Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination

Abstract

IMPORTANCE Vaccine-associated myocarditis is an unusual entity that has been described for the smallpox vaccine, but only anecdotal case reports have been described for other vaccines. Whether COVID-19 vaccination may be linked to the occurrence of myocarditis is unknown.OBJECTIVE To describe a group of 7 patients with acute myocarditis over 3 months, 4 of whom had recent messenger RNA (mRNA) COVID-19 vaccination.DESIGN, SETTING, AND PARTICIPANTS All patients referred for cardiovascular magnetic resonance imaging at Duke University Medical Center were asked to participate in a prospective outcomes registry. Two searches of the registry database were performed: first, to identify patients with acute myocarditis for the 3-month period between February 1 and April 30 for 2017 through 2021, and second, to identify all patients with possible vaccine-associated myocarditis for the past 20 years. Once patients with possible vaccine-associated myocarditis were identified, data available in the registry were supplemented by additional data collection from the electronic health record and a telephone interview.EXPOSURES mRNA COVID-19 vaccine. MAIN OUTCOMES AND MEASURESOccurrence of acute myocarditis by cardiovascular magnetic resonance imaging. RESULTSIn the 3-month period between February 1 and April 30, 2021, 7 patients with acute myocarditis were identified, of which 4 occurred within 5 days of COVID-19 vaccination. Three were younger male individuals (age, 23-36 years) and 1 was a 70-year-old female individual. All 4 had received the second dose of an mRNA vaccine (2 received mRNA-1273 [Moderna], and 2 received BNT162b2 [Pfizer]). All presented with severe chest pain, had biomarker evidence of myocardial injury, and were hospitalized. Coincident testing for COVID-19 and respiratory viruses provided no alternative explanation. Cardiac magnetic resonance imaging findings were typical for myocarditis, including regional dysfunction, late gadolinium enhancement, and elevated native T1 and T2.CONCLUSIONS AND RELEVANCE In this study, magnetic resonance imaging findings were found to be consistent with acute myocarditis in 7 patients; 4 of whom had preceding COVID-19 vaccination. Further investigation is needed to determine associations of COVID-19 vaccination and myocarditis.

Impact of disease-modifying antirheumatic drugs on vaccine immunogenicity in patients with inflammatory rheumatic and musculoskeletal diseases

“…Because of its substantial immunogenicity, there is concern that the SARS-CoV-2 vaccine may induce flares in patients with inflammatory diseases. This concern is supported by reports of thrombocytopaenic purpura [89][90][91][92] and myocarditis/pericarditis [93][94][95] after vaccination. There have additionally been observational reports of new-onset immune-mediated disease 96 and/ or disease flares after SARS-CoV-2 vaccination, 96 97 which must be balanced against the risk of immune-mediated disease resulting from SARS-CoV-2 infection itself.…”

Overview of the Main Anti-SARS-CoV-2 Vaccines: Mechanism of Action, Efficacy and Safety

“…As of June 28, 2021, VAERS (Vaccine Adverse Events Reporting System) has received 780 reports of myocarditis or pericarditis among people 30 years and younger who received a Covid-19 vaccine. 34,42 On July 14th, US FDA includes risk of Guillain-Barré Syndrome (GBS) in Janssen COVID-19 vaccine pertaining to an observed increased risk of GBS following vaccination (source: US Food and Drug Administration https:// www.fda.gov/news-events/press-announcements/corona virus-covid-19-update-july-13-2021).…”

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“…This is because this group of people has a higher risk for severe diseases if infected [85,86], and the advantages of getting vaccinated outweigh the potential disadvantages. There are some reports on vaccine-associated myocarditis [22,[87][88][89]. Further laboratory investigations showed elevated troponin with negative viral serologies, and cardiac magnetic resonance imaging (MRI) demonstrated edema and delayed gadolinium enhancement of the left ventricle in a midmyocardial and epicardial distribution [23].…”