Recurrence of pericarditis after influenza vaccination: a case report and review of the literature

Unmasking the Enigma: Influenza Vaccine and the Rare Case of Post-Vaccination Pericarditis

Acute pericarditis is an inflammatory condition involving the pericardium, the double-layered sac that surrounds the heart. It is characterized by chest pain, typically pleuritic and sharp, along with other clinical and laboratory findings indicative of pericardial inflammation. While acute pericarditis following influenza vaccination is rare, it has been reported in medical literature. The relationship between vaccinations, including the influenza vaccine, and pericarditis is particularly interesting, as it has implications for public health and vaccination programs. Understanding the pathophysiological mechanisms behind vaccine-induced pericarditis and recognizing the clinical presentation are essential for healthcare professionals to diagnose, manage, and educate patients appropriately.

The Evolving Etiologic and Epidemiologic Portrait of Pericardial Disease

Pericardial disease includes a variety of conditions, including inflammatory pericarditis, pericardial effusions, constrictive pericarditis, pericardial cysts, and primary and secondary pericardial neoplasms. The true incidence of this varied condition is not well established, and the causes vary greatly across the world. This review aims to describe the changing pattern of epidemiology of pericardial disease and to provide an overview of causative etiologies. Idiopathic pericarditis (assumed most often to be viral) remains the most common etiology for pericardial disease globally, with tuberculous pericarditis being most common in developing countries. Other important etiologies include fungal, autoimmune, autoinflammatory, neoplastic (both benign and malignant), immunotherapy-related, radiation therapy-induced, metabolic, postcardiac injury, postoperative, and postprocedural causes. Improved understanding of the immune pathophysiological pathways has led to identification and reclassification of some idiopathic pericarditis cases into autoinflammatory etiologies, including immunoglobulin G (IgG)4-related pericarditis, tumour necrosis factor receptor-associated periodic syndrome (TRAPS), and familial Mediterranean fever in the current era. Contemporary advances in percutaneous cardiac interventions and the recent COVID-19 pandemic have also resulted in changes in the epidemiology of pericardial diseases. Further research is needed to improve our understanding of the etiologies of pericarditis, using the assistance of contemporary advanced imaging techniques and laboratory testing. Careful consideration of the range of potential causes and local epidemiologic patterns of causality are important for the optimization of diagnostic and therapeutic approaches.

Influenza Type B Complicates a Previously Undiagnosed Case of Pericarditis

We report the first case of pericarditis exacerbation due to influenza B viral infection while emphasizing the importance of cardiac magnetic resonance (CMR) for the timely diagnosis and ruling out of non-effusive pericarditis in a patient with compatible, unexplained chest pain. The patient presented with left-sided chest pain that was partially relieved by leaning backward and noted persistent fatigue for several days. Pericardial friction rub, electrocardiogram (ECG), and echocardiogram abnormalities were not detected. After discharge on the morning following admission, fatigue and fever several minutes after physical exertion continued. The patient contracted influenza type B, leading to pneumonia and a second hospitalization, during which echocardiography showed moderate pericardial effusion. We conclude that the patient had pericarditis on the first admission because other compatible causes of chest pain were ruled out, symptoms were compatible with non-effusive pericarditis and could not be ruled out since CMR was not done, and the patient tested positive during his second admission for multiple known etiologic agents of pericarditis. We highlight the importance of CMR in screening patients presenting with chest pain of unknown origin to facilitate early detection and intervention.

Acute Polyserositis with Cardiac Tamponade and Bilateral Refractory Pleural Effusion after ChAdOx1 nCoV-19 Vaccination

The association of SARS-CoV-2 messenger ribonucleic acid vaccines with pericarditis in young adults has been reported. However, data regarding other types of vaccines are extremely limited. We presented a 94-year-old man with rapidly progressive dyspnea and fatigue six days after his first ChAdOx1 nCoV-19 vaccination. Impending cardiac tamponade and bilateral pleural effusion were found. Hence, massive yellowish pericardial and pleural effusion were drained. However, the pleural effusion persisted and pigtail catheters were inserted bilaterally. After serial studies including surgical pleural biopsy, acute polyserositis (pericarditis and pleurisy) was diagnosed. Anti-inflammatory treatment with colchicine and prednisolone was administered. All effusions resolved accordingly. This rare case sheds light on the presentation of ChAdOx1 nCoV-19 vaccine-related acute polyserositis. In conclusion, awareness of this potential adverse event may facilitate the diagnosis for unexplained pericardial or pleural effusion after vaccination.

