New-Onset Graves' Disease Presenting As Thyro-Pericarditis.

Acute perimyocarditis is commonly preceded by viral illness and presents with non-specific complaints that can be a manifestation of serious cardiac complications such as arrhythmias and heart failure. While pericarditis is a known complication of thyrotoxicosis, termed "thyrotoxic pericarditis," concomitant new-onset perimyocarditis and Graves' disease, termed "thyro-pericarditis," has been reported. We present a case of thyro-pericarditis as the initial presentation of undiagnosed and untreated Graves' disease co-occurring with recent Coxsackievirus A and B infection. A 27-year-old male with a family history of undifferentiated hyperthyroidism presented with acute pleuritic chest pain and shortness of breath. Laboratory testing showed elevated cardiac troponin I with ST elevations and PR depressions on initial ECG. Left heart catheterization was normal, but transthoracic echocardiogram showed right ventricular systolic dysfunction and enlargement. Cardiac MRI demonstrated diffuse pericardial enhancement suggesting pericarditis. Thyroid function testing and thyroid ultrasound suggested auto-immune thyrotoxicosis. Serology noted abnormal Coxsackievirus A and B IgG antibody titers, suggesting prior infection. The patient was treated with colchicine, ibuprofen, methimazole, and metoprolol, with resolution of symptoms. Thyro-pericarditis is a rare concomitant presentation of both Graves' disease and myopericarditis, and it remains unknown whether there is an increased risk of adverse cardiac outcomes.

Epstein-Barr Virus (EBV)-Associated Myopericarditis Provoking Severe Heart Failure in an Immunocompetent Young Male.

Myopericarditis, a rare inflammatory condition affecting the heart and its surrounding layers, can lead to serious consequences if not promptly diagnosed and treated. A recent case involved a 28-year-old man with no significant medical history who developed severe chest pain and was diagnosed with myopericarditis induced by the Epstein-Barr virus (EBV). The patient's symptoms, imaging, and lab test results suggest myopericarditis. Initially, he was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, and upon discharge, he continued with NSAIDs, as well as guideline-directed medical therapy, including an angiotensin-converting enzyme inhibitor, beta blocker, and SGLT2 inhibitor. Close follow-up with the cardiology and heart failure programs was planned. This case highlights the rare occurrence of this condition in individuals with a healthy immune system.

Occurrence of Myopericarditis Following COVID-19 Vaccination Among Adults in the Eastern Region, Saudi Arabia: A Multicenter Study.

Background: Evidence supporting the possible causal association of myopericarditis with the coronavirus disease (COVID-19) vaccine has mainly come from case reports. Epidemiological evidence indicating an increased relative risk for myopericarditis after COVID-19 vaccination is lacking. Therefore, this study aimed to identify and assess all confirmed COVID-19 vaccine- related cases of myopericarditis presenting to major cardiac centers in the Eastern Region of Saudi Arabia, before and after the introduction of the COVID-19 vaccine. Methods: According to case definition, the hospital's information system database detected all confirmed cases at two main cardiac centers. Results: Of the 18 confirmed myocarditis and myopericarditis cases detected after the administration of COVID-19 vaccines, three were possibly related to COVID-19 immunization. The first case was of myopericarditis following a third dose of mRNA-1273. The second case was myocarditis, which occurred seven days after the first dose of AstraZeneca. The third case was myocarditis, which occurred 12 days after the third dose of BNT162b2. A cardiologist carefully evaluated the cases using recognized protocols and case definitions to demonstrate a direct relationship with vaccination consequences rather than coincidence. Conclusion: We found no difference in the occurrence of myocarditis and myopericarditis after the COVID-19 vaccine compared with the background rate during a similar period (P = 0.9783). The incidences of myocarditis and myopericarditis following immunization were low. The advantages of the COVID-19 vaccination outweigh the risk of myopericarditis.

