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Jaiswal V, Mukherjee D, Peng Ang S, Kainth T, Naz S, Babu Shrestha A, Agrawal V, Mitra S, Ee Chia J, Jilma B, Mamas MA, Gebhard C, Postula M, Siller-Matula JM. COVID-19 vaccine-associated myocarditis: Analysis of the suspected cases reported to the EudraVigilance and a systematic review of the published literature. IJC HEART & VASCULATURE 2023; 49:101280. [PMID: 38143781 PMCID: PMC10746454 DOI: 10.1016/j.ijcha.2023.101280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/31/2023] [Accepted: 09/21/2023] [Indexed: 12/26/2023]
Abstract
Background Myocarditis secondary to Coronavirus Disease 2019 (COVID-19) vaccination has been reported in the literature. Objective This study aimed to characterize the reported cases of myocarditis after COVID-19 vaccination based on age, gender, doses, and vaccine type from published literature and the EudraVigilance database. Methods We performed an analysis in the EudraVigilance database (until December 18, 2021) and a systematic review of published literature for reported cases of suspected myocarditis and pericarditis (until 30th June 2022) after the COVID-19 vaccination. Results EudraVigilance database analysis revealed 16,514 reported cases of myocarditis or pericarditis due to the vaccination with COVID-19 vaccines. The cases of myo- or pericarditis were reported predominantly in the age group of 18-64 (n = 12,214), and in males with a male-to-female (M: F) ratio of 1.7:1. The mortality among myocarditis patients was low, with 128 deaths (2 cases per 10.000.000 administered doses) being reported. For the systematic review, 72 studies with 1026 cases of myocarditis due to the vaccination with COVID-19 vaccines were included. The analysis of published cases has revealed that the male gender was primarily affected with myocarditis post-COVID-vaccination. The median (IQR) age of the myocarditis cases was 24.6 [19.5-34.6] years, according to the systematic review of the literature. Myocarditis cases were most frequently published after the vaccination with m-RNA vaccines and after the second vaccination dose. The overall mortality of published cases was low (n = 5). Conclusion Myocarditis is a rare serious adverse event associated with a COVID-19 vaccination. With early recognition and management, the prognosis of COVID-19 vaccine-induced myocarditis is favorable.
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Affiliation(s)
| | | | - Song Peng Ang
- Department of Internal Medicine, Rutgers Health Community Medical Center, Toms River, NJ, USA
| | - Tejasvi Kainth
- Department of Psychiatry, Bronxcare Health System, NY, USA
| | - Sidra Naz
- Department of Internal Medicine, Harvard Medical School/BIDMC, Boston, USA
| | | | | | - Saloni Mitra
- OO Bogomolets National Medical University, Kyiv, Ukraine
| | - Jia Ee Chia
- Department of Internal Medicine, Texas Tech University Health Sciences, El Paso, TX, USA
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
| | - Catherine Gebhard
- Department of Cardiology, Inselspital, Bern University Hospital, Switzerland
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
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Suess C, Schwartz M, Hausmann R. Pulmonary capillaritis as a cause of lethal diffuse alveolar hemorrhage. Int J Legal Med 2023; 137:1481-1487. [PMID: 37402014 DOI: 10.1007/s00414-023-03056-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Abstract
Lethal pulmonary hemoptysis is a common finding in forensic medicine. Since hemoptysis does not necessarily occur before death and its previous symptoms are usually unspecific, indicative signs or findings at the site of a corpse may be completely absent. If lethal acute alveolar hemorrhage is found in the post-mortem examination, a differential diagnosis should be made for traumatic, substance-related, infectious, or organic causes. Cocaine-associated pulmonary hemorrhage and drug reactions are in the foreground. For organic causes, autoimmune diseases should be considered in addition to cardiac, haematological, and infectious causes. The following two cases show similarities both in the sudden, unexpected deaths and the anamnesis of the two deceased women. One of the deceased received a Corona vaccination a few months earlier. In each case, the post-mortem examination revealed an acute diffuse pulmonary hemorrhage caused by acute inflammation of the lung capillaries. This case presentation demonstrates the necessity of a complete autopsy including toxicological and histological analyses. The documentation and publication of rare causes of death are essential for medical research and practice in order to critically consider and discuss the possibility of to date unknown associations in similar cases.