Acute Lymphocyte Myocarditis Associated with Influenza Vaccination

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.

Intravenous Injection of Coronavirus Disease 2019 (COVID-19) mRNA Vaccine Can Induce Acute Myopericarditis in Mouse Model

BACKGROUND

Post-vaccination myopericarditis is reported after immunization with coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccines. The effect of inadvertent intravenous injection of this vaccine on the heart is unknown.

METHODS

We compared the clinical manifestations, histopathological changes, tissue mRNA expression, and serum levels of cytokine/chemokine and troponin in Balb/c mice at different time points after intravenous (IV) or intramuscular (IM) vaccine injection with normal saline (NS) control.

RESULTS

Although significant weight loss and higher serum cytokine/chemokine levels were found in IM group at 1-2 days post-injection (dpi), only IV group developed histopathological changes of myopericarditis as evidenced by cardiomyocyte degeneration, apoptosis, and necrosis with adjacent inflammatory cell infiltration and calcific deposits on visceral pericardium, although evidence of coronary artery or other cardiac pathologies was absent. Serum troponin level was significantly higher in IV group. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike antigen expression by immunostaining was occasionally found in infiltrating immune cells of the heart or injection site, in cardiomyocytes and intracardiac vascular endothelial cells, but not skeletal myocytes. The histological changes of myopericarditis after the first IV-priming dose persisted for 2 weeks and were markedly aggravated by a second IM- or IV-booster dose. Cardiac tissue mRNA expression of interleukin (IL)-1β, interferon (IFN)-β, IL-6, and tumor necrosis factor (TNF)-α increased significantly from 1 dpi to 2 dpi in the IV group but not the IM group, compatible with presence of myopericarditis in the IV group. Ballooning degeneration of hepatocytes was consistently found in the IV group. All other organs appeared normal.

CONCLUSIONS

This study provided in vivo evidence that inadvertent intravenous injection of COVID-19 mRNA vaccines may induce myopericarditis. Brief withdrawal of syringe plunger to exclude blood aspiration may be one possible way to reduce such risk.

Myopericarditis with hemorrhagic pericardial effusion following BNT162b2 mRNA COVID-19 vaccine

Since the onset of the COVID-19 pandemic, to date, around 385 million cases have been diagnosed worldwide leading to an estimated 5.7 million death toll. Mass vaccination campaigns have been conducted to control the spread of infection with the most commonly used vaccines being Pfizer-BioNTech and Moderna. However, the adverse effects of vaccination have not yet been fully investigated. Of concern are some serious cardiovascular events such as myocarditis, pericarditis, or perimyocarditis development post-vaccination. Hemorrhagic pericardial effusion has not been reported. However, we report a case of myopericarditis with a hemorrhagic pericardial effusion that developed two weeks following BNT162b2 mRNA COVID-19 vaccination. We performed a complete workup identifying the underlying cause that did not yield any significant findings. Our patient was treated with colchicine and ibuprofen, and he made a full recovery. A follow-up cardiovascular magnetic resonance imaging (CMR) showed no signs of active inflammation.

Cardiac Adverse Events after Vaccination—A Systematic Review

The Vaccine Adverse Event Reporting System database has been used to report adverse events following several vaccines. We studied the patient population predisposed to such reactions and how these reactions differ with respect to the vaccine type. We searched the electronic databases PubMed, EMBASE, and Scopus up to 9 July 2021 for any study describing cardiac adverse events attributed to the vaccination. A total of 56 studies met the criteria comprising 340 patients. There were 20 studies describing cardiac adverse events following smallpox vaccination, 11 studies describing adverse events after influenza vaccination, and 18 studies describing adverse events after COVID-19 vaccination. There was a total of six studies describing cardiac adverse events after the pneumococcal vaccine, tetanus toxoid, cholera vaccine, and rabies vaccine. Adverse events following influenza vaccination occurred more commonly in older females within an average duration of four days from vaccination. Pericardial involvement was the most reported adverse event. Adverse events following COVID-19 vaccination happened at a mean age of 42.7 years, more commonly in males, and mostly after a second dose. Adverse events following smallpox vaccination occurred more commonly in younger males, with an average onset of symptoms from vaccination around 16.6 days. Adverse events were mostly myopericarditis; however, the acute coronary syndrome has been reported with some vaccines.

