Acute Myopericarditis after COVID-19 Vaccine in Teenagers

COVID-19 vaccine-associated myocarditis: Analysis of the suspected cases reported to the EudraVigilance and a systematic review of the published literature

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.

Myopericarditis Following the Third Dose of COVID-19 mRNA Vaccination: A Case Report

Coronavirus disease 2019 (COVID-19) mRNA vaccine-related cases of pericarditis and myocarditis have been reported infrequently. Most of the patients usually present within a week of the vaccine, and on average, most of the cases were reported after the second dose of vaccine within two to four days. Chest pain was the most common presentation, and fever and shortness of breath were the other commonly reported symptoms. The patients can have positive cardiac markers and electrocardiogram (EKG) changes, and the cases can be mistaken for cardiac emergencies. We present a 17-year-old male patient with sudden onset substernal chest pain for two days who got the third dose of the Pfizer-BioNTech mRNA vaccine within 24 hours prior. EKG was remarkable for diffuse ST elevations, and troponins were elevated. Later, the cardiac magnetic resonance imaging confirmed the findings of myopericarditis. The patient was treated with colchicine and non-steroidal anti-inflammatory drugs (NSAIDs), completely recovered, and is doing fine to date. This case hights that post-vaccine myocarditis can be mistaken and early diagnosis and management can prevent unnecessary interventions.

Myopericarditis After COVID-19 mRNA Vaccination Among Adolescents and Young Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Published data on COVID-19 mRNA vaccine-associated myopericarditis in adolescents and young adults have been derived from small case series, national population-based studies, or passive reporting systems. Pooled evidence from a larger, international cohort is scarce.

OBJECTIVE

To investigate the clinical features and early outcomes associated with myopericarditis after COVID-19 mRNA vaccination in a heterogeneous population of adolescents and young adults.

DATA SOURCES

PubMed and EMBASE were searched through August 2022. Language restrictions were not applied.

STUDY SELECTION

Observational studies and case series describing COVID-19 vaccine-associated myopericarditis in adolescents and young adults aged 12 to 20 years and reporting clinical characteristics and early outcomes were included.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators extracted relevant data from each study. One-group meta-analysis in a random effects model was performed. The Preferred Reporting Items for Systematic Reviews and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology reporting guidelines were followed.

MAIN OUTCOMES AND MEASURES

The primary outcomes were clinical features and early outcomes for COVID-19 mRNA vaccine-associated myopericarditis, including incident rate, cardiac findings, hospitalization, intensive care unit (ICU) admission, and in-hospital mortality.

RESULTS

A total of 23 observational studies were identified, including 854 individuals (mean age, 15.9 [95% CI, 15.5-16.2] years) with COVID-19 vaccine-associated myopericarditis. Male sex was predominant, at 90.3% (95% CI, 87.3%-93.2%) of individuals. The incident rate was higher after the second dose than the first dose, with 74.4% (95% CI, 58.2%-90.5%) of events occurring after the second dose. Most patients (84.4% [95% CI, 80.5%-88.3%] of patients) had preserved left ventricular (LV) function. Of the 15.6% (95% CI, 11.7%-19.5%) of patients with LV systolic dysfunction (LV ejection fraction [LVEF] <55%), most (14.1% [95% CI, 10.2%-18.1%]) were mild (ie, LVEF 45%-54%), and only 1.3% (95% CI, 0%-2.6%) of patients had severe LV systolic dysfunction (ie, LVEF<35%). Interestingly, cardiac magnetic resonance imaging revealed late gadolinium enhancement in 87.2% (95% CI, 79.8%-94.7%) of patients. Although 92.6% (95% CI, 87.8%-97.3%) of patients were hospitalized and 23.2% (95% CI, 11.7%-34.7%) of patients required ICU admission, inotropes were used in only 1.3% (95% CI, 0%-2.7%) of patients, no patients died or required mechanical support, and the hospital length of stay was 2.8 (95% CI, 2.1-3.5) days.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found low incidence rate and largely favorable early outcomes of COVID-19 mRNA vaccine-associated myopericarditis in adolescents and young adults from a wide range of populations. These findings are reassuring but continued follow-up is warranted.

COVID-19 Vaccine-Related Myocardial and Pericardial Inflammation

PURPOSE OF REVIEW

To review myocarditis and pericarditis developing after COVID-19 vaccinations and identify the management strategies.

