key: cord-0991210-xli7wyg4
authors: Mimouni, Hamza; Bahouh, Choukri; amaqdouf, Saida; laaribi, Ilyass; Baddi, Mohammed; Berichi, Samya; Bkiyar, Houssam; ismaili, Nabila; El ouafi, Noha; Housni, Brahim
title: Cardiogenic shock revealing myocarditis after mRNA vaccination against covid-19: Case report and brief review for the first case in Morocco
date: 2021-12-30
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2021.103210
sha: 00cc2c2c06d6e936c7c543302db535821ba0249c
doc_id: 991210
cord_uid: xli7wyg4

INTRODUCTION: and importance: After its unexpected effectiveness in the clinical trials, the anti-COVID-19 vaccine type mRNA was launched on December 11, 2020, but a few months later, several reports of post-mRNA vaccination myocarditis were published, but without any proven causal link. CASE PRESENTATION: We report the case of a 14-year-old teenager admitted to the emergency department for a cardiogenic shock, the patient mentioned that he had an anti-COVID 19 vaccination 10 days before his admission. First, the vasoactive drugs had stabilized the patient; the troponins came back highly favorable but later confirmed myocarditis by magnetic resonance imaging. In this sense an etiological analysis was made and it came back without any particularities, leaving us relating the myocarditis to the vaccination. CLINICAL DISCUSSION: Post-vaccination myocarditis is a rare event, with very few reports in the literature. After the introduction of COVID vaccination, several reports were published, mostly after the mRNA vaccine. Until now, no causal link has been proven, so we need to have more reports in this sense to have a better knowledge of this phenomenon. CONCLUSION: Until we obtain a more precise explanation of the mechanism of myocarditis after vaccination with the anti-COVID-19 vaccine, all symptoms suggesting myocarditis should be systematically monitored during the first 7 days after vaccination.

Since April 2021, several cases of diseases including myocarditis have been reported after having COVID-19 vaccination type mARN [1] , Most of myocarditis conditions were reported in young people, but to date, there is no proven causal link. We report the case of a young patient admitted with myocarditis complicated by cardiogenic shock in whom the etiology was related to the anti-COVID-19 vaccination type mARN.

We report the case of a 14-year-old child, without any pathological history, admitted to the emergency room for extreme asthenia associated with a headache and fever reaching 40 C°, resistant to the usual analgesics. The initial examination found a conscious patient, without deficit, with a frank stiffness of the neck, hemodynamically unstable with a SBP ( systolic blood pressure) 80mmhg, and a DBP ( Diastolic blood pressure) 30mmhg, tachycardia at 132bpm, with coldness of the extremities, on the respiratory level the patient was polypneic with a FR at 29cpm and SpO2 at room air 90%. The clinical examination showed signs of right heart failure, including turgidity of the jugular veins and hepatomegaly, without skin signs in favor of purpura. The ECG showed sinus tachycardia without repolarization disorders, and the chest X-ray in front of the patient's bed showed an alveolar syndrome. It should be noted that myocarditis after vaccination is a rare event, and has been described in some vaccines such as the smallpox vaccine [8] . Concerning the vaccination against COVID-19, several reports were published in this sense, mostly after a mRNA vaccine [9] .

Regarding the physiopathology, there is no causal link yet demonstrated, but it is already noted in Pfizer-BioNTech clinical trials that systemic reactogenicity and immunogenicity are increased after the vaccine, especially for the young people [5] , this reactogenicity is mainly made of extreme asthenia, myalgias, J o u r n a l P r e -p r o o f fever, arthralgia or lymphandinitis [6] , and maybe the myocarditis would be explained by this reactogenicity situation.

The symptomatology of myocarditis is varied, ranging from simple shortness of breath, chest pain, or dyspnea to the fulminant myocarditis, in which the patient comes with a shock that usually requires circulatory support with positive inotropes [19] . Regarding myocarditis after mRNA vaccination, according to the Center for Disease Control and Prevention it is recommended to monitor the signs within 7 days after vaccination [9] .

The first steps in the diagnosis of myocarditis are the anamnesis and the electrocardiographic signs, which are generally non-specific, and which may show arrhythmia or repolarization disorders [11] . The biology may show an elevation of markers of inflammation including C-reactive protein, and an increase in the troponin levels, but it should be noted that a normal troponin level does not eliminate the diagnosis. Echocardiography is recommended in all patients suspected of having myocarditis, it helps us evaluate the regional and global function of the left ventricle, to estimate the ejection fraction, and it should be pointed out that a normal ejection fraction should not exclude the diagnosis of myocarditis [12] . Cardiac magnetic resonance imaging (CMR) remains the examination of choice for diagnosis, it allows a precise characterization of the myocardial tissue. The criteria lake louise is used to identify the type of myocardial damage [13] .

The therapeutic management of myocarditis after COVID-19 mRNA vaccine is essentially based on two elements: the first is the management of the hemodynamic instability by vasoactive inotropes or circulatory support such as the extracorporeal membrane oxygenation (ECMO), or the intra-aortic counterpulsation (IABP) in the fulminant forms [10] , the second is the management of the inflammation, corticosteroids and intravenous immunoglobulins (IVIG) are used to limit the activation of the nonspecific J o u r n a l P r e -p r o o f immune system [14] . For non-steroidal anti-inflammatory drugs, it is recommended to not use them due to their detrimental action on the kidney, which may aggravate the heart failure by the significant hydro-sodic retention [15] .

In our case, the hemodynamic instability was managed with vasoactive drugs only, and the use of corticosteroids alone was advocated to combat immune activation, and the evolution was favorable.

The SCARE guildlines were used in the writing of this paper [16] .

Given the seriousness of this disease, which can be fatal in its fulminant form, further research on the causal links between myocarditis and mRNA type COVID-19 vaccination is needed , especially in view of the large number of cases reported.

The authors state that they have no conflicts of interest for this report Ethical Approval The ethical committee approval was not required give the article type case report. However, the written consent to publish the clinical data of the patients were given and is available to check by the handling editor if needed.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Written informed Consent was obtained from the child's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

J o u r n a l P r e -p r o o f

Not commissioned, externally peer reviewed

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The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

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Please specify the contribution of each author to the paper, e.g. study concept or design, data collection, data analysis or interpretation, writing the paper, others, who have contributed in other ways should be listed as contributors.HAMZA MIMOUNI : study concept or design, data collection, data analysis or interpretation, writing the paper Choukri Bahouh : Data collection, data analysis Saida amaqdouf : Data collection, data analysis Ilyass laaribi : Data collection, data analysis Mohammd Baddi : Data collection, data analysis Samia berrichi : Data collection Houssam bkiyar : supervision and data validation Brahim Housni : supervision and data validation J o u r n a l P r e -p r o o f

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