Bivalent mRNA COVID-19 Vaccine-Related Pericarditis on 18 F-FDG PET/CT.

ABSTRACT: A 13-year-old boy was suspected with pericarditis after a second booster dose of bivalent mRNA COVID-19 vaccine. After specific preparation for cardiac inflammation with carbohydrate-free, high-fat diet, the 18 F-FDG PET/CT successfully demonstrated simultaneous presentation of vaccination-related axillary lymphadenopathy and pericarditis without the interference of physiological myocardial uptake.

Acute pericarditis in patients receiving coronavirus disease 2019 vaccines: a case series from the community.

BACKGROUND: International agencies reported that cases of pericarditis occur very rarely following the administration of coronavirus disease 2019 (COVID-19) vaccines. Herewith, we described a series of patients from the community diagnosed with acute pericarditis after vaccination. METHODS: We retrospectively included 28 patients (median age 51 years, 79% female) with or without a positive history of acute respiratory syndrome coronavirus 2 recovered infection who were diagnosed with acute pericarditis following the administration of COVID-19 vaccine. We excluded specific identifiable causes of pericarditis, including infectious, autoimmune, neoplastic and metabolic disease. Patients were referred for a complete cardiovascular evaluation. Transthoracic echocardiography (TTE) was performed and diagnosis of acute pericarditis was achieved according to current guidelines. RESULTS: There were 16 patients administered with Pfizer-BioNTech/Comirnaty vaccine, 8 with Moderna/Spikevax vaccine and 4 with Astra Zeneca/Vaxzevria vaccine. Nine patients had been previously diagnosed with COVID-19, while the others had no prior history of COVID-19. Eleven patients had no comorbidity while the others had between one and four comorbidities. Ten patients had a history of rheumatic or autoimmune diseases. Chest pain was present in 24 patients. Minor ECG abnormalities were detected in 10 patients, T-wave inversion in 6, and 7 patients had concave ST elevation. The majority of patients showed mild pericardial effusions at TTE. Only two patients exhibited large pericardial effusions. CONCLUSION: This case series shows a higher incidence of acute pericarditis in patients administered with COVID-19 vaccines than previously estimated, probably because of a more comprehensive assessment of clinical as well as echocardiographic parameters.

Persistent Cardiac Magnetic Resonance Imaging Findings in a Cohort of Adolescents with Post-Coronavirus Disease 2019 mRNA Vaccine Myopericarditis.

We describe the evolution of cardiac magnetic resonance imaging findings in 16 patients, aged 12-17 years, with myopericarditis after the second dose of the Pfizer mRNA coronavirus disease 2019 vaccine. Although all patients showed rapid clinical improvement, many had persistent cardiac magnetic resonance imaging findings at 3- to 8-month follow-up.

Cardiac magnetic resonance imaging of myocarditis and pericarditis following COVID-19 vaccination: a multicenter collection of 27 cases.

OBJECTIVES: To assess clinical and cardiac magnetic resonance (CMR) imaging features of patients with peri-myocarditis following Coronavirus Disease 2019 (COVID-19) vaccination. METHODS: We retrospectively collected a case series of 27 patients who underwent CMR in the clinical suspect of heart inflammation following COVID-19 vaccination, from 16 large tertiary centers. Our patient's cohort was relatively young (36.6 ± 16.8 years), predominately included males (n = 25/27) with few comorbidities and covered a catchment area of approximately 8 million vaccinated patients. RESULTS: CMR revealed typical mid-subepicardial non-ischemic late gadolinium enhancement (LGE) in 23 cases and matched positively with CMR T2 criteria of myocarditis. In 7 cases, typical hallmarks of acute pericarditis were present. Short-term follow-up (median = 20 days) from presentation was uneventful for 25/27 patients and unavailable in two cases. CONCLUSIONS: While establishing a causal relationship between peri-myocardial inflammation and vaccine administration can be challenging, our clinical experience suggests that CMR should be performed for diagnosis confirmation and to drive clinical decision-making and follow-up. KEY POINTS: • Acute onset of dyspnea, palpitations, or acute and persisting chest pain after COVID-19 vaccination should raise the suspicion of possible myocarditis or pericarditis, and patients should seek immediate medical attention and treatment to help recovery and avoid complications. • In case of elevated troponin levels and/or relevant ECG changes, cardiac magnetic resonance should be considered as the best non-invasive diagnostic option to confirm the diagnosis of myocarditis or pericarditis and to drive clinical decision-making and follow-up.

Reconsideration of the ECG in pericarditis; have we been led astray all these years?

