COVID-19 mRNA Vaccine and Myocarditis

Untoward immune effects of modern medication

Immune-related adverse events (irAEs) represent an increasingly concerning challenge in the assessment of biopharmaceutical products. In contrast to historically rare allergic reactions associated with small chemical drugs, contemporary biotherapeutics exhibit a significantly higher morbidity of irAEs, because of their complex structure and comprehensive mechanisms of action. While the immunogenicity of protein-based compounds is associated with the induction of anti-drug antibodies, the pathogenesis of irAEs in advanced biologics, such as cell and gene therapy, remains to be further delineated. In the current study, I present an updated profile regarding the untoward immune effects of medications, covering various material categories systematically, with the underlying mechanisms to inspire risk mitigation in biopharmaceutical development and application.

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.

A review of COVID-19 vaccination and the reported cardiac manifestations

In Singapore, 9.03 million doses of the mRNA COVID-19 vaccines by Pfizer-BioNTech and Moderna have been administered, and 4.46 million people are fully vaccinated. An additional 87,000 people have been vaccinated with vaccines in World Health Organization's Emergency Use Listing. The aim of this review is to explore the reported cardiac adverse events associated with different types of COVID-19 vaccines. A total of 42 studies that reported cardiac side effects after COVID-19 vaccination were included in this study. Reported COVID-19 vaccine-associated cardiac adverse events were mainly myocarditis and pericarditis, most commonly seen in adolescent and young adult male individuals after mRNA vaccination. Reports of other events such as acute myocardial infarction, arrhythmia and stress cardiomyopathy were rare. Outcomes of post-vaccine myocarditis and pericarditis were good. Given the good vaccine efficacy and the high number of cases of infection, hospitalisation and death that could potentially be prevented, COVID-19 vaccine remains of overall benefit, based on the current available data.

Research progress on circular RNA vaccines

Owing to the success of linear mRNA coronavirus disease 2019 (COVID-19) vaccines, biopharmaceutical companies and research teams worldwide have attempted to develop more stable circular RNA (circRNA) vaccines and have achieved some preliminary results. This review aims to summarize key findings and important progress made in circRNA research, the in vivo metabolism and biological functions of circRNAs, and research progress and production process of circRNA vaccines. Further, considerations regarding the quality control of circRNA vaccines are highlighted herein, and the main challenges and problem-solving strategies in circRNA vaccine development and quality control are outlined to provide a reference for circRNA vaccine-related research.

An Executed Plan to Combat COVID-19 in the United States

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in late 2019. To date, this coronavirus is responsible for greater than 90 million cases in the United States and more than 1 million confirmed deaths. When this virus came to the United States, testing was unorganized, no effective treatments were known, and no vaccines had been discovered. A plan to correct these deficiencies through cooperative science and efficient clinical trials was implemented to combat this novel virus. This plan developed efficient and inexpensive tests, highly effective medicines to treat and prevent disease progression, and vaccines to immunize the population.

Intricacies Affiliated With Post-COVID Vaccine Complications in Makkah Province, Saudi Arabia

