key: cord-0780912-089b1z4b authors: Hudson, Blake; Mantooth, Ryan; DeLaney, Matthew title: Myocarditis and pericarditis after vaccination for COVID‐19 date: 2021-07-26 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12498 sha: d85c81b91e083822af65b735e767d35fa7a2b543 doc_id: 780912 cord_uid: 089b1z4b Two previously healthy males presented to the emergency symptoms with signs of pericarditis/myocarditis after being vaccinated with an mRNA vaccine for COVID‐19. With the rapid development and rollout of vaccinations for COVID-19 patients are reporting a variety of possible vaccine-related adverse events. Acute myocarditis (AM) and pericarditis are 2 potential complications that have been associated with previous vaccinations. 1 Although the exact incidence of AM after vaccination is somewhat unclear, recent studies have reported cases of clinically significant AM in ∼1:5500 patients after smallpox vaccination. 2 Less commonly similar cases have been reported after vaccinations for influenza and human papillomavirus. 3 More recently there have been various reports in the lay press of AM after vaccination for COVID-19. This case series presents 2 patients with concerns of myocarditis shortly after receiving their second vaccine. A previously healthy 22-year-old male presented to the ED with 3 days of worsening chills, low-grade fevers, and chest pain. He states that the morning of presentation, his pain intensified and was described as pressure in the center-left chest without any radiation. He noticed his symptoms started ≈12 hours after his second Pfizer vaccination. He denied any other associated symptoms. Rapid influenza and COVID-19 testing nasal PCR testing were negative. The patient was noted to have significant diaphoresis but had an otherwise normal examination. Patient's initial ECG was normal; however, repeat ECG ( Figure 2 ) several hours later revealed the following. Notable laboratory tests: Erythrocyte sedimentation rate C-reactive protein 1.05 ng/mL (< 0.09) 268 ng/L (< 15) 491 ng/mL (< 499) 9.97 K/mcL 4 mm/hr (0-15 mm/hr) 3.6 mg/dL (< 0.9 mg/dL) The patient was admitted to the hospital and was started on aspirin and colchicine, and then transitioned to ibuprofen 400 mg three times a day with colchicine 0.6 mg daily at discharge. His initial echocardiogram showed a normal EF but did have trace mitral and tricuspid regurgitation. A subsequent echo 2 days later was normal. The patient was discharged after an uneventful hospital stay with a presumed diagnosis of myopericarditis. Historically year-old men but did not provide a precise estimate of the magnitude of any potential association in these patients. 8 Currently the response to these potential vaccine related cases has been variable. Following this report from Israel, a press release from Pfizer stated that although they were aware of these reported cases they had "not observed a higher rate of myocarditis than what would be expected in the general population. . . a causal link to the vaccine has not been established." In late May 2021, the Centers for Disease Control and Prevention (CDC) reported that they were aware of "increased cases of myocarditis and pericarditis" after vaccination with both the Pfizer and Moderna mRNA vaccines. Echoing the Israeli report, the CDC reported that these cases appeared more frequently in adolescent males after the second vaccination. Despite these reports, the CDC concluded that any potential risk from vaccination was likely outweighed by the potential benefits and continued to recommend the use of these agents in all patients 12 years of age and older. 9 There is considerable debate regarding a potential causal relationship between vaccinations and cases of myocarditis. Various potential mechanisms including hypersensitivity to vaccine components, inflammatory reaction, or inappropriate activation of the immune system have been proposed, yet given the relative rarity of these cases it is difficult to establish a true causal relationship. 10 Clinically the key to identifying these cases is to have a high index of suspicion in any patient who presents with acute symptoms after a response, yet there is little evidence to support their routine use. Salicylates and nonsteroidal anti-inflammatory drugs are the mainstay of treatment in acute pericarditis, but there has been some question of its use in myocarditis as there is concern for a potential increase in adverse events. 12 As the distribution of COVID-19 vaccines increases, there are a growing number of cases after patients received a novel mRNA vaccine. Although the current body of evidence is sparse, the majority of cases seem to occur in otherwise healthy young men most often after their second vaccination. Although the majority of reported cases are coming from the lay press as the number of reports increases there is growing concern for at least an association between COVID-19 vaccination and subsequent myocarditis. While we wait for more data clinicians should have a high suspicion for these potential complications in any patient who presents with cardiopulmonary symptoms after COVID-19 vaccination. Vaccine safety datalink investigator team. Myocarditis and pericarditis are rare following live viral vaccinations in adults A prospective study of the incidence of myocarditis/pericarditis and new onset cardiac symptoms following smallpox and influenza vaccination Myocarditis and pericarditis after immunization: gaining insights through the vaccine adverse event reporting system 19-year-old hospitalized in ICU days after receiving second Pfizer vaccine Israel examines heart inflammation cases after Pfizer shot Pentagon tracking 14 cases of heart inflammation in troops after COVID-19 shots. Military News Israel sees probable link between Pfizer-BioNTech vaccine and myocarditis cases Surveillance of myocarditis (inflammation of the heart muscle) cases between Clinical Considerations: Myocarditis and Pericarditis after Receipt of mRNA COVID-19 Vaccines Among Adolescents and Young Adults Acute fulminant myocarditis following influenza vaccination requiring extracorporeal membrane oxygenation Diagnostic and prognostic role of electrocardiogram in acute myocarditis: a comprehensive review American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology. Recognition and Initial Management of Fulminant Myocarditis: a Scientific Statement From the American Heart Association Myocarditis and pericarditis after vaccination for COVID-19 The authors report no conflict of interest.