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Affiliation(s)
- Christine Suess
- Institute of Legal Medicine, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH-9007, St. Gallen, Switzerland.
| | - Melanie Schwartz
- Institute of Legal Medicine, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH-9007, St. Gallen, Switzerland
| | - Roland Hausmann
- Institute of Legal Medicine, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH-9007, St. Gallen, Switzerland
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3
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Vaiyani D, Elias MD, Biko DM, Whitehead KK, Harris MA, Partington SL, Fogel MA. Patients with Post-COVID-19 Vaccination Myocarditis Have More Favorable Strain in Cardiac Magnetic Resonance Than Those With Viral Myocarditis. Pediatr Cardiol 2023; 44:1108-1117. [PMID: 37004523 PMCID: PMC10067005 DOI: 10.1007/s00246-023-03150-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/04/2023]
Abstract
There have been reports of myocarditis following vaccination against COVID-19. We sought to describe cardiac magnetic resonance (CMR) findings among pediatric patients. Retrospective review at a large academic center of patients clinically diagnosed with post-vaccine myocarditis (PVM) undergoing CMR. Data collected included parametric mapping, ventricular function, and degree of late gadolinium enhancement (LGE). Post-processing strain analysis was performed using feature tracking. Strain values, T1/T2 values, and ventricular function were compared to age- and gender-matched controls with viral myocarditis using a Wilcoxon Signed Rank test. Among 12 patients with presumed PVM, 11 were male and 11 presented after the second vaccination dose, typically within 4 days. All presented with chest pain and elevated troponin. 10 met MRI criteria for acute myocarditis. All had LGE typically seen in the lateral and inferior walls; only five had prolonged T1 values. 10 met criteria for edema based on skeletal muscle to myocardium signal intensity ratio and only 5 had prolonged T2 mapping values. Patients with PVM had greater short-axis global circumferential and radial strain, right ventricle function, and cardiac output when compared to those with viral myocarditis. Patients with PVM have greater short-axis global circumferential and radial strains compared to those with viral myocarditis. LGE was universal in our cohort. Signal intensity ratios between skeletal muscle and myocardium may be more sensitive in identifying edema than T2 mapping. Overall, the impact on myocardial strain by CMR is less significant in PVM compared to more classic viral myocarditis.
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Affiliation(s)
- Danish Vaiyani
- Division of Cardiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA.
| | - Matthew D Elias
- Division of Cardiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
| | - Kevin K Whitehead
- Division of Cardiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
- Department of Radiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
| | - Matthew A Harris
- Division of Cardiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
- Department of Radiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
| | - Sara L Partington
- Division of Cardiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
- Department of Radiology, Children's Hospital of Philadelphia, 3601 Civic Center Blvd, Philadelphia, PA, 19102, USA
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4
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Matsumori A. Myocarditis and Autoimmunity. Expert Rev Cardiovasc Ther 2023. [PMID: 37243585 DOI: 10.1080/14779072.2023.2219895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Autoimmune myocarditis may develop due to heterogeneous causes. Myocarditis is often caused by viral infections, but it can also be caused by systemic autoimmune diseases. Immune checkpoint inhibitors and virus vaccines induce immune activation, and they can cause the development of myocarditis, as well as several immune-related adverse events. The development of myocarditis is dependent on the genetic factors of the host, and the major histocompatibility complex (MHC) may be an important determinant of the type and severity of the disease. However, non-MHC immunoregulatory genes may also play a role in determining susceptibility. AREA COVERED This review summarizes the current knowledge of the etiology, pathogenesis, diagnosis and treatment of autoimmune myocarditis with a particular focus on viral infection and autoimmunity, and biomarkers of myocarditis. EXPERT OPINION An endomyocardial biopsy may not be the gold standard for the diagnosis of myocarditis. Cardiac magnetic resonance imaging is useful in diagnosing autoimmune myocarditis. Recently identified biomarkers of inflammation and myocyte injury are promising for the diagnosis of myocarditis when measured simultaneously. Future treatments should focus on the appropriate diagnosis of the etiologic agent, as well as on the specific stage of the evolution of immune and inflammatory processes.
