Myocarditis is one of the complications reported with COVID-19 vaccines, particularly both Pfizer-BioNTech and Moderna vaccines. Most of the published data about this association come from case reports and series. Integrating the geographical data, clinical manifestations, and outcomes is therefore important in patients with myocarditis to better understand the disease. A thorough literature search was conducted in Cochrane library, PubMed, ScienceDirect, and Google Scholar for published literature till 30 March 2022. We identified 26 patients eligible from 29 studies; the data were pooled from these qualifying case reports and case series. Around 94% of patients were male in this study, the median age for onset of myocarditis was 22 years and 85% developed symptoms after the second dose. The median time of admission for patients to hospitals post-vaccination was three days and chest pain was the most common presenting symptom in these patients. Most patients had elevated troponin on admission and about 90% of patients had cardiac magnetic resonance imaging (CMR) that showed late gadolinium enhancement. All patients admitted with myocarditis were discharged home after a median stay of four days. Results from this current analysis show that post-mRNA vaccination myocarditis is mainly seen in young males after the second dose of vaccination. The pathophysiology of vaccine-induced myocarditis is not entirely clear and late gadolinium enhancement is a common finding on CMR in these patients that may indicate myocardial fibrosis or necrosis. Prognosis remains good and all patients recovered from myocarditis, however further studies are advisable to assess long-term prognosis of myocarditis.
We present the case of a 54-year-old lady who presented to hospital with palpitations and was diagnosed with atrial fibrillation with rapid ventricular response. She was given intravenous metoprolol 5 mg initially followed by a further 5 mg and was commenced on bisoprolol 2.5 mg once daily. She reverted back to normal sinus rhythm and was referred for echocardiography following an episode of paroxysmal atrial fibrillation. The echocardiogram showed a large mobile atrial myxoma in the left atrium and mild-to-moderate mitral regurgitation with preserved left ventricular function. Her past medical history includes transsphenoidal surgery for acromegaly in 1979, followed by radiotherapy and partial thyroidectomy for goitre. Her chest radiograph was normal and blood results were unremarkable. She was accepted for inpatient transfer to a cardiothoracic centre for surgical removal of atrial myxoma. She underwent surgery with successful excision of the atrial myxoma, and biopsies confirmed the mass to be atrial myxoma. The surgery was complicated by the patient developing atrial fibrillation with fast ventricular response that was chemically cardioverted with an intravenous loading dose of amiodarone 300 mg over 2 hours followed by 900 mg infusion over 24 hours. She had follow-up in the outpatient clinic with cardiology and endocrine specialists for a year and no recurrence of myxoma was noted. Her blood tests including growth hormone and thyroid function tests were normal.
We discuss a case of a 31-year-old male patient who presented to the accident and emergency department with shortness of breath and chest pain since the morning of the day of presentation. His polymerase chain reaction (PCR) test had returned positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), two weeks ago and his main symptoms had been shortness of breath, dry cough, generalized body pain, and fever. He was not vaccinated against the COVID-19 virus. He had not required hospitalization for COVID-19 and his symptoms had improved on day 10 from the date of diagnosis; however, he developed pleuritic chest pain with shortness of breath on the day of presentation. He was found to have tachypnoea, hypoxia, and tachycardia on assessment. His electrocardiogram showed a right bundle branch block with sinus tachycardia. He underwent a CT pulmonary angiography (CTPA) that showed bilateral large pulmonary emboli extending from the main pulmonary arteries bilaterally extending to the sub-segmental level. There was evidence of right heart strain on the scan. He also had a bedside echocardiogram performed after the CT scan, which showed an enlarged right ventricle but no left ventricular thrombus.His blood results showed D-dimer levels of 14,000 ng/mL and troponin T of 255 ng/L. He received treatment with low molecular weight heparin (LMWH) and underwent emergency EkoSonic™ Endovascular System (EKOS) thrombolysis (Boston Scientific, Marlborough, MA). He remained on ultrasound-accelerated thrombolysis (USAT) for the next 12 hours and showed significant improvement and was taken off oxygen post-EKOS thrombolysis. He was discharged home on oral rivaroxaban after 48 hours of hospital stay; follow-up after two months showed normal-sized right ventricle with no evidence of pulmonary hypertension.
Myxedema coma is a rare and life-threatening manifestation of severe hypothyroidism. Myxedema refers to altered mental status observed in these patients. Clinical characteristics observed include hypothermia, bradycardia, respiratory failure, hyponatremia, and altered mental status. We present the case of a 57-yearold female who was brought into the hospital with a history of collapse and a long lie. On initial assessment, she was hypothermic, hypotensive, bradycardic, and hypoglycemic with elevated infection markers, acute kidney injury, and electrolyte derangement. Her thyroid function tests on admission were severely impaired with a TSH (thyroid stimulating hormone) level of 144.46 mU/L and Free T4 (thyroxine) levels of 3.4 pmol/L. She was admitted to the intensive care unit and was started on intravenous antibiotics, intravenous liothyronine, oral levothyroxine, and intravenous hydrocortisone. Initially, her hypothermia and bradycardia were slow to respond to treatment measures, but following the introduction of liothyronine, she showed marked improvement. Over the next few days, her infection markers improved, her acute kidney injury resolved, and her thyroid function tests normalized. Liothyronine was stopped after 6 days, levothyroxine was continued at her regular dose of 175 micrograms, and she was safely discharged with outpatient endocrinology follow-up.
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