A Case of Acute Pericarditis After COVID-19 Vaccination

A two-dose regimen of Pfizer-BioNTech COVID-19 vaccination confers 95% protection against COronaVIrus Disease 19 (COVID-19) and the safety profile is adequate. To the submission date, there were no reports in literature of acute pericarditis after BNT162b2 vaccination. However, pericarditis has been reported as a rare event associated with COVID-19 infection, which could be due to the pro-inflammatory effects of the spike protein. Recent evidence of post-vaccine myocarditis has been published. Herein we describe the case of a middle-aged healthy women who developed symptoms and signs of acute pericarditis 7-10 days after the second dose of Pfizer-BioNTech COVID-19 vaccination. Although a direct effect cannot be stated, it is important to report a potential adverse vaccine reaction effect that could be associated with the expression of SARS-CoV-2 spike protein induced from the mRNA of the vaccine.

Cardiac Tamponade After COVID-19 Vaccination

BACKGROUND

Acute pericarditis is a diffuse inflammation of the pericardial sac with many well-defined etiologies. Acute pericarditis as a vaccine-related adverse event is a rare entity, and the association between pericarditis and the immunogenic response to Coronavirus disease 2019 (COVID-19) vaccines is still being fully characterized.

CASE REPORT

A previously healthy 18-year-old man presented with fever, pleuritic chest pain, and shortness of breath 3 weeks after receiving the first dose of a COVID-19 mRNA-based vaccine. The patient was found to have a large pericardial effusion with early tamponade physiology requiring pericardiocentesis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As COVID-19 vaccination becomes more prevalent globally, physicians should be aware of pericarditis as a rare but potentially serious adverse reaction. Although a direct causal link cannot be demonstrated, we present this case to increase awareness among emergency physicians of pericarditis as a rare, but potentially serious adverse event associated with COVID-19 vaccination.

A small but significantly greater incidence of inflammatory heart disease identified after vaccination for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)

Background

SARS-CoV-2 vaccines are being administered on an unprecedented scale. Assessing the risks of side effects is needed to aid clinicians in early detection and treatment. This study examined the risk of inflammatory heart disease, including pericarditis and myocarditis, following SARS-CoV-2 vaccination.

Methods

Intermountain Healthcare patients with inflammatory heart disease from December 15, 2020, to June 15, 2021, and with or without preceding SARS-CoV-2 vaccinations were studied. Relative rates of inflammatory heart disease were examined for vaccinated patients compared to unvaccinated patients.

Results

Of 67 identified inflammatory heart disease patients, 21 (31.3%) had a SARS-Cov-2 vaccination within the previous 60 days. Overall, 914,611 Intermountain Healthcare patients received a SARS-CoV-2 vaccine, resulting in an inflammatory heart disease rate of 2.30 per 100,000 vaccinated patients. The relative risk of inflammatory heart disease for the vaccinated patients compared to the unvaccinated patients was 2.05 times higher rate within the 30-day window (p=0.01) and had a trend toward increase in the 60-day window (relative rate=1.63; p=0.07). All vaccinated patients with inflammatory heart disease were treated successfully with one death related to a pre-existing condition.

Conclusions

Though rare, the rate of inflammatory heart disease was greater in a SARS-CoV-2 vaccinated population than the unvaccinated population. This risk is eclipsed by the risk of contracting COVID-19 and its associated, commonly severe outcomes. Nevertheless, clinicians and patients should be informed of this risk to facilitate earlier recognition and treatment.

Cardiomyopathy Associated with Anti-SARS-CoV-2 Vaccination: What Do We Know?

The SARS-CoV-2 pandemic has mobilized many efforts worldwide to curb its impact on morbidity and mortality. Vaccination of the general population has resulted in the administration of more than 6,700,000,000 doses by the end of October 2021, which is the most effective method to prevent hospitalization and death. Among the adverse effects described, myocarditis and pericarditis are low-frequency events (less than 10 per 100,000 people), mainly observed with messenger RNA vaccines. The mechanisms responsible for these effects have not been specified, considering an exacerbated and uncontrolled immune response and an autoimmune response against specific cardiomyocyte proteins. This greater immunogenicity and reactogenicity is clinically manifested in a differential manner in pediatric patients, adults, and the elderly, determining specific characteristics of its presentation for each age group. It generally develops as a condition of mild to moderate severity, whose symptoms and imaging findings are self-limited, resolving favorably in days to weeks and, exceptionally, reporting deaths associated with this complication. The short- and medium-term prognosis is favorable, highlighting the lack of data on long-term evolution, which should be determined in longer follow-ups.

