key: cord-1049427-2sma4jht authors: Misumi, Ikuo; Ogata, Aki; Fukuda, Koichiro; Sato, Koji; Nagano, Miwa; Usuku, Hiroki; Tsujita, Kenichi title: Constrictive pericarditis following mRNA COVID-19 vaccination in a patient with systemic sclerosis date: 2022-04-04 journal: J Cardiol Cases DOI: 10.1016/j.jccase.2022.03.014 sha: 94b426329696c2aad523f0365566cb771d6f3e40 doc_id: 1049427 cord_uid: 2sma4jht A 59-year-old man with systemic sclerosis and interstitial pneumonia was referred to our department because he developed dyspnea and leg edema after receiving a first shot of coronavirus disease 2019 (COVID-19) vaccine. Transthoracic echocardiography showed moderate pericardial effusion with conspicuous fibrin deposition. Prednisolone was increased from 6 mg/day for systemic sclerosis to 20 mg/day. Thereafter, pericardial effusion gradually decreased. However, his symptoms continued. Transthoracic echocardiography showed disappearance of pericardial effusion and thickened pericardium. Pulsed-wave and tissue Doppler echocardiography revealed that the patient suffered from newly developed constrictive pericarditis. COVID-19 vaccination might have contributed to acute pericarditis and subsequent constrictive pericarditis in the present case of systemic sclerosis and pulmonary fibrosis. Learning objective Incidence of adverse effects after coronavirus disease 2019 vaccination is rare. The present case suggests the risk of pericarditis that may lead to constrictive pericarditis. The present case suggests the risk of pericarditis that may lead to constrictive pericarditis. On 23 June 2021, the US Centers for Disease Control and Prevention's safety committee stated there was a "likely association" between the Pfizer-BioNTech and Moderna coronavirus disease 2019 (COVID-19) vaccines and myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining around the heart) in some young adults [1] . We present a rare case of constrictive pericarditis in a 59-year-old man after the first shot of COVID-19 vaccine. He was successfully treated with increased prednisolone. A 59-year-old man with systemic sclerosis and interstitial pneumonia was referred to our department because he developed dyspnea. He had been treated with 6 mg of prednisolone for the underlying diseases. He received the Pfizer mRNA vaccine a week before our consultation and had felt dyspnea five days after vaccination. His body temperature was 36.7°C. Physical examination showed blood pressure was 123/83 mmHg and pulse rate was 123 beats per minute. Pulsus paradoxus was absent. Auscultation of the respiratory sounds revealed a fine crackle at the bilateral lung fields. The heart sounds were rather distant. There was evidence of pretibial edema. Results of blood tests showed hemoglobin level of 11.6 g/dL, serum creatinine phosphokinase level of 77 U/L (normal<248 U/L), serum C-reactive protein level of 3.4 mg/dL, and plasma brain natriuretic peptide level of 108 pg/mL. Plasma KL-6 level was 568 U/ml and did not increase from a month before. Serum cardiac troponin level was not measured. Thyroid function was normal. A 12-lead electrocardiogram (ECG) showed sinus rhythm with poor R wave progression in the precordial leads (Fig. 1a) . One month before, a chest radiography showed pulmonary fibrosis with a cardiothoracic ratio (CTR) of 57% ( Fig.1e, arrows) . Prednisolone was increased from 6 mg/day for systemic sclerosis to 20 mg/day. Thereafter, his body weight decreased, C-reactive protein (CRP) level decreased, and the pericardial effusion eventually disappeared within 3 months (Fig. 2) . A 12-lead ECG showed increased voltage of QRS complex. However, his symptoms did not improve and inferior vena cava remained dilated. A transthoracic echocardiography showed that pericardial effusion had completely disappeared and that pericardium was thickened to 8 mm ( Fig. 3a, b, arrows) . An M-mode echocardiography at the left ventricle showed septal bounce, which means movement of the interventricular septum to the left ventricle during inspiration (Fig. 3c) . A pulsed-wave Doppler echocardiography at the mitral inflow showed inspiratory decrease in E wave velocity (Fig. 3d) . Medial (Fig. 3e) and lateral (Fig. 3f ) mitral annular tissue Doppler recording showed increased early relaxation velocity (e' wave) with medial velocity greater than lateral (annulus reversus). A pulsed-wave Doppler recording within the hepatic vein showed prominent diastolic flow reversal in expiration (Fig. 3g) . These findings made the diagnosis of constrictive pericarditis [2] . Immunosuppressive effect of corticosteroids may influence the effectiveness of vaccine response [3] . Doses >40 mg/day prednisone more than 1 week or >20 mg of prednisone for 2 weeks or more induce immunosuppression. As evidence showed that the response of inactivated We report a case of acute pericarditis and subsequent constrictive pericarditis following COVID-19 vaccination in a patient with systemic sclerosis in spite of increasing prednisolone administration. We would like to thank Mr Yoshiharu Saito and Ms Yuko Sakami for taking echocardiographic images. Covid-19: Should we be worried about reports of myocarditis and pericarditis after mRNA vaccines? Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria COVID-19 vaccine and corticosteroids: A challenging issue Myocarditis and other cardiovascular complications of the mRNA-based COVID-19 vaccines Pericardial disease: diagnosis and management Constrictive pericarditis after SARS-CoV-2 vaccination: A case report The authors declare that there is no conflict of interest.