Introduction COVID-19 vaccine side effects have a fundamental role in public confidence in the vaccine and its uptake process. Thus far, evidence on vaccine safety has been exclusively obtained from manufacturer-sponsored studies; therefore, this study is designed to assess post-COVID-19 vaccine complications in Makkah province, Saudi Arabia. Method A cross-sectional study included 840 subjects conducted from August to November 2022 to collect data about COVID-19 vaccine side effects. A validated questionnaire was used with 21 multiple-choice items covering demographic data, COVID-19 vaccination type, side effects, and medication used to relieve side effects. The online Raosoft sample size calculator (Raosoft Inc., Seattle, Washington) was utilized for sample size calculation. The Statistical Package for the Social Sciences version 22.0 (IBM Inc., Armonk, New York) was utilized to carry out descriptive statistics. The Shapiro-Wilk test was used to evaluate normal data distribution. Significance of categorized data made by the Pearson's Chi-Squared test and of the vaccination side effects experienced in general wellbeing on a scale of 1-10 by the Kruskal-Wallis test. Result The survey found that most participants in the 18-26 age group were from Jeddah, women, and Saudis. Only 7.1% of participants had comorbidities alone, and 63.1% of participants had previously had COVID-19. The vaccine types used in this study were primarily Pfizer (83.3%), AstraZeneca (9.5%), Moderna (3.6%), and combination vaccines (3.6%). The majority of the participants received vaccination up to the third dose. No side effects were reported by 9.5% of participants, while mild and severe side effects were reported by 90.5% and 23.8% of participants, respectively. Mild side effects included injection site pain, redness, tenderness, or itching (34.5%), fatigue (22.6%), low-grade fever, chills, diarrhea, headache (17.9%), and myalgia (14.3%). Conclusion The majority of the side effects of COVID-19 vaccination were minor reactions (90.5%), but 23.8% were found to be serious side effects, most of which lasted one to three days. More independent studies are needed to investigate gender differences, COVID-19 vaccine efficacy, and the prevalence of side effects in other populations conducted by academic institutions. Additional independent research on vaccine safety is urgently needed to increase public confidence in vaccines and to better understand risk factors for vaccine side effects.

COVID-19 Vaccination-Associated Myocarditis: A Literature Review

Myocarditis is defined as a non-ischemic inflammation of the middle layer of the heart. It ensues changes that can lead to acute heart failure, dilated cardiomyopathy, and sudden death. Myocarditis is caused by several infectious and non-infectious agents. Vaccines are also known to cause myocarditis. The use of the coronavirus disease (COVID-19) vaccination was started to combat the severity of the COVID-19 infection and reduce the mortality and morbidity associated with it. The vaccination, however, caused side effects like myocarditis, among others. In order to investigate the association between the COVID-19 vaccination and myocarditis in adults and adolescents, we conducted a literature review by searching three databases: Google Scholar, PubMed, and ScienceDirect. From the published literature, we found that, though it is rare, the various vaccinations available can cause symptoms of myocarditis as a side effect more commonly in patients who have received both doses of a particular vaccine and that there are significant changes in cardiac magnetic resonance imaging (CMRI) and other biochemical markers, with young males being more commonly affected. Further prospective trial-based studies are required to establish a concrete relationship between myocarditis and the COVID-19 vaccine.

To Vaccinate or Not to Vaccinate-Reasons of Willingness and Reluctance of Students against SARS-CoV-2 Vaccination-An International Experience

Despite the vaccine against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) being reported to be safe and effective, the unwillingness to vaccinate and doubts are still common. The aim of this international study was to assess the major reasons for the unwillingness to vaccinate in a group of students from Poland (n = 1202), Bangladesh (n = 1586), India (n = 484), Mexico (n = 234), Egypt (n = 566), Philippines (n = 2076), Pakistan (n = 506), Vietnam (n = 98) and China (n = 503). We conducted an online cross-sectional study that aimed to assess (1) the percentage of vaccinated and unvaccinated students and (2) the reasons associated with willingness/unwillingness to the vaccine. The study included 7255 respondents from 9 countries with a mean age of 21.85 ± 3.66 years. Only 22.11% (n = 1604) of students were vaccinated. However, the majority (69.25%, n = 5025) expressed a willingness to be vaccinated. More willing to vaccinate were students in informal relationships who worked mentally, used psychological/psychiatric services before the pandemic, and studied medicine. There are cultural differences regarding the reasons associated with the unwillingness to vaccinate, but some 'universal' might be distinguished that apply to the whole group.

Immunological response and temporal associations in myocarditis after COVID-19 vaccination using cardiac magnetic resonance imaging: An amplified T-cell response at the heart of it?

Introduction

Although myocarditis after anti-SARS-CoV-2 vaccination is increasingly recognized, we have little data regarding the course of the disease and, consequently, the imaging findings, including the tissue-specific features. The purpose of this study is to describe the clinical, immunological, and cardiac magnetic resonance (CMR) features of myocarditis after COVID-19 immunization in the acute phase and during follow-up. We aimed to compare the trajectory of the disease to myocarditis cases unrelated to COVID-19.

