Severe coronary artery spasm after administration of a 5-hydroxytryptamine type 1 receptor agonist in a patient with new-onset Graves' disease and myocarditis after SARS-CoV2 vaccination.

Background: Coronary artery spasm is a well-known potential side effect of selective 5-hydroxytryptamine type 1 (5HT1) receptor agonists and, therefore, contraindicated in patients with cardiovascular disease. SARS-CoV-2 vaccination has been associated with myocarditis, mainly in young men.Case summary: A 55-year-old man with longstanding cluster headache, treated with the 5HT1-agonist Sumatriptan for ten years, received the mRNA-1273 SARS-CoV-2 booster vaccine. Four days later, he developed severe retrosternal pain several minutes after administering Sumatriptan with electrographic ST-elevation and a raised high-sensitivity cardiac troponin-T (hs-cTnT). Coronary angiogram was normal, but a diagnosis of acute myocarditis and hyperthyroidism secondary to Graves' disease was made.Discussion: We present a case of severe coronary artery spasm induced by a 5HT1-agonist secondary to newly diagnosed Graves' disease and myocarditis. The mRNA-1273 SARS-CoV-2 booster vaccine administered four days before admission probably triggered both immunoreactions.

A UNIQUE CASE OF SEVERE PULMONARY NOCARDIOSIS PRESENTING WITH ARDS AND CARDIOGENIC SHOCK

SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Nocardiosis is a rare bacterial infection, which frequently affects immunocompromised patients. It can present as an acute, subacute, or chronic pulmonary infection with non-specific symptoms, such as fever, cough, dyspnea, weight loss, and hemoptysis. CASE PRESENTATION: A 34-year-old female with a history of chronic granulomatous disease and hidradenitis suppurativa on adalimumab presented to the ED with fever, shortness of breath, and productive cough of 2 days. Her vitals were T 101F, BP 66/48, HR 148, RR 42, and SPO2 94% on room air. On exam, she was cachectic, with bilateral crackles and rales in the right lung base. Extremities were cold, with trace pitting edema was present on bilateral lower extremities. COVID-19 PCR was negative. Despite fluid resuscitation, she remained hypotensive and was started on norepinephrine. Blood cultures were collected, and broad-spectrum antibiotics and an antifungal agent were initiated. Chest CT demonstrated bilateral multifocal consolidation with surrounding ground-glass opacities and complete consolidation of the right lower lobe. Due to worsening respiratory distress and tachypnea, and lack of improvement with non-invasive ventilation, she was intubated, placed on mechanical ventilation, and admitted to the Medical ICU. On hospital day 1, due to the patient's immunosuppression, unresolving shock, and radiographic findings, a bronchoscopy with bronchoalveolar lavage (BAL) was performed. On hospital day 2, a transthoracic echocardiogram showed LV ejection fraction of 20-25% with severe global hypokinesis of the LV. ACS workup had been unremarkable, with mildly elevated troponin and no ischemic changes on EKG. She was initiated on cardiac inotropes. On hospital day 3, BAL culture revealed Nocardia cyriacigeorgica. TMP-SMX and ceftriaxone were started for severe pulmonary nocardiosis. On hospital day 11, she was liberated from mechanical ventilation, and by hospital day 14, she was weaned off all pressors and inotropes. Approximately 4 weeks after admission, repeat TTE showed recovery of LV ejection fraction (55-60%) and she was discharged with a prolonged course of TMP-SMX and IV ceftriaxone, with duration to be determined at outpatient infectious disease follow-up. DISCUSSION: We discuss a unique case of severe pulmonary nocardiosis, presenting with ARDS and cardiogenic shock. To the best of our knowledge, this is the first case of a patient with pulmonary nocardiosis presenting with stress cardiomyopathy reported in the literature. While the pathophysiology is not well understood, theorized mechanisms include catecholamine excess, coronary artery spasm, microvascular dysfunction. CONCLUSIONS: This case highlights the need for a broad differential diagnosis in patients presenting with ARDS and cardiogenic shock and illustrates the value of clinical bronchoscopy in patients with unique presenting features. Reference #1: Lerner PI. Nocardiosis. Clin Infect Dis. 1996 Jun;22(6):891-903;quiz 904-5. doi: 10.1093/clinids/22.6.891. PMID: 8783685. Reference #2: Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005 Feb 10;352(6):539-48. doi: 10.1056/NEJMoa043046. PMID: 15703419. Reference #3: Park JH, Kang SJ, Song JK, Kim HK, Lim CM, Kang DH, Koh Y. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest. 2005 Jul;128(1):296-302. doi: 10.1378/chest.128.1.296. PMID: 16002949. DISCLOSURES: no disclosure on file for D. Clark Files;No relevant relationships by Nisha Patel No relevant relationships by Meehir Shah