Recurrence of myopericarditis following mRNA COVID-19 vaccination in a male adolescent

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has spread worldwide, resulting in health and economic crises. Vaccination against SARS-CoV-2 infection is considered a valid prevention measure to control this pandemic. There have been reports of cases of myopericarditis following mRNA COVID-19 vaccination. We present a case of a 20-year-old man with recurrent myopericarditis following an initial episode of influenza virus-induced myopericarditis and after receiving a second dose of the mRNA-1273 Moderna COVID-19 vaccine. Careful attention should be paid to patients with a history of myocarditis following COVID-19 vaccination.

Evaluating the relationship between myocarditis and mRNA vaccination

Introduction

Inflammatory conditions affecting the heart and surrounding tissues have been recently reported following mRNA vaccination. Evaluating trends in the epidemiology of these events and possible mechanisms related to vaccination will enhance vaccine safety surveillance and inform best practices for future vaccine campaigns.

Areas covered

Epidemiology of the burden of vaccine-associated myocarditis are reviewed. Key summaries of available data from public health advisory bodies and vaccine safety surveillance databases are critically reviewed. The possible biological pathways for vaccine-associated heart inflammations are introduced. A critical synthesis of available information to inform vaccine recommendations and best practices is provided. The citations were selected by the authors based on PubMed searches of the literature, national vaccine safety surveillance databases and summaries from national public health bodies.

Expert opinion

Myocarditis may be associated with vaccination, through several biological mechanisms. Studies have shown that live viral vaccinations can act as a trigger for hypersensitivity inflammatory reactions, but further work is required to examine how the mRNA formulation may induce these autoimmune responses. Given that the risk of these adverse events is low, and the benefit of protection against disease is so great, the receipt of mRNA vaccines is recommended.

Myocarditis and pericarditis in association with COVID-19 mRNA-vaccination: cases from a regional pharmacovigilance centre

In this article we summarize suspected adverse events following immunization (AEFI) of pericarditis, myocarditis and perimyocarditis that were reported by our regional pharmacovigilance centre after COVID-19 mRNA-vaccination and discuss their association with these vaccines. Seventeen cases were reported between March and July 2021. Of these, nine had perimyocarditis, five myocarditis and three pericarditis. Twelve patients were male (71%). The median age was 38 years (range 17–88). The most commonly observed presenting symptom was acute chest pain (65%). While 47% of the patients were previously healthy, 53% had at least one pre-existing comorbidity, with hypertension being the most prevalent (24%). The European Society of Cardiology diagnostic criteria for the reported AEFIs were fulfilled in twelve cases (71%). The AEFIs occurred after the first vaccine dose in six cases (35%), after the second vaccine dose in ten cases (59%) and after both doses in one case (6%). The median latency of all AEFIs taken together was 14 days (range 1–28) after the first vaccination and 3 days (range 1–17) after the second one. All patients except one were hospitalized (94%) with a median length of stay of 7.5 days (range 3–13). The majority of patients (n = 11, 65%) did not experience any complications, and 13 (77%) of the patients had recovered or were recovering at the time of discharge. In 16 of the 17 cases (94%), the association between the AEFI and mRNA-vaccination was considered possible by the pharmacovigilance centre.

Transient Cardiac Injury in Adolescents Receiving the BNT162b2 mRNA COVID-19 Vaccine

BACKGROUND

Vaccines are paramount in the effort to end the coronavirus disease 2019 global epidemic. BNT162b2 is approved for the vaccination of adolescents over 16 years of age. Systemic adverse events were scarce though the pretested cohort of this age group was relatively small. The aim of the current study is to raise awareness for potential adverse reactions.

METHODS

This is a case series of patients diagnosed with perimyocarditis following vaccination. Patients were compiled from 3 pediatric medical centers in Israel through a network of pediatricians and data regarding those cases was collected. In addition, incidence of perimyocarditis during the vaccination period was compared with previous years.

RESULTS

All patients were males 16-18 years old, of Jewish descent, who presented with chest pain that began 1-3 days following vaccination (mean, 2.1 days). In 6 of the 7 patients, symptoms began following the 2nd dose and in 1 patient following the 1st dose. All cases were mild and none required cardiovascular or respiratory support. The incidence of perimyocarditis during the vaccination period was elevated in comparison to previous years.

CONCLUSIONS

This case series describes a time association between coronavirus disease 2019 vaccine and perimyocarditis in adolescents. All cases were mild, although only long-term follow-up can reveal the true impact of this cardiac injury. While it seems that the incidence of perimyocarditis during the vaccination campaign period is increased, a more comprehensive data collection on a wider scale should be done. We hope this report will serve as a reminder to report events and allow for analysis of potential adverse reactions.