Methods

We assembled a CMR-based registry of potentially COVID-19 vaccination-related myocarditis cases. All patients who experienced new-onset chest pain and troponin elevation after COVID-19 vaccination and imaging confirming the clinical suspicion of acute myocarditis were enrolled in our study. Participants underwent routine laboratory testing and testing of their humoral and cellular immune response to COVID-19 vaccination. Clinical and CMR follow-up was performed after 3–6 months. We included two separate, sex- and age-matched control groups: (1) individuals with myocarditis unrelated to COVID-19 infection or vaccination confirmed by CMR and (2) volunteers with similar immunological exposure to SARS-CoV-2 compared to our group of interest (no difference in the number of doses, types and the time since anti-SARS-CoV-2 vaccination and no difference in anti-nucleocapsid levels).

Results

We report 16 CMR-confirmed cases of myocarditis presenting (mean ± SD) 4 ± 2 days after administration of the anti-SARS-CoV-2 vaccine (male patients, 22 ± 7 years), frequently with predisposing factors such as immune-mediated disease and previous myocarditis. We found that 75% received mRNA vaccines, and 25% received vector vaccines. During follow-up, CMR metrics depicting myocardial injury, including oedema and necrosis, decreased or completely disappeared. There was no difference regarding the CMR metrics between myocarditis after immunization and myocarditis unrelated to COVID-19. We found an increased T-cell response among myocarditis patients compared to matched controls (p < 0.01), while there was no difference in the humoral immune response.

Conclusion

In our cohort, myocarditis occurred after both mRNA and vector anti-SARS-CoV-2 vaccination, frequently in individuals with predisposing factors. Upon follow-up, the myocardial injury had healed. Notably, an amplified cellular immune response was found in acute myocarditis cases occurring 4 days after COVID-19 vaccination.

Booster dose of COVID-19 mRNA vaccine does not increase risks of myocarditis and pericarditis compared with primary vaccination: New insights from the vaccine adverse event reporting system

Background

Despite the likely association between coronavirus 2019 (COVID-19) mRNA vaccines and cases of myocarditis/pericarditis, the benefit–risk assessment by the Centers for Disease Control (CDC) still showed a favorable balance for the primary series of COVID-19 mRNA vaccinations. Since August 2021, a full-scale booster vaccination in certain recipients has been recommended. Great concerns about whether the COVID-19 mRNA booster vaccination could increase the risks of myocarditis/pericarditis have been raised since then. The present study aimed to compare the incidence rates and risks of myocarditis/pericarditis between booster and primary vaccination programs.

Methods

The CDC COVID Data Tracker and the Vaccines Adverse Event Reporting System (VAERS) were queried between December 11, 2020 and March 15, 2022. Incidence rates were calculated by cases of myocarditis/pericarditis divided by the number of vaccinated people or the total doses of COVID-19 mRNA vaccines. Disproportionality patterns for myocarditis/pericarditis of different COVID-19 mRNA vaccinations were accessed based on the reporting odds and proportional reporting ratios (ROR and PRR, respectively).

Results

A total of 2,588 reports of myocarditis/pericarditis were identified after administration of primary-series COVID-19 mRNA vaccination and 269 after the booster dose program during the study period. The incidence of myocarditis/pericarditis following booster COVID-19 mRNA vaccination was lower than that of primary series. The results showed significantly high reporting of myocarditis/pericarditis following the administration of primary COVID-19 mRNA vaccination, whereas the disproportional level was lower in the booster-dose vaccination.

Conclusion

This study found that the booster dose of COVID-19 mRNA vaccination when compared with primary series course did not lead to an increase in the risks of myocarditis/pericarditis.

Transient Pneumonitis as a Possible Adverse Reaction to the BNT162b2 COVID-19 mRNA Vaccine in a Patient with Rheumatoid Arthritis: A Case Report and Review of the Literature

The coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to rapid progress in vaccine development to prevent the spread of the disease. Although COVID-19 vaccines have excellent effectiveness in reducing morbidity and disease severity with minor adverse reactions, some patients develop late hypersensitivity events as autoimmune reactions such as rheumatoid arthritis, lupus nephritis, and vasculitis following COVID-19 vaccination. Herein, we describe a case of pneumonitis following COVID-19 mRNA vaccination in a patient with rheumatoid arthritis, which resolved spontaneously.