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Affiliation(s)
- Akira Matsumori
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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5
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Wang WH, Wei KC, Huang YT, Huang KH, Tsai TH, Chang YC. The Incidence of Myocarditis Following an Influenza Vaccination: A Population-Based Observational Study. Drugs Aging 2023; 40:145-151. [PMID: 36626028 PMCID: PMC9838541 DOI: 10.1007/s40266-022-00997-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVE Recently, studies have pointed to a link between coronavirus disease 2019 vaccinations and myocarditis. Myocarditis following an influenza vaccine has been sporadically reported. However, it is not known whether this adverse event occurs among elderly individuals who have received influenza vaccines. We used a population-based database and a self-controlled case-series design to estimate the incidence of myocarditis following an influenza vaccination. METHODS Data were extracted from Taiwan's National Health Insurance Research Database. The study population consisted of elderly people aged ≥ 65 years who had de novo myocarditis, which required hospitalization, within 6 months after receiving an influenza vaccination between 2003 and 2017. The first 1-7, 1-14, and 1-42 days after vaccination were defined as risk intervals, and the other periods were defined as control intervals. Poisson regression was used to calculate the incidence rate ratio for myocarditis between the risk and control periods. RESULTS Within 180 days following a vaccination, 191 people were hospitalized for myocarditis among 19,678,904 people. In comparison with control intervals, the incidence rate ratios of an admission for myocarditis for days 1-7, 1-14, and 1-42 were 0.80 (95% confidence interval 0.36-1.81), 0.72 (95% confidence interval 0.39-1.32), and 0.73 (95% confidence interval 0.50-1.05), respectively. Subgroup analyses by sex, age, Charlson Comorbidity Index scores, and comorbidities did not yield significant differences in the incidence rate ratio. CONCLUSIONS Regardless of the post-vaccination time and underlying baseline characteristics, the incidence risk of myocarditis is not significantly increased in the elderly following an influenza vaccination.
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Affiliation(s)
- Wen-Hwa Wang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- College of Management, I-Shou University, Kaohsiung, Taiwan
| | - Kai-Che Wei
- Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Department of Medical Research and Development, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Hua Huang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Tung-Han Tsai
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Yu-Chia Chang
- Department of Long Term Care, College of Health and Nursing, National Quemoy University, Kinmen County, 892009, Taiwan.
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, 41354, Taiwan.
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Heidecker B, Dagan N, Balicer R, Eriksson U, Rosano G, Coats A, Tschöpe C, Kelle S, Poland GA, Frustaci A, Klingel K, Martin P, Hare JM, Cooper LT, Pantazis A, Imazio M, Prasad S, Lüscher TF. Myocarditis following COVID-19 vaccine: incidence, presentation, diagnosis, pathophysiology, therapy, and outcomes put into perspective. A clinical consensus document supported by the Heart Failure Association of the European Society of Cardiology (ESC) and the ESC Working Group on Myocardial and Pericardial Diseases. Eur J Heart Fail 2022; 24:2000-2018. [PMID: 36065751 PMCID: PMC9538893 DOI: 10.1002/ejhf.2669] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/12/2022] [Accepted: 08/25/2022] [Indexed: 01/18/2023] Open
Abstract
Over 10 million doses of COVID-19 vaccines based on RNA technology, viral vectors, recombinant protein, and inactivated virus have been administered worldwide. Although generally very safe, post-vaccine myocarditis can result from adaptive humoral and cellular, cardiac-specific inflammation within days and weeks of vaccination. Rates of vaccine-associated myocarditis vary by age and sex with the highest rates in males between 12 and 39 years. The clinical course is generally mild with rare cases of left ventricular dysfunction, heart failure and arrhythmias. Mild cases are likely underdiagnosed as cardiac magnetic resonance imaging (CMR) is not commonly performed even in suspected cases and not at all in asymptomatic and mildly symptomatic patients. Hospitalization of symptomatic patients with electrocardiographic changes and increased plasma troponin levels is considered necessary in the acute phase to monitor for arrhythmias and potential decline in left ventricular function. In addition to evaluation for symptoms, electrocardiographic changes and elevated troponin levels, CMR is the best non-invasive diagnostic tool with endomyocardial biopsy being restricted to severe cases with heart failure and/or arrhythmias. The management beyond guideline-directed treatment of heart failure and arrhythmias includes non-specific measures to control pain. Anti-inflammatory drugs such as non-steroidal anti-inflammatory drugs, and corticosteroids have been used in more severe cases, with only anecdotal evidence for their effectiveness. In all age groups studied, the overall risks of SARS-CoV-2 infection-related hospitalization and death are hugely greater than the risks from post-vaccine myocarditis. This consensus statement serves as a practical resource for physicians in their clinical practice, to understand, diagnose, and manage affected patients. Furthermore, it is intended to stimulate research in this area.
