key: cord-0789093-es5mmq3s authors: McLean, Kelsey; Johnson, Tiffani J. title: Myopericarditis in a previously healthy adolescent male following COVID‐19 vaccination: A case report date: 2021-07-21 journal: Acad Emerg Med DOI: 10.1111/acem.14322 sha: 968ac82e43d0f297fcfa213e770a9999cb520af2 doc_id: 789093 cord_uid: es5mmq3s We report the case of a previously healthy 16‐year‐old male who developed myopericarditis following the second dose of his Pfizer‐BioNTech COVID‐19 vaccine, with no other identified triggers. Adolescents and young adults experiencing chest pain after COVD‐19 vaccination should seek emergent medical care, and emergency providers should have a low threshold to consider and evaluate for myopericarditis. More data are needed to better understand the potential association between COVID‐19 vaccines and myopericarditis. If a true causal link is identified, the risk must also be viewed in context with the millions of patients who have been safely vaccinated and the known morbidity and mortality from COVID‐19 infection. As we see widespread vaccine rollout, it is important that all potential adverse reactions are reported as we continue to monitor for more rare but potentially serious side effects not identified in vaccination trials. COVID-19 has infected over 3.9 million children and adolescents in the United States and has resulted in over 3,700 cases of multisystem inflammatory syndrome in children (MIS-C) and 400 deaths in children 0 to 17. 1 Beyond the immediate health impacts, there have also been worsening mental and behavioral health for children and their families, loss of childcare and in-person education, increased food insecurity, and economic distress. 2 Widespread vaccination has been identified as our best hope for ending the pandemic. The Pfizer-BioNTech COVID-19 vaccine, Moderna COVID-19 vaccine, and Janssen COVID-19 vaccine received emergency authorization use for patients 16 years and older in December 2020. The Pfizer-BioNTech COVID-19 vaccine then received emergency authorization us for patients aged 12 to 15 on May 10, 2021. 3 The clinical trials data in adolescents age 12 to 17 overall demonstrates a vaccine efficacy rate of 96% and was 100% effective among 12 to 15 year olds. 4 The most common side effects reported include headache, fatigue, myalgias, and chills, with no serious safety concerns identified. 4 Presentations may be acute, defined by direct viral cytotoxicity and focal or diffuse necrosis of the myocardium; subacute, defined by an increase in auto-immune mediated injury; or chronic, defined by diffuse myocardial fibrosis and cardiac dysfunction that may lead to dilated cardiomyopathy and its sequelae. 7 Presenting symptoms vary based on age of the patient, with infants and toddlers often presenting with fatigue, respiratory distress, fever, poor appetite, and tachycardia, while older children more often present with chest pain, abdominal pain, myalgias, fatigue, cough, and edema. 8 In one study, the most common presenting symptoms in the ED in cases of pediatric myocarditis were respiratory distress, tachycardia, lethargy, hepatomegaly, abnormal heart sound, and fever. 9 The incidence of myocarditis has been reported as approximately 1.5 million cases worldwide per year and is estimated between 10 to 20 cases per 100,000 persons. 7 However, it is thought to be underdiagnosed as many cases are subclinical. While the disease course is unpredictable and variable, higher levels of troponin (greater than 3× the upper limit of the reference range) likely correlate with more myocardial damage. 7 The prognosis of patients with myocarditis varies. Those with severe disease (decreased systolic function or development of dilated cardiomyopathy) have a poor prognosis without a transplant, but patients with mild disease typically have good outcomes. The mortality rate is as high as 20% at 1 year and 50% at 5 years. 7 While the disease process in our patient appears related to this vaccine and has been previously reported with other vaccines, we highlight that current evidence only supports a causal relationship secondary to timing. There have been case reports of pericarditis following influenza vaccine 10, 11 and hepatitis B vaccination, 12 myopericarditis after DTaP, 13 and more widespread instances of myopericarditis following smallpox vaccination (0.05%). 6 Outside of the association with smallpox vaccination, most myocarditis or pericarditis cases following vaccinations are very rare and reported as unique cases. In the wake of widespread COVID-19 vaccination that is occurring nationally and internationally, there are emerging cases of myopericarditis reported after vaccination. [14] [15] [16] As more cases arise we will better understand the mechanism of myocardial infiltration, the true incidence of potential vaccine-associated myopericarditis, and the long-term sequela and burden of this disease. COVID-19 caries a serious health burden for pediatric patients. reported among patients with COVID-19 infection, with a rate estimated at less than 5% in adults. 19 At least two pediatric patients have been diagnosed with COVID-19-associated myocarditis, although one was coinfected with adenovirus. 20, 21 As we consider the health consequences of COVID-19 infections, we are beginning to see more cases of "long-haul" COVID-19 among pediatric patients with symptoms of fatigue, shortness of F I G U R E 1 Myocarditis case [Color figure can be viewed at wileyonlinelibrary. com] breath, body aches, chest pain, headaches, depression, and brain fog. 22 The burden and incidence of serious COVID-19 infections, long-haul symptoms, and MIS-C in pediatric populations continue to be defined, as do the social, emotional, economic, and academic repercussions brought on by more than 12 months of isolation and societal shutdowns and the devastating impact of racial disparities. Several important implications should be considered in light of this case and other recent reports in the media and literature while awaiting further data and conclusions from the CDC. First, while chest pain usually has a benign etiology in pediatric populations, 23 as more children, adolescents, and young adults become vaccinated against COVID-19, even young patients experiencing chest pain after COVD-19 vaccination should seek emergent evaluation. Also, health care providers should have a low threshold to consider and evaluate for myopericarditis among patients presenting with chest pain in the postvaccine period. This and other emerging cases also help to illustrate the important role that emergency medicine providers can play in identifying, treating, and reporting potential vaccine-associated conditions. It is important that any cases of myopericarditis and other potential adverse reactions occurring after COVID-19 vaccination are reported to vaccine manufacturers and governing vaccine event reporting systems as we continue to monitor for more rare but serious side effects that were not identified in vaccination trials. More data are needed to better understand the potential association between COVID-19 vaccines and myopericarditis as well as more long-term follow-up to better characterize prognosis and sequelae. If a true causal link is identified, it must also be viewed in context with the millions of patients who have been safely vaccinated and the known morbidity and mortality from COVID-19 infection. https://orcid.org/0000-0003-0241-2140 Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States Well-being of parents and children during the COVID-19 pandemic: a national survey Vaccine for Emergency Use in Adolescents in Another Important Action in Fight Against Pandemic. U.S. Food and Drug Administration website COV-2 RNA VACCINE CANDIDATES AGAINST COVID-19 IN HEALTHY INDIVIDUALS Adverse events associated with smallpox vaccination in the United States Viral Myocarditis. StatPearls Outcome of acute fulminant myocarditis in children Symptomatic pericarditis after influenza vaccination Recurrent pericarditis: a rare complication of influenza vaccination Péricardite aiguë bénigne après vaccination contre l'hépatite B Acute myopericarditis after diphtheria, tetanus, and polio vaccination Myocarditis following COVID-19 vaccination Is Investigating a Heart Problem in a Few Young Vaccine Recipients. The New York Times website Teen's Parents Warning about Myocarditis, Rare Condition Possibly Linked to COVID-19. WPXI website Information for Pediatric Healthcare Providers Pathological evidence for SARS-CoV-2 as a cause of myocarditis COVID-19-associated myocarditis in an adolescent Acute fulminant myocarditis in a pediatric patient with COVID-19 infection Centers for Disease Control and Prevention website. 2021. 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