RECENT FINDINGS

COVID-19 mRNA vaccines are safe and effective. Systemic side effects of the vaccines are usually mild and transient. The incidence of acute myocarditis/pericarditis following COVID-19 vaccination is extremely low and ranges 2-20 per 100,000. The absolute number of myocarditis events is 1-10 per million after COVID-19 vaccination as compared to 40 per million after a COVID-19 infection. Higher rates are reported for pericarditis and myocarditis in COVID-19 infection as compared to COVID-19 vaccines. COVID-19 vaccine-related inflammatory heart conditions are transient and self-limiting in most cases. Patients present with chest pain, shortness of breath, and fever. Most patients have elevated cardiac enzymes and diffuse ST-segment elevation on electrocardiogram. Presence of myocardial edema on T2 mapping and evidence of late gadolinium enhancement on cardiac magnetic resonance imaging are also helpful additional findings. Patients were treated with non-steroidal anti-inflammatory drugs and colchicine with corticosteroids reserved for refractory cases. At least 3-6 months of exercise abstinence is recommended in athletes diagnosed with vaccine-related myocarditis. COVID-19 vaccination is recommended in all age groups for the overall benefits of preventing hospitalizations and severe COVID-19 infection sequela.

Myocarditis Following COVID-19 Vaccination: Cardiac Imaging Findings in 118 Studies

We reviewed the reported imaging findings of myocarditis in the literature following COVID-19 vaccination on cardiac imaging by a literature search in online databases, including Scopus, Medline (PubMed), Web of Science, Embase (Elsevier), and Google Scholar. In total, 532 cases of myocarditis after COVID-19 vaccination were reported (462, 86.8% men and 70, 13.2% women, age range 12 to 80) with the following distribution: Pfizer-BioNTech: 367 (69%), Moderna: 137 (25.8%), AstraZeneca: 12 (2.3%), Janssen/Johnson & Johnson: 6 (1.1%), COVAXIN: 1 (0.1%), and unknown mRNA vaccine: 9 (1.7%). The distribution of patients receiving vaccine dosage was investigated. On cardiac MR Imaging, late intravenous gadolinium enhancement (LGE) was observed mainly in the epicardial/subepicardial segments (90.8%, 318 of 350 enhancing segments), with the dominance of inferolateral segment and inferior walls. Pericardial effusion was reported in 13.1% of cases. The vast majority of patients (94%, 500 of 532) were discharged from the hospital except for 4 (0.7%) cases. Post-COVID-19 myocarditis was most commonly reported in symptomatic men after the second or third dose, with CMRI findings including LGE in 90.8% of inferior and inferolateral epicardial/subepicardial segments. Most cases were self-limited.

COVID-19 review shows that benefits of vaccinating children and adolescents appear to outweigh risks of post-vaccination myopericarditis

AIM

Myopericarditis after COVID-19 vaccination were the most serious adverse events reported in children over 5 years of age. We want summarize these cases, describing their incidence, clinical features, diagnostic pathways, therapeutic strategies and outcome.

METHODS

A systematic review of the literature was conducted until 20 March 2022 by bibliographic electronic databases. We included all reports of post-vaccination myopericarditis in children aged between 5 and 18 years.

RESULTS

All reported cases had elevated serum Troponin levels, associated with electrocardiogram changes, but often with normal echocardiogram. Cardiac magnetic resonance images always showed typical alterations. The pathogenetic mechanism is still unknown. Myocarditis following post-COVID vaccination is more frequent in males with an average age of about 15 years. Treatment involves the usage of non-steroidal anti-inflammatory drugs, and the average hospitalization is about 3 days. The long-term consequences are not yet known, so these patients should be studied in a cardiological follow up and abstention from physical activity should be recommended.

CONCLUSION

The benefits of COVID-19 vaccination in children and adolescents appear to outweigh the risk of developing post-vaccination myopericarditis. We can also speculate a possible approval of vaccination in children under 5 years for the coming winter.

Myocarditis Following COVID-19 Vaccination: A Systematic Review (October 2020-October 2021)

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.

COVID-19 Vaccine Cardiac Complications: A Case Series on Implications of Marijuana in Adolescents With Myopericarditis

We report on two critically ill pediatric patients, aged 16 and 18 years, presenting with acute myopericarditis at a tertiary-care center in New Jersey, United States. Both patients had their severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccinations, tested negative for SARS-CoV-2, and shared only significant history of asthma. Clinical presentations were similar to acute onset chest pain that worsened with deep inspiration. One patient reported a history of vaping and escalating marijuana use several hours preceding presentation. Both patients had elevated troponin on admission and had ST-segment elevation on electrocardiogram (EKG), thus prompting admission to the pediatric intensive care unit (PICU) for cardiac monitoring. Myopericarditis has multiple etiologies and is a newly described rare complication of the SARS-CoV-2 vaccine. It can also occur as a complication of vaping and frequent marijuana drug use. Our paper highlights the importance of a detailed social and drug history in adolescents presenting with chest pain. The clinical characterization is necessary to promote better case definitions and the design of targeted interventions for this vulnerable group.