Coronary Vasospasm in a Pediatric Patient with Myopericardit is After COVID-19 Vaccine

Introduction: The COVID-19 vaccine was approved for use in adolescents ages 12-17 on May 10, 2021. There have since been case reports of myocarditis shortly after the COVID-19 vaccine, mostly in adolescent males. Among these cases, coronary vasospasm has not been described. Case Description: A 16 year old previously healthy male presented with two days of chest pain and subjective fevers three days after receiving the second dose of the Pfizer COVID-19 vaccine. High-sensitivity troponin I was 10,819 ng/L (reference range: 3-57), and ECG showed mild diffuse ST segment elevations (Image 1). He was admitted for suspected myopericarditis and treated with ketorolac, prednisone, and IVIG. Shortly after admission, he experienced sudden crushing, substernal chest pain. An ECG obtained during the episode showed striking ST segment elevation in the inferolateral leads (Image 2). He was started on a nitroglycerin drip, supplemental oxygen, low dose aspirin and received 3 doses of morphine. The acute chest pain responded rapidly to these measures, and the nitroglycerin drip was stopped after 24 hours without recurrence of symptoms. An echocardiogram was normal. Cardiac MRI showed subepicardial enhancement without evidence of acute infarction. He was discharged on hospital day #4, chest pain free for 24 hours with downtrending troponin. Discussion: Our patient's initial presentation of chest pain with elevated troponin and mild diffuse ST segment elevation is consistent with myopericarditis, similar to described cases occurring after the COVID-19 vaccine. During an acute, more severe, episode of chest pain, there was further localized ST segment elevation consistent with myocardial ischemia. Serial ECGs demonstrated improvement as the chest pain resolved, suggesting acute coronary artery vasospasm. Intravenous nitroglycerin, the mainstay of treatment for coronary vasospasm, was therapeutic with no recurrence of chest pain. Interestingly, our patient's acute inferolateral ST segment elevations during the episode of severe chest pain correlated with the distribution of myocardial enhancement noted on cardiac MRI, implicating subepicardial myocarditis as the likely cause. This complication has been reported in adults with viral myocarditis. Conclusion: This case highlights the importance of recognizing coronary vasospasm as a potential complication of COVID vaccine-induced myopericarditis.

A broken heart? Unexplained cardiac ischaemia after intrauterine fetal death

Introduction: Cardiac disease is the leading cause of maternal death in the UK [1].We present the case of awoman with late intrauterine fetal death (IUFD) and intrapartum cardiac ischaemia. A family history of limb girdle muscular dystrophy (LGMD) may be relevant. Case Report: A 23-year-old nulliparous woman at 39 weeks of gestation presented with reduced fetal movements and IUFD was confirmed. She had no medical history, and despite two first degree relatives with LGMD, she was asymptomatic and had not been tested. Uterine contractions started and epidural analgesia was initiated. Shortly thereafter, the woman was found to be bradycardic at 35– 40 beats/min. All other observations were normal and she was asymptomatic with no detectable sensory or motor block. A 12 -lead ECG showed inferior T-wave inversion and serial troponins were markedly elevated. Caesarean section (CS) under general anaesthesia was performed at maternal request and was uneventful. Postpartum echocardiogram demonstrated a dilated left atrium, left ventricular akinesis and an ejection fraction of 45–50%. The next day the woman developed chest pain and desaturated. CTPA and CT coronary angiogram were normal. Oxygenation improved and other than sporadic chest heaviness she remained well and was discharged 4 days post CS. Cardiology follow-up did not occur due to a communication breakdown. Post-mortem of the fetus found no cause for the IUFD and no features of LGMD. Thewoman suffered a miscarriage four months after this but delivered a healthy baby at elective CS two years later. During the latter pregnancy cardiology input from a tertiary centrewas requested but did not occur due to the COVID-19 pandemic. An echocardiogram in the third trimester was normal and the woman has been well since. Discussion: Troponin rise is abnormal in pregnancy and requires investigation. IUFD in itself can lead to sequelae requiring a low threshold for investigation. The family history in this case is autosomal dominant type 1B LGMD, associated with cardiomyopathy and arrhythmias [2]. The woman has declined testing and the cause for the peripartum cardiac disease remains unknown. The recovery and recent uneventful pregnancy suggest Takotsubo’s cardiomyopathy or coronary vasospasm as additional possible diagnoses. This case also underlines the importance in sensitive communication in cases of IUFD to ensure women are investigated and not lost to follow-up.

