Drug Reaction With Eosinophilia and Systemic Symptoms-Associated Perimyocarditis After Initiation of Anti-tuberculosis Therapy: A Case Report.

A 34-year-old female who was recently placed on anti-tuberculosis medication with rifampin, isoniazid, pyrazinamide, and levofloxacin therapy for suspected tuberculosis reinfection presented with subjective fevers, rash, and generalized fatigue. Labs showed signs of end-organ damage with eosinophilia and leukocytosis. One day later, the patient became hypotensive with a worsening fever, and an electrocardiogram showed new diffuse ST segment elevations with an elevated troponin. An echocardiogram revealed a reduction in ejection fraction with diffuse hypokinesis, and cardiac magnetic resonance imaging (MRI) showed circumferential myocardial edema with subepicardial and pericardial inflammation. Prompt diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome using the European Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) criteria and discontinuation of therapy was initiated. Due to the hemodynamic instability of the patient, the patient was started on systemic corticosteroids and cyclosporine, with the improvement of her symptoms and rash. A skin biopsy was performed, which revealed perivascular lymphocytic dermatitis, consistent with DRESS syndrome. As the patient's ejection fraction improved spontaneously with corticosteroids, the patient was discharged with oral corticosteroids, and a repeat echocardiogram showed full recovery of ejection fraction. Perimyocarditis is a rare complication of DRESS syndrome that is associated with degranulation and the release of cytotoxic agents into myocardial cells. Early discontinuation of offending agents and initiation of corticosteroids are essential to rapid recovery of ejection fraction and improved clinical outcomes. Multimodality imaging, including MRI, should be used to confirm perimyocardial involvement and guide the necessity for mechanical support or transplant. Further research should be on the mortality of DRESS syndrome with and without myocardial involvement, with an increased emphasis on cardiac evaluation in DRESS syndrome.

COVID-19 Vaccine-Induced Acute Perimyocarditis: A Case Report.

Perimyocarditis is the inflammation of the pericardium along with the myocardium. Presentation is similar to acute pericarditis, but it is associated with myocardial damage, leading to an elevation in serum troponin and a left ventricular dysfunction (manifested as an ejection fraction of less than 55 percent). Perimyocarditis is mostly managed like acute myocarditis. Etiology is generally idiopathic and likely secondary to viral infections. Cases of vaccine-associated myocarditis have been infrequently reported in past, most recently with the COVID-19 mRNA vaccine. We present a rare case of a young healthy adolescent male who developed perimyocarditis after the first booster dose of the COVID-19 mRNA vaccine.

Prognosis of Myocarditis Developing After mRNA COVID-19 Vaccination Compared With Viral Myocarditis.

BACKGROUND: Association between messenger RNA (mRNA) COVID-19 vaccines and myocarditis has aroused public concern over vaccine safety. OBJECTIVES: The goal of this study was to compare the prognosis of this condition with viral infection-related myocarditis over 180 days. METHODS: A territory-wide electronic public health care database in Hong Kong linked with population-based vaccination records was used to conduct a retrospective cohort study. Since the roll-out of BNT162b2 (Pfizer-BioNTech), patients aged ≥12 years hospitalized with myocarditis within 28 days after BNT162b2 vaccination were compared against viral infection-related myocarditis recorded before the pandemic (2000-2019), over a 180-day follow-up period (starting from diagnosis of myocarditis). All-cause mortality, heart failure, dilated cardiomyopathy, heart transplant, and postdischarge health care utilization were examined with Cox proportional hazards models. RESULTS: A total of 866 patients were included for analysis. Over the follow-up period, 1 death (1.0%) of 104 patients with postvaccination myocarditis and 84 deaths (11.0%) of 762 patients with viral infection-related myocarditis were identified. One case (1.0%) of dilated cardiomyopathy and 2 cases (1.9%) of heart failure were identified in the postvaccination group, compared with 28 (3.7%) and 93 (12.2%) in the viral infection-related myocarditis group, respectively. Adjusted analysis showed that the postvaccination myocarditis group had a 92% lower mortality risk (adjusted HR: 0.08; 95% CI: 0.01-0.57). No significant differences in other prognostic outcomes were seen. CONCLUSIONS: This study found a significantly lower rate of mortality among individuals with myocarditis after mRNA vaccination compared with those with viral infection-related myocarditis. Prognosis of this iatrogenic condition may be less severe than naturally acquired viral infection-related myocarditis.

