CASE

A 17-year-old male with a past medical history of major depressive disorder, anxiety, and obsessive-compulsive disorder presented to a pediatric emergency department with two days of a frontal headache and nonradiating, aching left sided chest pain. He was accompanied by his mother. The patient had received a third dose of the Pfizer-BioNTech mRNA COVID-19 vaccine three days prior. The day after vaccination, he had experienced a low grade fever, injection site tenderness, and myalgias. These had since resolved. His chest pain and headache had both increased in severity from mild or moderate to severe, which prompted him to seek care. His chest pain was not positional and there was no pleuritic component. He had no photophobia, nausea, or recent head trauma. He had been taking ibuprofen with mild benefit. The patient had no personal history of cardiac abnormalities, no family history of sudden cardiac death, and denied substance use.

His heart rate was 80. He was normotensive and afebrile. His cardiopulmonary, HEENT, and neurological exams were normal. His labs were significant for a high-sensitivity troponin of 8,215 (ref range: 3-57ng/L) which peaked at 11,262 during admission and CRP of 49.07 (ref range: 0-10mg/L). His other labs including CBC, erythrocyte sedimentation rate, and brain natriuretic peptide were unremarkable. His EKG showed normal sinus rhythm and mild ST segment elevation in leads II, V5, and V6 (Image 1). Point-of-care ultrasound was unremarkable. A comprehensive echocardiogram showed normal function without pericardial effusion, though did show prominent pericardial thickening.

DIAGNOSIS

The patient was diagnosed with coronavirus disease 2019 vaccination-associated myocarditis (C-VAM).

DISCUSSION

Myocarditis is inflammation of the myocardium. The clinical manifestations of myocarditis can be broad, ranging from chest pain with transient EKG changes to arrhythmias to cardiogenic shock. The gold standard for diagnosis is biopsy or cardiovascular magnetic resonance imaging, but no specific criteria for clinical diagnosis currently exist. [1]

Myocarditis following smallpox, influenza, and tetanus vaccination has been well documented. However, data from COVID-19 vaccination clinical trials did not reveal this association prior to their authorization for use in children and adolescents. In June 2021, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices reported an association between myocarditis and mRNA COVID-19 vaccination among adolescent and young adult males. [2] Prior to this report case studies had documented these events and since then, retrospective studies reviewing C-VAM cases have been performed.

 Jain et al. retrospectively collected data from sixteen United States academic hospitals from March to June 2021 identifying 63 C-VAM cases. [3] The mean age was 15.6 years, 92% were male, 68% were white, and all had been previously healthy prior to receiving the vaccine. Nearly all of the patients (94%) had received the Pfizer-BioNTech vaccine, all but one patient presented after their second vaccine dose, and 71% presented 2 days post-vaccination. The latest presentation was 7 days post-vaccination. All patients had elevated troponin levels. All but one had an elevated C-reactive protein. Truong et al. performed a retrospective study of 136 patients and report very similar findings. [4]

There were no deaths reported and no patients required invasive interventions such as inotropic support, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). Approximately half were treated with nonsteroidal antiinflammatory drugs and one quarter with either intravenous immunoglobulin or corticosteroids. Aspirin, clopidogrel, heparin, or beta-blockers were administered to 10% of patients due to concern for myocardial infarction on presentation.

Jain et al. compared outcomes of C-VAM to multisystem inflammatory syndrome in children (MIS-C) outcomes to evaluate for vaccine safety. [3] They found that MIS-C patients had longer lengths of stay in intensive care units, required invasive interventions including ECMO, and had worse ventricular function compared to C-VAM patients. Similarly, the CDC found significantly higher rates of morbidity and mortality of COVID-19 infection compared to C-VAM. [2] Since C-VAM is typically mild and transient, the benefits of COVID-19 mRNA vaccination outweigh the risks and the CDC still strongly recommends COVID-19 vaccination for children and adolescents.

 CASE RESOLUTION

The patient was admitted to the Pediatric Cardiology service for telemetry monitoring and symptom control. He was treated with ketorolac then transitioned to oral ibuprofen with good effect. He was discharged after approximately 36 hours in the hospital. He followed up in the cardiology clinic 5 and 40 days after discharge. His symptoms have resolved and his EKG has normalized.

TAKE-AWAYS

1. There is an association between receiving the mRNA COVID-19 vaccine and development of myocarditis among adolescent and young adult males.

2. Cases are more common after the second or third dose, present within 7 days and usually on day 2 post-vaccine, and are associated with elevated troponin and CRP as well as EKG changes.

3. These events are rare.

4. Cases are typically mild and respond rapidly to conservative treatment.

5. Vaccination is strongly recommended as COVID-19 infection and subsequent complications including MIS-C lead to significantly worse morbidity and mortality compared to C-VAM.

Author: Courtney Bearnot, MD, MPH, is a current fourth year emergency medicine resident at Brown Emergency Medicine.

Faculty Reviewer: Michelle Myles, MD, is a clinician educator and attending  at Brown Emergency Medicine.

REFERENCES

1. Law, Yuk M., et al. "Diagnosis and management of myocarditis in children: a scientific statement from the American Heart Association." Circulation 144.6 (2021): e123-e135.

2. Gargano, Julia W., et al. "Use of mRNA COVID-19 vaccine after reports of myocarditis among vaccine recipients: update from the Advisory Committee on Immunization Practices—United States, June 2021." Morbidity and Mortality Weekly Report 70.27 (2021): 977.

3. Jain, Supriya S., et al. "COVID-19 Vaccination–Associated Myocarditis in Adolescents." Pediatrics 148.5 (2021).

4. Truong, Dongngan T., et al. "Clinically suspected myocarditis temporally related to COVID-19 vaccination in adolescents and young adults." Circulation (2021).