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Affiliation(s)
- Bettina Heidecker
- Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin und Humboldt, Universität zu Berlin, Berlin, Germany
| | - Noa Dagan
- Clalit Health Services, Clalit Research Institute, Ramat Gan, Israel
| | - Ran Balicer
- Clalit Health Services, Clalit Research Institute, Ramat Gan, Israel
| | - Urs Eriksson
- Department of Internal Medicine, Division of Cardiology, GZO - Zurich Regional Health Center, Wetzikon & University of Zurich, Zurich, Switzerland
| | | | - Andrew Coats
- Monash University, Melbourne, Victoria, Australia.,University of Warwick, Warwick, UK
| | - Carsten Tschöpe
- Cardiology, German Heart Center, Charité - University Medicine, Berlin, Germany
| | - Sebastian Kelle
- Cardiology, German Heart Center, Charité - University Medicine, Berlin, Germany
| | | | - Andrea Frustaci
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, La Sapienza University, Rome, Italy.,IRCCS L. Spallanzani, Rome, Italy
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Pilar Martin
- Cientro Nacional de Investigationes Cardiovasculares, Madrid, Spain
| | - Joshua M Hare
- Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, USA
| | - Leslie T Cooper
- Mayo Clinic Vaccine Research Group, Mayo Clinic, Rochester, MN, USA, and Cardiology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Antonis Pantazis
- Royal Brompton and Harefield Hospitals and Imperial College London, London, UK
| | - Massimo Imazio
- Cardiothoracic Department, Cardiology, Udine University Health Integrated Agency, Udine, Italy
| | - Sanjay Prasad
- Royal Brompton and Harefield Hospitals and Imperial College London, London, UK
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospitals and Imperial College London, London, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
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7
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Doeblin P, Jahnke C, Schneider M, Al-Tabatabaee S, Goetze C, Weiss KJ, Tanacli R, Faragli A, Witt U, Stehning C, Seidel F, Elsanhoury A, Kühne T, Tschöpe C, Pieske B, Kelle S. CMR findings after COVID-19 and after COVID-19-vaccination-same but different? Int J Cardiovasc Imaging 2022; 38:2057-2071. [PMID: 37726611 PMCID: PMC9097142 DOI: 10.1007/s10554-022-02623-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/15/2022] [Indexed: 01/05/2023]
Abstract
Cardiac involvement has been described in varying proportions of patients recovered from COVID-19 and proposed as a potential cause of prolonged symptoms, often described as post-COVID or long COVID syndrome. Recently, cardiac complications have been reported from COVID-19 vaccines as well. We aimed to compare CMR-findings in patients with clinical cardiac symptoms after COVID-19 and after vaccination. From May 2020 to May 2021, we included 104 patients with suspected cardiac involvement after COVID-19 who received a clinically indicated cardiac magnetic resonance (CMR) examination at a high-volume center. The mean time from first positive PCR to CMR was 112 ± 76 days. During their COVID-19 disease, 21% of patients required hospitalization, 17% supplemental oxygen and 7% mechanical ventilation. In 34 (32.7%) of patients, CMR provided a clinically relevant diagnosis: Isolated pericarditis in 10 (9.6%), %), acute myocarditis (both LLC) in 7 (6.7%), possible myocarditis (one LLC) in 5 (4.8%), ischemia in 4 (3.8%), recent infarction in 2 (1.9%), old infarction in 4 (3.8%), dilated cardiomyopathy in 3 (2.9%), hypertrophic cardiomyopathy in 2 (1.9%), aortic stenosis, pleural tumor and mitral valve prolapse each in 1 (1.0%). Between May 2021 and August 2021, we examined an additional 27 patients with suspected cardiac disease after COVID-19 vaccination. Of these, CMR provided at least one diagnosis in 22 (81.5%): Isolated pericarditis in 4 (14.8%), acute myocarditis in 9 (33.3%), possible myocarditis (acute or subsided) in 6 (22.2%), ischemia in 3 (37.5% out of 8 patients with stress test), isolated pericardial effusion (> 10 mm) and non-compaction-cardiomyopathy each in 1 (3.7%). The number of myocarditis diagnoses after COVID-19 was highly dependent on the stringency of the myocarditis criteria applied. When including only cases of matching edema and LGE and excluding findings in the right ventricular insertion site, the number of cases dropped from 7 to 2 while the number of cases after COVID-19 vaccination remained unchanged at 9. While myocarditis is an overall rare side effect after COVID-19 vaccination, it is currently the leading cause of myocarditis in our institution due to the large number of vaccinations applied over the last months. Contrary to myocarditis after vaccination, LGE and edema in myocarditis after COVID-19 often did not match or were confined to the RV-insertion site. Whether these cases truly represent myocarditis or a different pathological entity is to be determined in further studies.
