exposition to young patients [6] . LGE, myocardial edema, and pericardial thickening as well as pathological findings in ECG and laboratory values confirm the diagnosis of myocarditis. In this context, the Lake Louis criteria are used to qualitatively assess cardiac MRI [7, 8] . Myocarditis is diagnosed when two of the following criteria are matched by the findings: myocardial edema in T2-WI; early Gadolinium enhancement indicating hyperemia; myocardial damage with non-ischemic morphology and corresponding LGE. Myocarditis has been reported mainly after administration of mRNA vaccines [4, 5, 9] ; only 8 cases have been reported to the German Paul Ehrlich Institute after vaccination with the adenovirus-based vector vaccine Vaxzevria (formerly known as COVID-19 vaccine AstraZeneca) with over 9 million doses of this vaccine recently administered in Germany [10] . The evaluation of foreign vaccination surveillance showed a rather negative association with the occurrence of myocarditis and vaccination with Vaxzevria or the COVID-19 vaccine Janssen [11] . From the view of pathophysiology, the literature suggests autoimmune myocarditis as the most likely cause for post-vaccination myocarditis [1, 4, 11] . This is explained by "molecular mimicry" as viral antigens are similar to the antigen-proteins on myocardial cells, thus an autoimmunological reaction causes lymphocytes, phagocytes, and granulocytes to attack the body's own cells. Secondly, a hypersensitivity reaction could have taken place after vaccination. In our case, the patient only received a single dose of vaccine, making this overshooting reaction less likely compared to patients receiving two vaccinations (BioNTech, Moderna, etc) [2, 3, 11] . So far, myocarditis hasn't been confirmed as a specific complication after vaccination with a vector vaccine against SARS-CoV-2 but should be considered if there is a temporal coincidence and no other explanation. As our experience so far with a single patient may be an exception, there should be more cases collected and analyzed to prove this correlation between COVID-19 vaccination and myocarditis. COVID-19 vaccine-induced myocarditis: Case report with literature review Post-vaccination myositis and myocarditis in a previously healthy male Acute Fulminant Myocarditis Following Influenza Vaccination Requiring Extracorporeal Membrane Oxygenation Pericarditis and Cardiomyopathy After COVID-19 Vaccination Safety of the BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Setting Myocarditis After SARS-CoV-2 Vaccination: A Vaccine-Induced Reaction? Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations Assessment of acute myocarditis by cardiac magnetic resonance imaging: Comparison of qualitative and quantitative analysis methods COVID-19 Vaccine and Myocarditis Bericht über Verdachtsfälle von Nebenwirkungen und Impfkomplikationen nach Impfung zum Schutzvor COVID-19 COVID-19 vaccines and myocarditis