Boerhaave syndrome: an unusual myocardial infarction mimic-a case report.

Background: A rare complication of oesophageal rupture or Boerhaave syndrome is myopericarditis due to leakage of oesophageal contents. This presentation can mimic a myocardial infarction, making diagnosis and management challenging. Case summary: We present the case of a middle-aged man presenting with chest pain, who was diagnosed with Boerhaave syndrome complicated by myopericarditis, although the presentation was concerning for acute coronary syndrome. Discussion: Through this case, we aim to highlight an unusual alternative aetiology of findings classically seen in myocardial infarction.

Short- and long-term outcomes of cardiac adverse events following COVID-19 immunization managed in a Canadian pediatric center.

BACKGROUND: Numerous reports have described the clinical presentation of cardiac adverse events following immunization (AEFI) with COVID-19 vaccines but long-term outcome studies are limited, especially in the pediatric population. METHODS: This is a single center retrospective case series of pediatric patients with cardiac AEFI following the Pfizer/BioNTech mRNA COVID-19, diagnosed between May 2021 and May 2022, and managed following a standardized protocol. Follow up information is presented up to 12 months post diagnosis. The incidence rate of cardiac AEFI was estimated for Ottawa residents. RESULTS: All cases were male (N = 17) with an average age of 16 years (range = 12-17). The majority of cases occurred after the 2nd (12/17) or 3rd vaccine dose (4/17) and were manifested mostly as myopericarditis (15/17). Average interval between the 1st and 2nd vaccine (n = 12) doses was 38 days (21-69 days). All patients improved promptly on non-steroidal anti-inflammatory drugs without recurrence. Five patients reported negative impact on quality of life and mental health, including 2 cases that led to new vaccine hesitancy, not only to COVID-19 vaccine, but also to other routine vaccines. The rate of cardiac AEFI was estimated for residents of the city of Ottawa and found to be 12.01 cases (CI 90 5.98-21.68) per 100,000 doses following the 2nd dose and 16.56 cases (CI 90 5.66-37.90) per 100,000 doses following the 3rd dose for males aged 12 to 17 years. CONCLUSIONS: Twelve months following the AEFI, all patients clinically recovered from their myopericarditis, but some reported negative impact on quality of life and mental health, including new vaccine hesitancy. This highlights the importance for timely and systematic evaluation of AEFI and the need to provide support, follow up and vaccine counseling in individuals experiencing an AEFI.

The Utility of Troponin Dynamics in Influenza Myopericarditis: A Literature Review.

Influenza, typically recognized as a respiratory ailment, can manifest severe cardiac complications, notably, myocarditis and pericarditis, with potential fatal outcomes. Interestingly, influenza B demonstrates a reduced occurrence of troponin I elevation despite the risk of cardiac issues, such as isolated pericarditis. Interpreting the absence of troponin elevation as an indication of no cardiac involvement in cases of influenza B-related pericarditis may be contributing to poorer clinical outcomes. This trend may stem from the cellular tropism and unique affinity of certain influenza strains for pericardial cells rather than myocardiocytes. A thorough grasp of troponin dynamics in influenza is pivotal for customizing approaches aimed at improving clinical outcomes in myopericarditis cases.

Left Anterior Descending Coronary T-wave Inversion Pattern (Wellens' Syndrome) Associated with Myopericarditis and a Normal Left Coronary Artery.