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Affiliation(s)
- Patrick Doeblin
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.
| | - Constantin Jahnke
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Matthias Schneider
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Al-Tabatabaee
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Collin Goetze
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Karl J Weiss
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Radu Tanacli
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Alessandro Faragli
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Undine Witt
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | | | - Franziska Seidel
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Ahmed Elsanhoury
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- BIH Berlin Institute of Health at Charite (BIH), BIH Center for Regenerative Therapies (BCRT) Universitätsmedizin Berlin, Berlin, Germany
| | - Titus Kühne
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Carsten Tschöpe
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- BIH Berlin Institute of Health at Charite (BIH), BIH Center for Regenerative Therapies (BCRT) Universitätsmedizin Berlin, Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- BIH Berlin Institute of Health at Charite (BIH), BIH Center for Regenerative Therapies (BCRT) Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Kelle
- Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
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8
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Nakamura R, Ando SI, Kato S, Kadokami T. Acute Lymphocyte Myocarditis Associated with Influenza Vaccination. Intern Med 2022; 61:2307-2313. [PMID: 35022355 PMCID: PMC9424099 DOI: 10.2169/internalmedicine.8855-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
An elderly patient was admitted to our hospital for acute heart failure soon after receiving influenza vaccination. On admission, chest radiography revealed pulmonary edema. An electrocardiogram showed poor R progression, and echocardiography showed diffuse hypokinesis and myocardial edema. The serum troponin level was elevated. A histopathological evaluation indicated active myocarditis with lymphocyte-predominant infiltrates. A drug-induced lymphocyte stimulation test (DLST) was positive. The patient rapidly recovered from heart failure after treatment with conventional heart failure drugs, such as intravenous diuretics and vasodilators. These experimental data and the clinical course suggest that influenza vaccination was responsible for heart failure due to acute lymphocyte myocarditis.
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Affiliation(s)
- Ryo Nakamura
- Department of Cardiology Division, Saiseikai Futsukaichi Hospital, Japan
| | - Shin-Ichi Ando
- Department of Cardiology Division, Saiseikai Futsukaichi Hospital, Japan
- Sleep Apnea Center, Kyushu University Hospital, Japan
| | - Seiya Kato
- Division of Pathology, Saiseikai Fukuoka General Hospital, Japan
| | - Toshiaki Kadokami
- Department of Cardiology Division, Saiseikai Futsukaichi Hospital, Japan
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9
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Mahroum N, Lavine N, Ohayon A, Seida R, Alwani A, Alrais M, Zoubi M, Bragazzi NL. COVID-19 Vaccination and the Rate of Immune and Autoimmune Adverse Events Following Immunization: Insights From a Narrative Literature Review. Front Immunol 2022; 13:872683. [PMID: 35865539 PMCID: PMC9294236 DOI: 10.3389/fimmu.2022.872683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022] Open
Abstract
Despite their proven efficacy and huge contribution to the health of humankind, vaccines continue to be a source of concern for some individuals around the world. Vaccinations against COVID-19 increased the number of distressed people and intensified their distrust, particularly as the pandemic was still emerging and the populations were encouraged to be vaccinated under various slogans like “back to normal life” and “stop coronavirus”, goals which are still to be achieved. As fear of vaccination-related adverse events following immunization (AEFIs) is the main reason for vaccine hesitancy, we reviewed immune and autoimmune AEFIs in particular, though very rare, as the most worrisome aspect of the vaccines. Among others, autoimmune AEFIs of the most commonly administered COVID-19 vaccines include neurological ones such as Guillain-Barre syndrome, transverse myelitis, and Bell’s palsy, as well as myocarditis. In addition, the newly introduced notion related to COVID-19 vaccines, “vaccine-induced immune thrombotic thrombocytopenia/vaccine-induced prothrombotic immune thrombotic thrombocytopenia” (VITT/VIPITT)”, is of importance as well. Overviewing recent medical literature while focusing on the major immune and autoimmune AEFIs, demonstrating their rate of occurrence, presenting the cases reported, and their link to the specific type of COVID-19 vaccines represented the main aim of our work. In this narrative review, we illustrate the different vaccine types in current use, their associated immune and autoimmune AEFIs, with a focus on the 3 main COVID-19 vaccines (BNT162b2, mRNA-1273, and ChAdOx1). While the rate of AEFIs is extremely low, addressing the issue in this manner, in our opinion, is the best strategy for coping with vaccine hesitancy.