Rare Heterogeneous Adverse Events Associated with mRNA-Based COVID-19 Vaccines: A Systematic Review

Background: Since the successful development, approval, and administration of vaccines against SARS-CoV-2, the causative agent of COVID-19, there have been reports in the published literature, passive surveillance systems, and other pharmacovigilance platforms of a broad spectrum of adverse events following COVID-19 vaccination. A comprehensive review of the more serious adverse events associated with the Pfizer-BioNTech and Moderna mRNA vaccines is warranted, given the massive number of vaccine doses administered worldwide and the novel mechanism of action of these mRNA vaccines in the healthcare industry. Methods: A systematic review of the literature was conducted to identify relevant studies that have reported mRNA COVID-19 vaccine-related adverse events. Results: Serious and severe adverse events following mRNA COVID-19 vaccinations are rare. While a definitive causal relationship was not established in most cases, important adverse events associated with post-vaccination included rare and non-fatal myocarditis and pericarditis in younger vaccine recipients, thrombocytopenia, neurological effects such as seizures and orofacial events, skin reactions, and allergic hypersensitivities. Conclusions: As a relatively new set of vaccines already administered to billions of people, COVID-19 mRNA-based vaccines are generally safe and efficacious. Further studies on long-term adverse events and other unpredictable reactions in close proximity to mRNA vaccination are required.

Clinical Characteristics of Patients with Myocarditis following COVID-19 mRNA Vaccination: A Systematic Review and Meta-Analysis

COVID-19 mRNA vaccinations have recently been implicated in causing myocarditis. Therefore, the primary aim of this systematic review and meta-analysis was to investigate the clinical characteristics of patients with myocarditis following mRNA vaccination. The secondary aims were to report common imaging and laboratory findings, as well as treatment regimes, in these patients. A literature search was performed from December 2019 to June 2022. Eligible studies reported patients older than 18 years vaccinated with mRNA, a diagnosis of myocarditis, and subsequent outcomes. Pooled mean or proportion were analyzed using a random-effects model. Seventy-five unique studies (patient n = 188, 89.4% male, mean age 18–67 years) were included. Eighty-six patients had Moderna vaccines while one hundred and two patients had Pfizer-BioNTech vaccines. The most common presenting symptoms were chest pain (34.5%), fever (17.1%), myalgia (12.4%), and chills (12.1%). The most common radiologic findings were ST-related changes on an electrocardiogram (58.7%) and hypokinesia on cardiac magnetic resonance imaging or echocardiography (50.7%). Laboratory findings included elevated Troponin I levels (81.7%) and elevated C-reactive protein (71.5%). Seven patients were admitted to the intensive care unit. The most common treatment modality was non-steroid anti-inflammatory drugs (36.6%) followed by colchicine (28.5%). This meta-analysis presents novel evidence to suggest possible myocarditis post mRNA vaccination in certain individuals, especially young male patients. Clinical practice must therefore take appropriate pre-cautionary measures when administrating COVID-19 mRNA vaccinations.

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.

A Comprehensive Analysis of Myocarditis in Formerly Healthy Individuals Following SARS-CoV-2 Vaccination (COVID-19 Immunization)

Due to the rapid development of the coronavirus disease 2019 (COVID-19) pandemic, the Food and Drug Administration (FDA) expedited the authorization of immunizations to counteract life-threatening COVID-19 effects. COVID-19 immunization was seen as an essential component of surviving endemically with COVID-19. Although there were no major adverse event reports that mandated an early authorization of the mass vaccination approval in initial studies, a few significant adverse events were reported after real-world usage. The most prevalent adverse events are regional reactions, such as discomfort at the injection site. Anaphylactic shock and acute responses were quite infrequent. Current evidence strongly convince the community that the advantages of immunization outweigh the risks.