Background: Wellens' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3 (may extend to involve all precordial and lateral limb leads - the type B Wellens' pattern). A Wellens' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD). However, there are no reported cases of an association of a Wellens' EKG pattern with myopericarditis. Here, we present such a rare case. Case description: A thirty-one-year-old female with known essential hypertension and psoriatic arthritis presented with a constant, central chest pain radiating to the shoulders and back. The patient's physical examination was unremarkable at presentation other than elevated blood pressure at 170/68 mmHg. An EKG at presentation demonstrated deep symmetric T-wave inversions in anterolateral leads with elevated high-sensitivity troponin, and an elevated erythrocyte sedimentation rate. The patient was referred to the cardiac catheterisation laboratory for concerns of a Wellens' EKG pattern; however, invasive angiography demonstrated only obtuse marginal branch disease - no LAD disease was noted. Cardiac magnetic resonance (CMR) imaging confirmed the diagnosis of myopericarditis and absence of myocardial infarction. The patient was medically managed and discharged home in a stable condition. Conclusion: In literature and established clinical practice, the Wellens' EKG pattern is considered highly concerning for critical ostial/proximal LAD stenosis. However, we now propose that myopericarditis may be considered in a differential diagnosis for this EKG pattern. LEARNING POINTS: Wellens' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3.A Wellens' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD).Association of Wellens' pattern EKG has been described in association with various other pathologies; however, its association with acute myopericarditis has not been well described.

COVID-19 mRNA Vaccination-Induced Myopericarditis in an Otherwise Healthy Young Male: An Evidence-Based Approach to Differentiating From Perimyocarditis.

A 29-year-old male, otherwise healthy with no past medical history, presented to the hospital after a two-day history of pleuritic chest pain with a fever. He had received his first dose of the mRNA-1273 coronavirus disease (COVID-19) vaccine (Moderna) two months prior without any adverse reactions. He received his second dose approximately 24 hours before symptom onset and hospital presentation. Work-up was unremarkable for respiratory, autoimmune, and rheumatological etiologies. The patient was found to have electrocardiogram features and symptoms in keeping with pericarditis, C-reactive protein elevation, and a peak high-sensitivity troponin level of 9,992 ng/L suggestive of a component of myocarditis. A dilemma arose regarding whether this patient should be diagnosed with perimyocarditis or myopericarditis, terms often used interchangeably without proper reference to the primary pathology, which can ultimately affect management. A subsequent echocardiogram was unremarkable, with a normal left ventricular systolic function, but cardiac resonance imaging revealed myocardial edema suggestive of myocarditis. Without convincing evidence for an alternative explanation after an extensive work-up of ischemic, autoimmune, rheumatological, and infectious etiologies, this patient was diagnosed with COVID-19 mRNA vaccine-induced myopericarditis. The patient fully recovered after receiving a treatment course of ibuprofen and colchicine. This case explores how the diagnosis of COVID-19 vaccine-induced myopericarditis was made and treated using an evidence-based approach, highlighting its differentiation from perimyocarditis.

Re-enforcing High-Risk Acute Pericarditis Requiring Hospital Admission: An Unusual Case of Critical Idiopathic Acute Pericarditis Presenting As Tamponade and Pleuro-Pericardial Complications in a Patient Presenting With Flu-Like Symptoms.

Pericarditis is an inflammatory process that affects the pericardium, the fibrous sac surrounding the heart. Acute pericarditis accounts for approximately 0.1% of inpatient admissions and 5% of non-ischemic chest pain visits to the emergency departments (EDs). Most patients who present with acute pericarditis have a benign course and good prognosis. However, a rare percent of the patients develop complicated pericarditis. Examples of complications include pericardiac effusion, cardiac tamponade, constrictive pericarditis, effusive and constrictive pericarditis and, even more rarely, large pleural effusion The occurrence of complicated pericarditis can lead to high morbidity and mortality if not urgently managed in most patients. Our case presents a 60-year-old male that presented to the emergency room with flu-like symptoms. However, the viral panel test was negative. He initially got discharged with supportive care but was brought back to the ED by his wife in a critical, life-threatening state due to pericarditis symptoms complicated by tamponade and shock. His condition required urgent intervention and critical level of care. The patient's course was also complicated by myopericarditis and recurrent bilateral pleural effusions, which required therapeutic interventions. This unique case presents the patient group that develop multiple life-threatening complications of acute pericarditis, including cardiac tamponade and shock, affecting several end organs. This case also highlights clues to the predisposing factors to complications of acute pericarditis. Patients who present with high-risk signs and symptoms indicating poorer prognosis warrant further observation and admission. This will also add to the literature reviews regarding the risk factors associated with development of complicated acute pericarditis. This will also serve as a review of pathophysiology, etiology, current diagnosis and available novel treatment for such patients.