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Affiliation(s)
- Naim Mahroum
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
| | - Noy Lavine
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
- St. George School of Medicine, University of London, London, United Kingdom
| | - Aviran Ohayon
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
- St. George School of Medicine, University of London, London, United Kingdom
| | - Ravend Seida
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Abdulkarim Alwani
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mahmoud Alrais
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Magdi Zoubi
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON, Canada
- *Correspondence: Nicola Luigi Bragazzi,
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10
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Lee AS, Balakrishnan IDD, Khoo CY, Ng CT, Loh JK, Chan LL, Teo LL, Sim DK. Myocarditis Following COVID-19 Vaccination: A Systematic Review (October 2020-October 2021). Heart Lung Circ 2022; 31:757-765. [PMID: 35227610 PMCID: PMC8874750 DOI: 10.1016/j.hlc.2022.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/06/2022] [Accepted: 02/01/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Reports of SARS-CoV-2 coronavirus (COVID-19) vaccine-related myocarditis, particularly after mRNA vaccines, have raised concerns amongst the general public. This review examined the literature regarding myocarditis post COVID-19 vaccination, drawing from vaccine safety surveillance databases and case reports. METHODS Combinations of search terms were used in PubMed and COVID-19-specific repositories - LitCovid and the Cochrane COVID-19 Study Register - between 1 October 2020 and 31 October 2021. Manual searches of GoogleScholar and screening of article bibliographies were also performed. RESULTS Information was obtained from five vaccine safety surveillance databases. Fifty-two (52) case reports totalling 200 cases of possible COVID-19 vaccine-related myocarditis were summarised. Vaccine surveillance databases differed in reporting formats and vaccination rates; however, gross estimates suggested low overall incidence rates of 2-5 per million mRNA vaccines. The incidence appeared to be higher in younger male populations, with onset of symptoms within a few days, usually after the second dose. Some with prior COVID-19 infections had onset after the first dose. Cases with prior unrelated myocarditis were also noted. Almost all presented with chest pain (98.0%). Troponin elevation was universally described and cardiac magnetic resonance imaging was commonly reported based on the updated Lake Louise criteria. Clinical course was mild in the majority, with response to anti-inflammatory treatment. CONCLUSION COVID-19 vaccine-related myocarditis is an important but rare adverse event. More research is needed into its pathogenesis and reasons for its predominance in young males, while gaps in data exist in those aged <16 years, as well as those with prior COVID-19 infections and prior myocarditis.
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Affiliation(s)
- Audry S.Y. Lee
- Corresponding author at: National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609
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11
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Kimura M, Hashimoto T, Noda E, Ishikawa Y, Ishikita A, Fujino T, Matsushima S, Ide T, Kinugawa S, Nagaoka K, Ushijima T, Shiose A, Tsutsui H. Fulminant necrotizing eosinophilic myocarditis after COVID-19 vaccination survived with mechanical circulatory support. ESC Heart Fail 2022; 9:2732-2737. [PMID: 35616026 PMCID: PMC9288782 DOI: 10.1002/ehf2.13962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/21/2022] [Accepted: 04/27/2022] [Indexed: 01/05/2023] Open
Abstract
A 69‐year‐old man was hospitalized for heart failure 7 days after coronavirus disease 2019 (COVID‐19) mRNA vaccination. Electrocardiography showed ST‐segment elevation and echocardiography demonstrated severe left ventricular dysfunction. Venoarterial extracorporeal membrane oxygenation and Impella 5.0 were instituted because of cardiogenic shock and ventricular fibrillation. Endomyocardial biopsy demonstrated necrotizing eosinophilic myocarditis (NEM). Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) PCR test was negative. He had no infection or history of new drug exposure. NEM was likely related to COVID‐19 vaccination. He was administered 10 mg/kg of prednisolone following methylprednisolone pulse treatment (1000 mg/day for 3 days). Left ventricular function recovered and he was weaned from mechanical circulatory support (MCS). Follow‐up endomyocardial biopsy showed no inflammatory cell infiltration. This is the first report of biopsy‐proven NEM after COVID‐19 vaccination survived with MCS and immunosuppression therapy. It is a rare condition but early, accurate diagnosis and early aggressive intervention can rescue patients.