The review investigates the potential adverse reaction in the form of myocarditis caused by the COVID-19 vaccine. Age, sexuality, vaccination type, clinical manifestations, and diagnostic modalities were among the confounding factors associated with vaccine-induced myocarditis. This picture depicts COVID-19 immunization-induced myocarditis and the treatment options available to practitioners. Further evaluation is needed to establish the underlying cause of this association. We compiled the most recent data on SARS-CoV-2 vaccine-induced myocarditis after reviewing available research. Information sources including PubMed and Google Scholar were evaluated retrospectively.

Myocarditis Following COVID-19 Vaccination: A Systematic Review of Case Reports

Introduction: COVID-19, the infectious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), often presents with a spectrum of symptoms at varying levels of severity, ranging from asymptomatic patients to those with fatal complications, such as myocarditis. With increased availability of COVID-19 vaccines, the awareness of possible side effects has expanded as reports surface. This study reviewed cases of myocarditis following COVID-19 vaccination and with existing literature on COVID-19 infection-induced myocarditis to compare clinical courses and analyze possible mechanisms of action. Methods: A systematic review of literature was conducted to identify published case reports (as of February 3, 2022) pertaining to the development of myocarditis following COVID-19 vaccination with either Pfizer or Moderna for an in-depth analysis. Additional subgroup analyses were conducted based on age, past medical history, vaccine manufacturer, and dose number. Results: There were 53 eligible case reports that were included in this study. Patients were mostly male with a median age of 24 years, and the most reported symptom upon presentation was chest pain. Seventy percent of the cases involved the Pfizer vaccine with a majority of myocarditis developing subsequent to second dose. Resolution of symptoms was achieved in all but one patient. Clinical severity, as measured primarily by left ventricular ejection fraction, appeared to be worse among adult patients than pediatric, as well as for patients with comorbidities. Conclusion: This study revealed an observable association between COVID-19 vaccines and myocarditis. However, the clinical course and prognosis seem favorable and less prevalent than those conferred from natural infection.

The Rise of mRNA COVID-19 Vaccine-Associated Myocarditis and Its Implications on the Future Use of This New Vaccine Platform

Vaccine-associated myocarditis is becoming increasingly documented as a complication of the messenger ribonucleic acid (mRNA) vaccination platform. This complication so far has been found to predominantly affect the younger male population within seven days of receiving the second dose of an mRNA vaccine. We present a case of a 45-year-old male found to have clinical, biochemical, and radiological evidence of myocarditis three days after receipt of the second dose of the Moderna COVID-19 vaccine. Troponin I and inflammatory marker trends, in addition to the use of cardiac MRI imaging, was important in making the diagnosis. Symptom resolution was achieved after two months of colchicine and anti-heart failure medications. We highlight the occurrence of this rare vaccine complication in an endeavor to stress the need for further research to better understand this condition so that better guidance can be provided to the medical community on how best to screen and manage it.

Acute cardiac side effects after COVID-19 mRNA vaccination: a case series

BACKGROUND

Vaccination against SARS-CoV-2 has been the main tool to contain the pandemic. The rush development of the 3 vaccines and their expedited approval have led to inoculation of millions of patients around the world, leading to a containment of the disease. Despite continuous viral mutations and the identification of weaker variants, the severity of the infections has been mild, with many patients being either asymptomatic or recovering at home. Currently the focus has shifted from the host of organ damage related to the infection to potential side effects of the vaccine. Myocarditis has been reported as one of the potential side effects from the mRNA vaccine, affecting young healthy individuals. Up to September 30, 2021, 1.243 cases of myocarditis after vaccination with BNT162b2 Comirnaty© were registered in young adults by the Paul-Ehrlich-Institute in Germany alone. The exact pathophysiology and the risk factors for myocarditis following vaccination remain unclear. We present a case series of eight patients with cardiac symptom shortly after SARS-CoV-2 mRNA vaccination (BNT162b6, Biontech, Comirnaty© or mRNA-1237 Moderna, Spikevax©).