A case report of sodium azide-induced myopericarditis.

Background: Sodium azide exposures are rare but can be lethal as the substance inhibits complex IV in the electron transport chain, blocking adenosine-triphosphate (ATP) synthesis. Sodium azide is mostly used as a propellant in vehicular airbags but is also used in laboratory, pharmacy, and industrial settings. No known antidote exists and its cardiotoxic effects are poorly described in the literature. Case summary: We describe the case of a 31-year-old patient with major depressive disorder presenting with altered mental status after ingestion of an unknown amount of sodium azide. Although initially chest pain free, she developed pleuritic chest pain 48 h after ingestion. This was accompanied by new diffuse ST elevations on the electrocardiogram and serum troponin elevations concerning for myopericarditis. Treatment was pursued with a 14-day course of colchicine resulting in complete symptom resolution within 4 days of treatment initiation. The patient's transthoracic echocardiogram was only notable for a preserved left ventricular ejection fraction (LVEF). Discussion: Cardiac toxicity after sodium azide ingestion usually occurs days after ingestion and has been previously described in the forms of heart failure with reduced ejection fraction complicated by cardiogenic shock. We describe the first case of sodium azide-induced myopericarditis with a preserved LVEF treated with colchicine. Colchicine is an established treatment for pericarditis, but its inhibition of endocytosis, an ATP-dependent cellular function, could be mechanistically relevant to this case.

Myocarditis, Coagulopathy, and Small Fibre, Sensory, and Multiple Cranial Nerve Neuropathy Complicating BNT162b2 Vaccination: A Case Report.

SARS-CoV-2 vaccinations can lead to complications, including post-acute COVID-19 vaccination syndrome (PACVS). There has been no report of a patient with PACVS presenting with Guillain-Barre syndrome (GBS), myocarditis/pericarditis, immunodeficiency, or coagulopathy after the second BNT162b2 dose. The patient is a 51-year-old woman with chronic myopericarditis, coagulopathy due to factor-VIII increase and protein-S deficiency, GBS, and a number of other ocular, dermatological, immunological, and central nervous system abnormalities related to the second dose of the BNT172b2 vaccine. GBS manifested with mild, multiple cranial nerve lesions, small fibre neuropathy (SFN) affecting the autonomic system with postural tachycardia syndrome (POTS) and orthostatic hypotension, and sensory disturbances in the upper and lower limbs. PACVS was diagnosed months after onset, but despite the delayed diagnosis, the patient benefited from glucocorticoids, repeated HELP apheresis, and multiple symptomatic treatments. The case shows that SARS-CoV-2 vaccination can be complicated by PACVS manifesting as chronic myopericarditis, coagulopathy, GBS with predominant dysautonomia, and impaired immune competence, and that diagnosis of PACVS can be delayed for months. Delayed diagnosis of PACVS may result in a delay in appropriate treatment and the prolongation of disabling symptoms. Patients and physicians should be made aware of PACVS to improve diagnostic and therapeutic management in terms of patient and healthcare system costs.

Acute Severe Ulcerative Colitis Flare Complicated by Myopericarditis and Infliximab-Induced Hepatitis.