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Affiliation(s)
- Mitsukuni Kimura
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Advanced Cardiopulmonary Failure, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eri Noda
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Ishikawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihito Ishikita
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeo Fujino
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouji Matsushima
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhiro Nagaoka
- Department of Cardiovascular Medicine, St. Mary's Hospital, Fukuoka, Japan
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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12
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Al-Kindi S, Zidar DA. COVID-lateral damage: cardiovascular manifestations of SARS-CoV-2 infection. Transl Res 2022; 241:25-40. [PMID: 34780967 PMCID: PMC8588575 DOI: 10.1016/j.trsl.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 02/07/2023]
Abstract
Early in the pandemic, concern that cardiovascular effects would accompany COVID-19 was fueled by lessons from the first SARS epidemic, knowledge that the SARS-COV2 entry receptor (Angiotensin-converting enzyme 2, ACE2) is highly expressed in the heart, early reports of myocarditis, and first-hand accounts by physicians caring for those with severe COVID-19. Over 18 months, our understanding of the cardiovascular manifestations has expanded greatly, leaving more new questions than those conclusively answered. Cardiac involvement is common (∼20%) but not uniformly observed in those who require treatment in a hospitalized setting. Cardiac MRI studies raise the possibility of manifestations in those with minimal symptoms. Some appear to experience protracted cardiovascular symptoms as part of a larger syndrome of post-acute sequelae of COVID-19. Instances of vaccine induced thrombosis and myocarditis are exceedingly rare but illustrate the need to monitor the cardiovascular safety of interventions that induce inflammation. Here, we will summarize the current understanding of potential cardiovascular manifestations of SARS-COV2. To provide proper context, paradigms of cardiovascular injury due to other inflammatory processes will also be discussed. Ongoing research and a deeper understanding COVID-19 may ultimately reveal new insight into the mechanistic underpinnings of cardiovascular disease. Thus, in this time of unprecedented suffering and risk to global health, there exists the opportunity that well conducted translational research of SARS-COV2 may provide health dividends that outlast the current pandemic.
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Key Words
- ace2, angiotensin-converting enzyme 2
- pasc, post-acute sequelae of covid-19
- cvd, cardiovascular disease
- tnf, tumor necrosis factor
- pamp, pathogen associated molecular patterns
- damps, damage associated molecular patterns
- car-t, chimeric antigen receptor therapy
- dvt, deep venous thrombosis
- tf, tissue factor
- psgl, p-selectin glycoprotein ligand
- nets, neutrophil extracellular traps
- lv, left ventricular
- crp, c-reactive protein
- lge, late gadolinium enhancement
- cbv, coxsackie virus b
- b19v, parvovirus b12
- car, coxsackievirus and adenovirus receptor
- ns1, nonstructural protein 1
- ec, endothelial cells
- scrnaseq, single cell rna sequencing
- embx, endomyocardial biopsy
- tte, transthoracic echocardiograms
- rv, right ventricular
- gls, global longitudinal strain
- hscrp, high sensitivity c-reative protein
- vitt, vaccine-induced immune thrombotic thrombocytopenia
- dtap, diphtheria, tetanus, and polio
- vaers, vaccine adverse event reporting system
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Affiliation(s)
- Sadeer Al-Kindi
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | - David A Zidar
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio; Louis Stokes VA Medical Center, Cleveland, Ohio.
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13
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Agdamag ACC, Gonzalez D, Carlson K, Konety S, McDonald WC, Martin CM, Maharaj V, Alexy T. Fulminant myocarditis following coronavirus disease 2019 vaccination: a case report. Eur Heart J Case Rep 2022; 6:ytac007. [PMID: 35088026 PMCID: PMC8790078 DOI: 10.1093/ehjcr/ytac007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/27/2021] [Accepted: 01/04/2022] [Indexed: 01/07/2023]
Abstract
Background The BNT162b2 vaccine received emergency use authorization from the U.S. Food and Drug Administration for the prevention of severe coronavirus disease 2019 (COVID-19) infection. We report a case of biopsy and magnetic resonance imaging (MRI)-proven severe myocarditis that developed in a previously healthy individual within days of receiving the first dose of the BNT162b2 COVID-19 vaccine. Case Summary An 80-year-old female with no significant cardiac history presented with cardiogenic shock and biopsy-proven fulminant myocarditis within 12 days of receiving the BNT162b2 COVID-19 vaccine. She required temporary mechanical circulatory support, inotropic agents, and high-dose steroids for stabilization and management. Ultimately, her cardiac function recovered, and she was discharged in stable condition after 2 weeks of hospitalization. A repeat cardiac MRI 3 months after her initial presentation demonstrated stable biventricular function and continued improvement in myocardial inflammation. Discussion Fulminant myocarditis is a rare complication of vaccination. Clinicians should stay vigilant to recognize this rare, but potentially deadly complication. Due to the high morbidity and mortality associated with COVID-19 infection, the clinical benefits of the BNT162b2 vaccine greatly outweighs the risks of complications.