A Case Series of Myocarditis Related to the COVID-19 Vaccine.

Perimyocarditis related to the coronavirus disease 2019 (COVID-19) vaccine is one of the rare adverse events that emerged in April 2021 and then the number of cases commensurably increased as the number of vaccinated people rose. This is a case series of myocarditis/pericarditis related to the messenger RNA (mRNA) COVID-19 vaccine in which we identified four cases with different presentations and outcomes. A short-term follow-up period of five months revealed a full recovery of three cases within one to 12 weeks and persistent left ventricular systolic dysfunction in the fourth case which will require further follow-up to assess long-term outcomes.

Acute Perimyocarditis in an Adolescent Japanese Male after a Booster Dose of the BNT162b2 COVID-19 Vaccine.

Perimyocarditis is a rare and serious cardiac complication following COVID-19 vaccination. Young males are most at risk after the second dose. With the introduction of the booster (third) dose, some reports have focused on the risk of perimyocarditis after a booster dose. However, no currently available report in Japan has comprehensively described this phenomenon. A healthy 14-year-old Japanese male, who had completed a two-dose primary series of the BNT162b2 (Pfizer-BioNTech) vaccine six months prior, developed fever and chest pain within 24 hours after a homologous booster dose. He was transferred to our institute because of worsening chest pain. A multiplex PCR test showed no evidence of active viral infections, including SARS-CoV-2. Electrocardiography revealed ST-segment elevation in almost all leads, suggesting pericarditis. Echocardiography showed normal systolic function. Laboratory data demonstrated C-reactive protein levels of 8.8 mg/dL and elevated cardiac damage markers (troponin T, 1.9 ng/mL; creatine phosphokinase, 1527 U/L; MB isoenzyme, 120 U/L), suggesting myocarditis. He was diagnosed with perimyocarditis associated with the booster dose, which was confirmed by cardiac magnetic resonance imaging four days after initial symptoms. Chest pain improved spontaneously along with a resolution of electrocardiographic findings and laboratory data within several days. He was discharged eight days after admission. Perimyocarditis is less frequent after a booster dose than after primary doses. In this case, the patient with booster-dose-associated perimyocarditis showed favorable clinical course without severe sequelae. The patient's clinical course was consistent with findings on previous large-scale reports on primary-dose-associated perimyocarditis and case series on booster-dose-associated perimyocarditis.

Epidemiology, clinical ramifications, and cellular pathogenesis of COVID-19 mRNA-vaccination-induced adverse cardiovascular outcomes: A state-of-the-heart review.

The coronavirus disease 2019 (COVID-19) has overwhelming healthcare systems globally. To date, a myriad of therapeutic regimens has been employed in an attempt to curb the ramifications of a severe COVID-19 infection. Amidst the ongoing pandemic, the advent and efficacious uptake of COVID-19 vaccination has significantly reduced disease-related hospitalizations and mortality. Nevertheless, many side-effects are being reported after COVID-19 vaccinations and myocarditis is the most commonly reported sequelae post vaccination. Majority of these diseases are associated with COVID-19 mRNA vaccines. Various studies have established a temporal relationship between these complications, yet the causality and the underlying pathogenesis remain hypothetical. In this review, we aim to critically appraise the available literature regarding the cardiovascular side effects of the various mRNA vaccines and the associated pathophysiology.

Transient Myopericarditis Following Vaccination for COVID-19.

