key: cord-0868984-msvwzv5m
authors: Perna, Francesco; Verecchia, Elena; Pinnacchio, Gaetano; Gerardino, Laura; Brucato, Antonio; Manna, Raffaele
title: Rapid resolution of severe pericardial effusion using anakinra in a patient with COVID-19 vaccine-related acute pericarditis relapse: a case report.
date: 2022-03-18
journal: Eur Heart J Case Rep
DOI: 10.1093/ehjcr/ytac123
sha: 3ec7a063af6a7847716e49924b49f3bdf52525b9
doc_id: 868984
cord_uid: msvwzv5m

BACKGROUND: Pericarditis, along with myocarditis, is being increasingly reported after COVID-19 vaccine, but the best treatment strategy in this specific setting is still unclear. CASE SUMMARY: We report a case of acute pericarditis after the second dose of mRNA coronavirus disease 19 (COVID-19) vaccine with recurrence of large pericardial effusion after a previous pericardiocentesis and anti-inflammatory drugs tapering. The patient was successfully treated with the recombinant interleukin-1 (IL-1) receptor antagonist anakinra, with full reabsorption of the pericardial effusion and an abrupt drop of the inflammatory markers within 72 hours. The patient was discharged a few days later, with further decrease of the inflammatory markers and no residual symptoms. DISCUSSION: Anakinra is being increasingly used in the treatment of recurrent pericarditis due to its capability to interrupt the autoinflammatory response leading to deleterious cytokine storm. On account of its high efficacy and rapid onset, it has been reported to rapidly reverse large inflammatory pericardial effusions. Pericarditis and myocarditis have been reported after COVID-19 vaccine, but this is the first case of COVID-19 vaccine-related pericarditis and pericardial effusion successfully treated with anakinra, avoiding a second pericardiocentesis.

Discussion. Anakinra is being increasingly used in the treatment of recurrent pericarditis due to 11 its capability to interrupt the autoinflammatory response leading to deleterious cytokine storm. 12 On account of its high efficacy and rapid onset, it has been reported to rapidly reverse large 13 inflammatory pericardial effusions. Pericarditis and myocarditis have been reported after 14 COVID-19 vaccine, but this is the first case of COVID-19 vaccine-related pericarditis and 15 pericardial effusion successfully treated with anakinra, avoiding a second pericardiocentesis. Background. Pericarditis, along with myocarditis, is being increasingly reported after vaccine, but the best treatment strategy in this specific setting is still unclear. Discussion. Anakinra is being increasingly used in the treatment of recurrent pericarditis due to 13 its capability to interrupt the autoinflammatory response leading to deleterious cytokine storm.

14 On account of its high efficacy and rapid onset, it has been reported to rapidly reverse large 15 inflammatory pericardial effusions. Pericarditis and myocarditis have been reported after 16 COVID-19 vaccine, but this is the first case of COVID-19 vaccine-related pericarditis and 17 pericardial effusion successfully treated with anakinra, avoiding a second pericardiocentesis.

Keywords: pericarditis; anakinra; COVID-19 vaccine; pericardial effusion; pericardiocentesis; 19 case report.

The management of recurrent pericarditis can be challenging because of frequent recurrences 2 with severely impaired quality of life, and requires close cooperation between cardiologists, 3 rheumatologists and internists 1,2 . Acute pericarditis has been described as a rare complication 4 of the COVID-19 vaccine, showing an overall incidence of 1.8/million vaccine doses in the 5 European Economic Area and United States, with a slightly higher incidence for Adenovirus-6 vectored vaccines as compared to mRNA vaccines 3 . The incidence of recurrent pericarditis after 7 COVID-19 vaccine is currently unknown. Treatment options for COVID-19 vaccine-related 8 pericarditis have not been thoroughly investigated 3 . We report a case of COVID-19 vaccine-9 related recurrent pericarditis with pericardial effusion successfully treated with anakinra, 10 avoiding a second pericardiocentesis.

A 30-year-old man with no past medical history (in particular, he had no prior evidence of 13 pericarditis or any inflammatory/autoimmune disease) was admitted to our Cardiac Intensive 14 Care Unit (CICU) because of cardiac tamponade with large circumferential (mainly anterior) 15 pericardial effusion, in the context of acute pericarditis, with diffuse ST elevation and PR 16 depression on the ECG (Fig. 1a) . The cardiovascular examination showed increased heart rate 17 (100 bpm), muffled heart sounds, jugular vein distension, low blood pressure (90/55 mmHg).

He had received his second dose of mRNA COVID-19 vaccine (Comirnaty, Pfizer-BioNTech) 40 19 days before, and had complained of fever and typical pleuritic chest pain for the next 5 days, 20 with subsequent reduction of the symptoms (which had never completely disappeared though), injury has been identified as a predictor of adverse outcomes 11 . Proinflammatory cytokines, 19 such as IL-1, IL-6, and TNF-α, lead to activation of T-lymphocytes, which cause myocyte damage, 20 alarmins production and further cytokine release that sustain the autoinflammatory response. 

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