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Affiliation(s)
- Arianne Clare C Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Daniel Gonzalez
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Katie Carlson
- Department of Cardiology, Metropolitan Heart and Vascular Institute, Mercy Hospital, Coon Rapids, MN 55433, USA
| | - Suma Konety
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - William C McDonald
- Department of Pathology, Abbott Northwestern Hospital, Minneapolis, MN 55407, USA
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Valmiki Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
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14
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Cereda A, Conca C, Barbieri L, Ferrante G, Tumminello G, Lucreziotti S, Guazzi M, Mafrici A. Acute myocarditis after the second dose of SARS-CoV-2 vaccine: Serendipity or atypical causal relationship? Anatol J Cardiol 2021; 25:522-523. [PMID: 34236331 DOI: 10.5152/anatoljcardiol.2021.99] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Alberto Cereda
- Department of Cardiology, ASST Santi Paolo e Carlo; Milan-Italy
| | - Cristina Conca
- Department of Cardiology, ASST Santi Paolo e Carlo; Milan-Italy
| | - Lucia Barbieri
- Department of Cardiology, ASST Santi Paolo e Carlo; Milan-Italy
| | - Giulia Ferrante
- Department of Cardiology, ASST Santi Paolo e Carlo; Milan-Italy
| | | | | | - Marco Guazzi
- Department of Cardiology, ASST Santi Paolo e Carlo; Milan-Italy
| | - Antonio Mafrici
- Department of Cardiology, ASST Santi Paolo e Carlo; Milan-Italy
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15
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D'Angelo T, Cattafi A, Carerj ML, Booz C, Ascenti G, Cicero G, Blandino A, Mazziotti S. Myocarditis after SARS-CoV-2 Vaccination: A Vaccine-induced Reaction? Can J Cardiol 2021; 37:1665-1667. [PMID: 34118375 PMCID: PMC8187737 DOI: 10.1016/j.cjca.2021.05.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/04/2021] [Accepted: 05/21/2021] [Indexed: 01/05/2023] Open
Abstract
Vaccination plays an important role in the fight against the current pandemic of SARS-CoV-2, in order to minimize the spread of coronavirus disease 2019 (COVID-19) and its life-threatening complications. Myocarditis has been reported as a possible and rare adverse consequence of different vaccines, and its clinical presentation can range from influenza-like symptoms to acute heart failure. We report a case of a 30-year-old male who presented progressive dyspnea and constrictive retrosternal pain after receiving SARS-CoV-2 vaccine. Cardiac magnetic resonance and laboratory data revealed typical findings of acute myopericarditis.
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Affiliation(s)
- Tommaso D'Angelo
- Diagnostic and Interventional Radiology Unit, Department of Biomedical Sciences and Morphological and Functional Imaging, "G. Martino" University Hospital Messina, Messina, Italy.
| | - Antonino Cattafi
- Diagnostic and Interventional Radiology Unit, Department of Biomedical Sciences and Morphological and Functional Imaging, "G. Martino" University Hospital Messina, Messina, Italy
| | - Maria Ludovica Carerj
- Diagnostic and Interventional Radiology Unit, Department of Biomedical Sciences and Morphological and Functional Imaging, "G. Martino" University Hospital Messina, Messina, Italy
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, "W. Goethe" University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Giorgio Ascenti
- Diagnostic and Interventional Radiology Unit, Department of Biomedical Sciences and Morphological and Functional Imaging, "G. Martino" University Hospital Messina, Messina, Italy
| | - Giuseppe Cicero
- Diagnostic and Interventional Radiology Unit, Department of Biomedical Sciences and Morphological and Functional Imaging, "G. Martino" University Hospital Messina, Messina, Italy
| | - Alfredo Blandino
- Diagnostic and Interventional Radiology Unit, Department of Biomedical Sciences and Morphological and Functional Imaging, "G. Martino" University Hospital Messina, Messina, Italy
| | - Silvio Mazziotti
- Diagnostic and Interventional Radiology Unit, Department of Biomedical Sciences and Morphological and Functional Imaging, "G. Martino" University Hospital Messina, Messina, Italy
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