Recently, new criteria for the diagnosis of pericarditis have been published. This paper has been thought to point out the limits in the new criteria specificity as well in the application of the new criteria for the diagnosis of pericarditis as recently demonstrated by studies based on cardiac magnetic resonance imaging. We report the case of A 18y old male with no significant past medical history who presented with complaints of chest pain typical for pericarditis, initially labeled as pericarditis; the patient was evaluated by electrocardiography, trans-thoracic echocardiography and cardiac magnetic resonance imaging; the condition, based on electrocardiogram and trans-thoracic echocardiography findings, was labeled as pericarditis in keeping with current diagnostic criteria. Cardiac magnetic resonance imaging demonstrated myocardial edema with no T2-defined pericardial inflammation on TIR/T2 imaging; late gadolinium enhancement imaging demonstrated multiple irregular, punctate, epicardial zones. The constellation of findings was consistent with acute myocarditis without pericardial involvement. In conclusion, limits in specificity of the newly published criteria for diagnosis of pericarditis, which add to the already demonstrated limits in sensitivity, subsist. Cardiac magnetic resonance imaging plays a unique role in the initial assessment of pericarditis; this is particularly important in the Covid-19 era in light of the increasing incidence of myocarditis and pericarditis; also, the case suggests that the combination of information between advanced echocardiography and cardiac magnetic resonance imaging may have an important diagnostic role in this setting. Additionally, we suggest that despite recent enthusiasm for colchicine, its role may be best defined in those with myocarditis, not pericarditis.

Longitudinally Extensive Transverse Myelitis (LETM) and Myopericarditis in a 7-Month-Old Child with SARs-CoV-2 Infection.

INTRODUCTION: In the last few months, some pediatric cases with neurological and neuroradiological pictures related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections have been reported, often associated with multisystem inflammatory syndrome (MIS-C). The most frequently encountered pediatric neurological complications seem to be postinfectious immune-mediated acute disseminated encephalomyelitis (ADEM)-like changes of the brain, myelitis, neural enhancement, and splenial lesions. Concomitant neurological and cardiac involvement has been reported only in MIS-C, although specific clinical details are often not fully available. METHODS: In this case report, a very young child infected with SARs-CoV-2 and diagnosed as longitudinal extensive transverse myelitis with concomitant myo-pericarditis is presented. RESULTS: A previously healthy 7-month-old girl presented with abrupt onset of generalized weakness with inability to sit up. She had had mild respiratory symptoms 1 week earlier. Spinal magnetic resonance imaging (MRI) showed a T2-hyperintense intramedullary lesion extending from C4 to T2, compatible with acute longitudinally extensive transverse myelitis (LETM). Cerebrospinal fluid analysis was negative.Echocardiography and blood tests were suggestive for myo-pericarditis. Real time polymerase chain reaction for SARS-CoV-2 on nasopharyngeal swab sample tested positive. She was promptly treated with high dose of steroids and immunoglobulin with satisfactory clinical response. CONCLUSION: To the evolving literature of neurological complications of SARs-CoV-2 infection, we add the youngest patient described to date with isolated LETM and concomitant cardiac involvement. Our case suggests that clinicians should be aware of this association, although difficult to recognize in infants. Practitioners are encouraged to consider aggressive first-line immunotherapies with the final aim to prevent permanent disability.

Subacute effusive-constrictive pericarditis in a patient with COVID-19.

We report the case of a previously healthy young woman, who developed a severe form of COVID-19 with massive pneumonia and acute pericarditis in whom constrictive physiology developed rapidly. To our knowledge, this represents the second reported case of SARS-CoV-2 constrictive pericarditis, a rare, but severe cardiac complication.

Pericardial Diseases in COVID19: a Contemporary Review.

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID19) involves the heart, including pericardium. This article reviews the possible pathophysiological mechanisms in pericardial involvement in COVID19 and pericardial manifestations of COVID19. It also summarizes the patients with pericarditis secondary to COVID19 and outlines the contemporary treatment strategies in this patient population. RECENT FINDINGS: A high degree of suspicion is required to identify the pericardial involvement in COVID19 patients. It is proposed that an underlying hyperinflammatory reaction in COVID19 leads to pericardial inflammation. Acute pericarditis with or without myocardial involvement is diagnosed on clinical presentation, serum inflammatory markers, electrocardiogram, and echocardiogram. Multimodality imaging may also have an additional diagnostic value. Patients are usually managed medically, but some patients develop a life-threatening pericardial tamponade necessitating pericardial drainage. Pericardial involvement is an important clinical manifestation of COVID19 requiring a proper workup. Timely diagnosis and a specific management plan based on the presentation and concomitant organ involvement usually lead to a complete recovery.

COVID-19 multisystemic inflammatory syndrome in adults: a not to be missed diagnosis.

We report COVID-19 multisystemic inflammatory syndrome in an adult patient with an atypical presentation (mild abdominal pain) and a negative (repeated) reverse transcriptase-PCR, in the absence of lung involvement on lung ultrasound. In this case, focused cardiac ultrasound revealed signs of myopericarditis and enabled us to focus on the problem that was putting our patient in a perilous situation, with a quick, non-time-consuming and easy-to-access technique. Serology test was performed and SARS-CoV-2 infection was confirmed more than a week after admission to the coronary unit. As the patient had a general good appearance, the potential implications of missing this diagnosis could have been fatal.