Clinical trials of the messenger ribonucleic acid (mRNA)-1273 vaccine developed by Moderna proved excellent safety and efficacy for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) prevention. However, the Centers for Disease Control and Prevention (CDC) has been investigating cases of myocarditis and pericarditis reported in the Vaccine Adverse Event Reporting System (VAERS) database. Currently, the CDC is reporting rates of 40.6 cases per million after second doses of mRNA vaccines administered to males 30 years or younger. Notably, the initial vaccine trials consisted of a limited number of adolescents and young adults; therefore, they were likely not powered to detect this rare potential side effect. We present a case of transient myopericarditis occurring in a young and healthy patient within 48 h of his second vaccination dose. Although a definitive causal relationship has yet to be determined, we came to this correlation because of the temporal association seen in our patient, secondary to the second dose of vaccination. Furthermore, we also suspect an autoimmune mechanism as the cause of cardiac injury, augmented by the increased vaccine reactogenicity seen in younger patients.

COVID-19 associated perimyocarditis.

Perimyocarditis is a well-known acute inflammation of the pericardium and the underlying myocardium. Most commonly perimyocarditis is of viral aetiology, specifically the coxsackie B virus. However, nowadays SARS-CoV-2 associated with COVID-19 infections has emerged as a potential rare cause of perimyocarditis. This case report will demonstrate a case of a young female with perimyocarditis as diagnosed by magnetic resonance imaging (MRI) accompanied by antigens indicating a past COVID-19 infection. Clinical status as well as Findings at MRI, echocardiography and lab results will be reviewed.

[Fatal course of COVID-19 despite IL-6 receptor blockade in cytokine storm : Perimyocarditis and coagulopathy after administration of tocilizumab]. / Fataler COVID-19-Verlauf trotz IL­6­Rezeptor-Blockade im Zytokinsturm : Perimyokarditis und Koagulopathie nach Tocilizumabgabe.

A 59-year-old male patient was admitted to hospital diagnosed with moderate pneumonia associated with COVID-19. Upfront treatment with hydroxychloroquine and azithromycin was started. Due to a clinical deterioration (ARDS, circulatory shock) and greatly increased inflammation markers 6 days after admission, a cytokine storm was suspected and off-label treatment with the IL­6 receptor antagonist tocilizumab was initiated. Subsequently there was a dramatic rise of D­dimers indicating pulmonary intravascular coagulopathy and respiratory insufficiency worsened. After a second dose of tocilizumab was administered severe perimyocarditis with cardiac arrhythmia, hemodynamic instability and ST elevation occurred. Shortly afterwards the patient died due to multiorgan failure. From our experience, exacerbation of COVID-19 following treatment with tocilizumab cannot be ruled out. Randomized controlled studies are necessary to further investigate the efficacy, safety and patient selection criteria for tocilizumab treatment in COVID-19.

Unusual Presentation of Acute Perimyocarditis Following SARS-COV-2 mRNA-1237 Moderna Vaccination.

Since the start of the pandemic, to date, around 180 million cases have been diagnosed with COVID-19 worldwide with an estimated 3.9 million death toll. Mass vaccination has taken place to control spread of infection with the most commonly used vaccines being Pfizer-BioNTech and Moderna. However, the adverse events associated with vaccination have not been fully investigated. Of concern are some serious cardiovascular events such as myocarditis, pericarditis or perimyocarditis development post-vaccination. In this report, we present an unusual case of acute perimyocarditis and pericardial effusion 10 days following the second dose of Moderna COVID-19 vaccination in Qatar. At the time of presentation, the patient presented with non-specific symptoms of headache, diarrhea, vomiting, lethargy and dehydration. COVID-19 polymerase chain reaction (PCR) was negative. Once admitted to the emergency department, she started to deteriorate with very low blood pressure readings reaching 40/33 mmHg which was treated with aggressive fluid resuscitation. After 5.5 liters of intravenous fluids, echocardiography and electrocardiogram (ECG) were performed. Findings were consistent with pericardial effusion, signs of impending cardiac tamponade and acute perimyocarditis. Cardiac biomarkers including troponin T and pro-brain natriuretic peptide (BNP) were elevated. Hospital course was complicated with cardiac arrest, acute kidney injury, disseminated intravascular coagulation (DIC) and hemodynamic instability. Eventually, the patient recovered after a three-week hospital stay and was discharged on non-steroidal anti-inflammatory medication (NSAIDs). This case report highlights the hospital course and outcome linking the second dose of Moderna vaccination and the development of perimyocarditis.