Ulcerative colitis (UC) is an autoimmune disease associated with both intestinal and extraintestinal manifestations. The latter may include heart complications, such as myopericarditis leading to life-threatening arrythmias. Nowadays, UC is commonly treated with biologic medications and infliximab is the first line therapy in an outpatient setting, while it is also used as rescue therapy in acute severe UC. However, it has been associated with severe immunosuppression, cytomegalovirus (CMV) reactivation and drug-induced hepatitis. We report a case of UC flare in a biologic naïve patient admitted with myopericarditis, which was further complicated by positive CMV biopsies and infliximab-induced transaminitis. LEARNING POINTS: In acute inflammatory bowel disease (IBD) flare presentation with tachycardia and chest pain, an underlying myocardial injury should be investigated.Mucosal healing should be evaluated endoscopically in cases of partial response to biologics.Both cytomegalovirus (CMV) infection and infliximab-induced liver injury may lead to acute hepatitis.

Hemophagocytic lymphohistiocytosis and myopericarditis induced by campylobacter: a case report.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a severe disorder characterized by excessive activation of the immune system, leading to hypercytokinemia and damage to multiple organs. We report a rare case of HLH with myopericarditis caused by Campylobacter infection. CASE PRESENTATION: A 28-year-old male patient with a history of hypertension without medicine control presented at the hospital after a four-day fever, decreasing urine amount, rashes on his trunk and limbs, and other symptoms. He was admitted with a provisional diagnosis of atypical infection and allergic skin rash related to diclofenac. However, his condition deteriorated, and he developed shock, tachycardia, chest distress, and bilateral pleural effusion after admission. Further investigations revealed cardiogenic shock related to myopericarditis, and he was transferred to the ICU. In addition, a stool PCR panel subsequently revealed a positive result for Campylobacter. On day 6, he was diagnosed with HLH. Under Clarithromycin and dexamethasone infusion, leukocytosis, anemia and thrombocytopenia with cardiogenic shock status improved. Then, he was later discharged in stable condition. CONCLUSIONS: HLH and myopericarditis caused by Campylobacter are very rare. Early detection of Campylobacter-induced HLH and multiple organ failure, as well as prompt use of antibiotics and immunosuppressants, can be helpful for prognosis.

Acute Myopericarditis as the First Manifestation of Familial Mediterranean Fever: A Case Report.

Familial Mediterranean fever (FMF) is an autoinflammatory disorder, characterized by recurrent episodes of fever and polyserositis, and usually presents during the first two decades of life. Acute pericarditis is a rare manifestation of FMF and typically presents with other symptoms of the inflammatory disorder. A 27-year-old Arabian male presented to our hospital with pleuritic chest pain and shortness of breath while lying flat. His electrocardiogram showed changes suggestive of pericarditis, and his inflammatory markers and troponin were raised. His echocardiogram revealed a moderate-sized pericardial effusion with septa and a normal left ventricular function. He had a strong family history of FMF and consanguinity of the parents. He was treated for acute myopericarditis with colchicine and ibuprofen, and his symptoms improved gradually along with his inflammatory markers and troponin. Six weeks after discharge, he had a cardiac MRI, which revealed a thickened pericardium with profound enhancement (features suggestive of pericarditis) and no signs of myocarditis. He was asymptomatic, and his markers and troponin were within the normal range. His colchicine medication was continued indefinitely, and he was referred to a tertiary care hospital with a specialized periodic fever clinic for follow-up and genotype testing.

Lyme-Associated Pericarditis: A Case Report and Literature Review.

Lyme disease is caused by Borrelia burgdorferi (B. burgdorferi), which is a spirochete transmitted by ticks of the genus Ixodes. Complications related to the cardiovascular system usually occur in the early phase of infection, and the most common cardiovascular complication of Lyme disease is atrioventricular block, especially third-degree heart block. We report a case of a young Caucasian male patient who presented to the emergency department (ED) with complaints of chest pain and shortness of breath. Initial investigations, including chest X-ray, were negative. An EKG revealed ST elevation and PR depression with troponin elevation. The echocardiogram showed a normal ejection fraction with no pericardial effusion. Skin examination was positive for erythema migrans concerning Lyme. Initial Lyme testing was negative in the patient and it should be repeated after four to six weeks, according to the guidelines. This case report highlights the importance of keeping the differentials broad in these patients even if the initial testing is negative, especially since misdiagnosis or delayed diagnosis can cause cardiac complications.