A case report: symptomatic pericarditis post-COVID-19 vaccination

BACKGROUND

The Coronavirus disease 2019 (COVID-19) pandemic has led to the rapid development of COVID-19 vaccine. The Centers for Disease Control and Prevention (CDC) has recently reported increase in myopericarditis incidence post-COVID-19 vaccination. Post-vaccination myopericarditis as side effect has been reported, however, is infrequent. We described a case of pericarditis post-first dose of Pfizer-BioNTech vaccine.

CASE SUMMARY

A patient presented with typical symptoms of pericarditis and related electrocardiogram and echocardiogram changes, 7 days post receiving the first dose of COVID-19 vaccine. No other causes were identified from series of investigations. Patient had good symptomatic relief with non-steroidal anti-inflammatory medication.

DISCUSSION

The incidence of pericarditis post-vaccination is rare, with limited reporting in previous literatures. No causal relationship has yet to be established due to small number of cases. The benefits of COVID-19 vaccination currently outweigh the side effect profile and are recommended as the first-line approach to control the current pandemic.

Myopericarditis after vaccination, Vaccine Adverse Event Reporting System (VAERS), 1990-2018

BACKGROUND

Myopericarditis after vaccination has been sporadically reported in the medical literature. Here, we present a thorough descriptive analysis of reports to a national passive vaccine safety surveillance system (VAERS) of myopericarditis after vaccines licensed for use in the United States.

METHODS

We identified U.S. reports of myopericarditis received by VAERS during 1990-2018 that met a published case definition for myopericarditis or were physician-diagnosed. We stratified analysis by age group (<19, 19-49, ≥50 years), describing reports by serious/non-serious status, sex, time to symptom onset after vaccination, vaccine(s) administered, and exposure to other known causes of myopericarditis. We used Empirical Bayesian data mining to detect disproportionate reporting of myopericarditis after vaccination.

RESULTS

VAERS received 620,195 reports during 1990-2018: 708 (0.1%) met the case definition or were physician-diagnosed as myopericarditis. Most (79%) myopericarditis reports described males; 69% were serious; 72% had symptom onset ≤ 2 weeks postvaccination. Overall, smallpox (59%) and anthrax (23%) vaccines were most commonly reported. By age, among persons aged < 19 years, Haemophilus influenzae type b (22, 22%) and hepatitis B (18, 18%); among persons aged 19-49 years smallpox (387, 79%); among persons aged ≥ 50 years inactivated influenza (31, 36%) and live attenuated zoster (19, 22%) vaccines were most commonly reported. The vaccines most commonly reported remained unchanged when excluding 138 reports describing other known causes of myopericarditis. Data mining revealed disproportionate reporting of myopericarditis only after smallpox vaccine.

CONCLUSIONS

Despite the introduction of new vaccines over the years, myopericarditis remains rarely reported after vaccines licensed for use in the United States. In this analysis, myopericarditis was most commonly reported after smallpox vaccine, and less commonly after other vaccines.

Influenza Vaccination and Myo-Pericarditis in Patients Receiving Immune Checkpoint Inhibitors: Investigating the Likelihood of Interaction through the Vaccine Adverse Event Reporting System and VigiBase

Background: Evidence on whether the influenza vaccine could exacerbate immune-related adverse events, including myopericarditis (MP), in patients treated with immune checkpoint inhibitors (ICIs), is still conflicting. We explored this issue through a global real-world approach. Methods: We queried the Vaccine Adverse Event Reporting System (VAERS) and VigiBase to retrieve cases of MP in which the influenza vaccine and ICIs were recorded as suspect and were concomitantly reported. For the included cases, causality assessment and Drug Interaction Probability Scale (DIPS) algorithms were applied. Results: There were 191 and 399 reports of MP with the influenza vaccine that were retrieved (VAERS and VigiBase, respectively). No case of MP reporting the concomitant use of ICIs and the influenza vaccine was found in VAERS, while three cases of myocarditis were retrieved in VigiBase. All of the cases were unclassifiable for a causality assessment because of the lack of data concerning latency. According to the DIPS, one report was categorized as possible and two as doubtful. Conclusion: The paucity of cases coupled with the doubtful causality assessment make the potential interaction between influenza vaccines and ICIs in cancer patients negligible from clinical and epidemiological standpoints. These findings support the cardiovascular safety of the influenza vaccination, which remains strongly recommended in cancer patients, especially in the current COVID-19 era.