A 23-year-old transgender male (he/him) on weekly testosterone therapy presented to the emergency department with acute chest pain. He had received the Janssen COVID-19 vaccine several months prior and booster shot of Pfizer COVID-19 vaccine 2 days prior to presentation. His symptoms began 1 day after vaccination and included chest pain that worsened with lying flat and improved with leaning forward. Initial investigations included elevated high sensitivity troponin 1059 → 1286, C-reactive protein (CRP) of 4.9 and erythrocyte sedimentation rate (ESR) of 16. Electrocardiogram (ECG) showed anterolateral ST‐elevation myocardial infarction (STEMI) (Figure 1) for which the patient underwent coronary angiogram that did not show any epicardial coronary artery disease. Patient underwent cardiac magnetic resonance imaging (CMR) (Figure 2) for further assessment.
Figure 1
Figure 1
Figure 2
Figure 2
Figure 2: CMR images depicting: A. Delayed enhancement in four chambers in the subepicardial aspect of myocardium and pericardium in the inferolateral wall; B. Delayed enhancement in the subepicardial myocardium and pericardium in the mid-distal inferolateral wall; C. T2 stir images confirming inflammation and edema suggesting active focal myopericarditis.
Figure 2: CMR images depicting: A. Delayed enhancement in four chambers in the subepicardial aspect of myocardium and pericardium in the inferolateral wall; B. Delayed enhancement in the subepicardial myocardium and pericardium in the mid-distal inferolateral wall; C. T2 stir images confirming inflammation and edema suggesting active focal myopericarditis.
What is the next best step in management?
Show Answer
The correct answer is: A. Ibuprofen 800 mg TID and colchicine 0.6 mg BID
This is a case of myopericarditis after vaccination for COVID-19. Pericarditis is a well-documented vaccine adverse event reported post COVID-19 vaccine.1 Along with myocarditis, pericarditis is also frequently reported in adolescents and young adult males within 7 days after COVID-19 vaccination. Testosterone is postulated to play a role by inhibiting anti-inflammatory cells and differential Th1 response.2-4 A study from Greece reported nine events of pericarditis in eight patients following COVID-19 vaccination; while most patients recovered from symptoms, one patient had a large pericardial effusion complicated by pericardiocentesis and requiring surgical decompression.5
Most patients who receive conventional treatment (high dose non-steroidal anti-inflammatory drugs [NSAIDs] and colchicine) respond well. Colchicine is completed for 3 months while NSAIDs can be tapered after 2 weeks if patient is symptom free for at least 24 hours. Prednisone therapy is used second line due to increased rates of recurrent pericarditis.6 Rilonacept, while a well-established effective therapy for pericarditis, is recommended for treating active flare in recurrent pericarditis. CMR is gold standard for diagnosis of myopericarditis and given clinical picture of typical chest pain and classic ECG findings, a cardiac catheterization and biopsy will not be necessary.
References
Lazaros G, Anastassopoulou C, Hatziantoniou S, et al. A case series of acute pericarditis following COVID-19 vaccination in the context of recent reports from Europe and the United States. Vaccine 2021;39:6585-90.
Diaz GA, Parsons GT, Gering SK, Meier AR, Hutchinson IV, Robicsek A. Myocarditis and pericarditis after vaccination for COVID-19. JAMA 2021;326:1210–12.
Su JR, McNeil MM, Welsh KJ, et al. Myopericarditis after vaccination, Vaccine Adverse Event Reporting System (VAERS), 1990-2018. Vaccine 2021;39:839-45.
Bozkurt B, Kamat I, Hotez PJ. Myocarditis with COVID-19 mRNA vaccines. Circulation 2021;144:471-84.
Lazaros G, Klein AL, Hatziantoniou S, Tsioufis C, Tsakris A, Anastassopoulou C. Thenovel platform of mRNA COVID-19 vaccines and myocarditis: clues into the potential underlying mechanism. Vaccine 2021;39:4925-27.
Imazio M, Brucato A, Maestroni S, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation 2011;124:1270-75.