The Great Imitator: A Case of Lyme Carditis Mimicking ST Elevation Myocardial Infarction.

Lyme disease, caused by Borrelia burgdorferi and transmitted via Ixodes ticks, is a common vector-borne illness in the United States, with an estimated 476,000 annual cases. While primarily known for its neurological and rheumatological manifestations, Lyme disease can also involve the cardiac system, known as Lyme carditis, which occurs in about 4% to 10% of cases. This case report details a rare instance of Lyme carditis presenting as ST-segment elevation myocardial infarction (STEMI) in a 31-year-old female with no significant medical history. The patient exhibited symptoms of chest pressure and shortness of breath, with laboratory results showing significantly elevated troponin levels and other indicative markers. Notably, cardiac catheterization revealed no coronary occlusion, suggesting an alternative diagnosis to acute coronary syndrome (ACS). Further testing confirmed Lyme carditis through positive serological tests for Lyme-specific IgM antibodies. The case underscores the importance of considering Lyme myopericarditis in differential diagnoses for STEMI in Lyme-endemic areas and in patients without typical risk factors for coronary artery disease. This report aims to increase clinical awareness of this condition, highlighting the need for thorough investigation in atypical cardiac presentations.

Achy Breaky Heart: A Rare Case of Myopericarditis Secondary to Mesalamine in a Patient With Inflammatory Bowel Disease.

Mesalamine is a first-line drug used in the treatment of inflammatory bowel disease (IBD), specifically ulcerative colitis (UC), with side effects ranging from gastrointestinal effects to cardiotoxicity. We present a rare case of mesalamine-induced myopericarditis in a patient with IBD, who presented with epigastric pain and was found to have elevated an c-reactive protein (CRP) in the absence of chest pain and any other gastrointestinal symptoms. This case highlights the importance of including myopericarditis as a differential for IBD patients on mesalamine with an isolated elevated CRP, especially within the first month of initiating this medication, as drug cessation usually leads to immediate clinical improvement.

Fatal Left Ventricular Free Wall Rupture Complicating Acute Myopericarditis.

This is a case of a 59-year-old man presenting with myopericarditis. Over a 2-week period, he developed progressive symptoms and worsening pericardial effusion, leading to cardiac tamponade. Pericardiocentesis revealed hemopericardium, and multidetector computed tomography angiography showed left ventricular free wall rupture. The patient collapsed abruptly, and autopsy confirmed the findings.

Fibrosing Mediastinitis Caused by Histoplasmosis in an Adolescent.

Fibrosing mediastinitis (FM) is a rare, potentially progressive disease resulting from an idiosyncratic immune response to a variety of stimuli that lead to fibrous infiltration of the mediastinum and possible narrowing of the bronchovascular structures. We report an unusual case of FM in a pediatric patient presenting as myopericarditis and progressing to pericardial thickening and encasement of the mediastinal vascular structures needing surgical intervention. Imaging, including transthoracic echocardiography, cardiac computed tomography, and cardiac magnetic resonance played a crucial role in the diagnosis, assessment, and follow-up. Contrast-enhanced computed tomography can be especially helpful to demonstrate potential findings associated with FM.

Spontaneous coronary artery dissection and myopericarditis.

Spontaneous Coronary Artery Dissection (SCAD) is a significant cause of acute coronary syndrome. SCAD frequently affects young women, often without cardiovascular risk factors. Coronary angiography is the diagnostic mode of choice. Based on clinical context, treatment is divided into conservative methods and revascularization with either percutaneous coronary intervention or bypass grafting. This case report describes a 26-year-old female with a preceding diagnosis of myopericarditis who presented to the ED with inferior STEMI and was subsequently diagnosed with a spontaneous right coronary artery dissection.