Pericarditis as the Main Clinical Manifestation of COVID-19 in Adolescents.

Children and adolescents with severe acute respiratory syndrome coronavirus 2 infection usually have a milder illness, lower mortality rates and may manifest different clinical entities compared with adults. Acute effusive pericarditis is a rare clinical manifestation in patients with COVID-19, especially among those without concurrent pulmonary disease or myocardial injury. We present 2 cases of acute pericarditis, in the absence of initial respiratory or other symptoms, in adolescents with COVID-19.

Acute pericarditis and severe acute respiratory syndrome coronavirus 2: Case report.

We present the case of a 51-year-old patient with acute pericarditis as the dominant manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The patient was admitted to the emergency department during a coronavirus disease 2019 (COVID-19) outbreak with a suspected ST-elevation myocardial infarction. A coronary angiogram was normal. Real-time reverse transcriptase PCR for the detection of nucleic acid from SARS-CoV-2 in a nasopharyngeal swab was positive. Laboratory tests revealed an increased white blood cell count, with neutrophilia and lymphocytopenia, elevated level of C-reactive protein, borderline elevated erythrocyte sedimentation rate, and slightly elevated interleukin 6. Echocardiography showed a hyperechogenic pericardium posterolaterally with minimal localized pericardial effusion. A chest computed tomography scan showed a small zone of ground-glass opacity in the right lower lobe (classified as CO-RADS 3). In patients with chest pain, ST elevation on electrocardiogram, a normal coronary angiogram, and suspected COVID-19, we should think of pericarditis as an unusual presentation of SARS-CoV-2 infection.

Myocarditis: imaging up to date.

Myocarditis is an inflammatory disease of the heart muscle, diagnosed by histological, immunological, and immunohistochemical criteria. Endomyocardial biopsy represents the diagnostic gold standard for its diagnosis but is infrequently used. Due to its noninvasive ability to detect the presence of myocardial edema, hyperemia and necrosis/fibrosis, Cardiac MR imaging is routinely used in the clinical practice for the diagnosis of acute myocarditis. Recently pixel-wise mapping of T1 and T2 relaxation time have been introduced into the clinical Cardiac MR protocol increasing its accuracy. Our paper will review the role of MR imaging in the diagnosis of acute myocarditis.

Pediatric COVID-19 and Pericarditis Presenting With Acute Pericardial Tamponade.

We describe a seven-year-old female with acute pericarditis presenting with pericardial tamponade, who screened positive for coronavirus disease 2019 (COVID-19 [SARS-CoV-2]) in the setting of cough, chest pain, and orthopnea. She required emergent pericardiocentesis. Due to continued chest pain and orthopnea, rising inflammatory markers, and worsening pericardial inflammation, she underwent surgical pericardial decortication and pericardiectomy. Her symptoms and pericardial effusion resolved, and she was discharged to home 3 days later on ibuprofen and colchicine with instruction to quarantine at home for 14 days from the date of her positive testing for COVID-19.

Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19).

Importance: Virus infection has been widely described as one of the most common causes of myocarditis. However, less is known about the cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Objective: To describe the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from the influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms. Design, Setting, and Participant: This case report describes an otherwise healthy 53-year-old woman who tested positive for COVID-19 and was admitted to the cardiac care unit in March 2020 for acute myopericarditis with systolic dysfunction, confirmed on cardiac magnetic resonance imaging, the week after onset of fever and dry cough due to COVID-19. The patient did not show any respiratory involvement during the clinical course. Exposure: Cardiac involvement with COVID-19. Main Outcomes and Measures: Detection of cardiac involvement with an increase in levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T, echocardiography changes, and diffuse biventricular myocardial edema and late gadolinium enhancement on cardiac magnetic resonance imaging. Results: An otherwise healthy 53-year-old white woman presented to the emergency department with severe fatigue. She described fever and dry cough the week before. She was afebrile but hypotensive; electrocardiography showed diffuse ST elevation, and elevated high-sensitivity troponin T and NT-proBNP levels were detected. Findings on chest radiography were normal. There was no evidence of obstructive coronary disease on coronary angiography. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay. Cardiac magnetic resonance imaging showed increased wall thickness with diffuse biventricular hypokinesis, especially in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%). Short tau inversion recovery and T2-mapping sequences showed marked biventricular myocardial interstitial edema, and there was also diffuse late gadolinium enhancement involving the entire biventricular wall. There was a circumferential pericardial effusion that was most notable around the right cardiac chambers. These findings were all consistent with acute myopericarditis. She was treated with dobutamine, antiviral drugs (lopinavir/ritonavir), steroids, chloroquine, and medical treatment for heart failure, with progressive clinical and instrumental stabilization. Conclusions and Relevance: This case highlights cardiac involvement as a complication associated with COVID-19, even without symptoms and signs of interstitial pneumonia.