CAUGHT IN THE ACT: MINOCA IN A PATIENT WITH SEVERE CORONARY VASOSPASM

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a complex and diagnostically challenging entity. Case: A 62-year-old female with recent COVID19 infection presented with chest pain. She was discharged just one week prior for NSTEMI, with mild non-obstructive CAD by left heart catheterization (LHC) and a normal transthoracic echocardiogram. This admission, Initial Troponin I peaked at 0.87 ng/mL and ECG without ischemic changes. Cardiac MRI (CMR) showed no myocarditis/pericarditis but moderate-severely hypokinetic apical cap, distal inferior and septal walls, with a small focus of subendocardial scar/infarction involving the distal septum (Fig.1A,B,C). LHC showed severe vasospasm in the right coronary artery and left anterior descending artery (Fig. 1D,E), which resolved after intracoronary nitroglycerin (Fig. 1F). With initiation of isosorbide mononitrate to manage coronary vasospasm, the patient’s symptoms improved. At 6-month follow-up, patient was doing well with no repeat hospitalizations. Decision-making: Even though initial workup did not identify a clear etiology, CMR was pivotal in prompting further evaluation that revealed severe coronary vasospasm. Given the transient nature of vasospasm, it is likely this had resolved prior to her initial LHC, but was caught on repeat imaging. Conclusion: CMR is a key diagnostic tool in preliminary investigation of MINOCA when a clear cause is not found, and can alter next steps in management. [Formula presented]

STEMI PRESENTATIONS IN YOUNG MALES AFTER MRNA VACCINE

Background: Vaccination efforts worldwide continue in the face of the ongoing pandemic of COVID-19. More than 6.65 billion doses of the COVID-19 vaccine have been administered thus far. Adverse events after receiving the vaccine are being reported and monitored closely. Recently, there have been increasing reports of myocarditis/pericarditis in young men after receiving a second dose of the mRNA vaccine. Rare complications such as vaccine-induced immune thrombotic thrombocytopenia and thrombotic thrombocytopenic syndrome have been identified after the administration of viral vector vaccines. We present here three STEMI cases in young, healthy males three days after receiving the second dose of an mRNA vaccine. Methods: Three males aged 19-34 years old with no past medical history presented to the emergency department with ST elevations on EKG and increased troponin I. They were each taken to the cardiac catheterization lab. All patients had received a second dose of mRNA vaccine within four days prior to presentation. Results: All three patients had no evidence of coronary obstruction on cardiac catheterization. They were admitted overnight, and their troponin I levels trended downwards without further intervention. Conclusion: With the relatively new advent of mRNA vaccines against the COVID-19 virus, there are still many potential short and long-term complications that have yet to be identified. The patient presentations herein were suspicious for acute coronary syndrome given their typical anginal chest pain, acute troponin I rise and fall, and EKG changes indicative of myocardial ischemia. However, there was no evidence of obstruction on left heart catheterization in any of these cases. Given these findings, it is possible that cardiac inflammation or coronary vasospasm are correlated with having received a second dose of the mRNA vaccine. Further studies are needed to determine if these occurrences are merely coincidental or if they can be directly attributed to such vaccines. Going forward, it is imperative to obtain COVID-19 vaccination history whenever a patient presents to a healthcare setting, as we continue to learn about the possible and varied sequelae of such vaccines.

Characteristics of patients referred to a cardiovascular disease clinic for post-acute sequelae of sars-cov-2 infection

Introduction: There is limited literature on the cardiovascular manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC). Methods: All consecutive adult patients presenting to the cardiology clinic at Yale-New Haven Hospital since July 2020, with positive COVID-19 serologic testing, were included. Results: Of 71 patients, average age was 46 years (range 19-74 years), 44 (62%) were female. 51 (72%) were White. 19 (27%) patients were hospitalized for COVID-19 (Table). Comorbidities included Hypertension (27%), hyperlipidemia (25%), diabetes (24%), and obesity (30%). On average, patients presented four months after COVID-19 diagnosis. The most common symptoms at presentation were dyspnea (45%, almost all exertional), palpitations (49%), and chest pain/pressure (49%). Patients also had memory impairment (20%), fatigue (39%), and headache (14%). There was no significant difference in cardiopulmonary symptoms (dyspnea, palpitations, and chest pain/pressure) by hospitalization status (p=0.70). TTE was abnormal in 13 of 62 patients and cardiac MRI was abnormal in 10 of 17 patients. Women experienced more cardiopulmonary symptoms (p=0.02) than men. Hospitalized patients were more likely to have ventricular dysfunction than non-hospitalized patients, although there were no significant differences in abnormal MRI findings (p=0.38). Diagnostic yield included: nonischemic cardiomyopathy (6%);new ischemia (3%);coronary vasospasm (1%);new atrial fibrillation (1%);possible myocarditis based on symptoms, MRI LGE (8%) or inflammation (3%). Two people met POTS criteria;majority of patients had evidence of sinus tachycardia and exertional fatigue consistent with orthostatic intolerance and deconditioning. Conclusions: In this cohort of patients referred to a cardiology clinic for PASC, cardiopulmonary symptoms did not differ by hospitalization status, however women were more likely to experience these symptoms than men.