PATIENTS AND METHODS

Eight patients between 13 and 56 years of age, vaccinated with either BNT162b2 or mRNA-1273 mRNA vaccine between January and August 2021 developed cardiac side effects shortly after either their first or second dose of the vaccine. Clinical data were retrieved from the clinical information system and analyzed. To support diagnosis of myocarditis or pericarditis, cardiac magnetic resonance imaging (MRI) was performed shortly after the onset of symptoms, with further investigations in severe cases. Symptoms were defined as dyspnea, chest pain and cardiac arrhythmia as determined by electrocardiography.

RESULTS

Eight patients (5 males and 3 females) developed cardiac symptoms compatible with myocarditis, according to the CDC criteria, shortly after SARS-CoV-2 mRNA vaccination. Three patients (2 males, 1 female) required hospitalization due to severe chest pain and elevated troponin levels. All patients recovered fully within 7 days from the symptom onset.

CONCLUSIONS

Our data suggest that cardiac adverse events such as myocarditis or pericarditis shortly after SARS-CoV-2 mRNA vaccination are rare but possible and occur particularly in male patients.

A Rare Case of Myocarditis After the First Dose of Moderna Vaccine in a Patient With Two Previous COVID-19 Infections

Myocarditis is the inflammation of the cardiac muscle caused by a variety of factors ranging from infections to autoimmune diseases. Most cases of vaccine-induced myocarditis occur after the second dose of vaccination; however, a few cases have been reported following the first dose of vaccination with or without previous coronavirus disease 2019 (COVID-19) infection. A case of myocarditis occurring about three weeks after the first dose of the Moderna vaccine has been reported in a patient with one previous COVID-19 infection. However, there have not been any documented cases of myocarditis after the first dose of the Moderna vaccine in a patient with two prior COVID-19 infections. Our index patient had already experienced two COVID-19 infections in the past and was diagnosed with myocarditis eight hours after receiving the first dose of the Moderna vaccine. The susceptibility to developing this likely stems from the possible production of antibodies to the viral antigen from previous COVID-19 infections. Furthermore, the fact that our patient developed symptoms eight hours after receiving the vaccine suggests a possible additive effect of antibodies produced from the two previous COVID-19 infections. This case report suggests that individuals repeatedly infected with COVID-19 may be at increased risk of myocarditis following the administration of the Moderna vaccine.

Temporal Association Between the COVID-19 Ad26.COV2.S Vaccine and Acute Myocarditis: A Case Report and Literature Review

With the recent approval and widespread administration of the Pfizer-BioNTech, Moderna, and Janssen vaccines worldwide, incidence of severe Coronavirus Disease 2019 (COVID-19) infection has significantly decreased. In spite of their undisputed role in reducing the severity of the disease and reduction of the disease burden in the community, there have been case reports of serious side effects with these vaccines. We aim to describe a case report of myocarditis following administration of the Janssen vaccine in a healthy, young male and review the available literature on COVID-19 vaccine related myocarditis and its possible pathogenesis. This case and literature review notes a temporal association between COVID-19 vaccination and myocarditis. Despite these observations, the benefits of the vaccines far outweigh the risks of possible myocarditis.

Comorbidities and Symptomatology of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)-Related Myocarditis and SARS-CoV-2 Vaccine-Related Myocarditis: A Review

Myocarditis is an inflammatory disease of the heart muscle, with manifestations that include myocardial infarction, arrhythmia, and even sudden death. The primary etiology of myocarditis is a viral infection, with studies demonstrating that infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to myocarditis. This enzyme is involved in many body tissues, including the gastrointestinal system and the cardiac system. This enzyme is responsible for converting angiotensin I to angiotensin II in the renin-angiotensin system of our body. This review aims to characterize the symptomatology and comorbidities of males, females, and pediatric patients who developed the SARS-CoV-2-related myocarditis (SARS-CoV-2RM) or the SARS-CoV-2 vaccine-related myocarditis (SARS-CoV-2VRM). From July 10 to July 20, 2021, a PubMed database search for “SARS CoV-2 Related Myocarditis” was conducted. From July 21 to July 30, 2021, the search for “SARS CoV-2 Vaccine Related Myocarditis” was conducted. The search completed was specific for title/abstract fields using keywords “Covid-19” AND “Myocarditis” AND “Vaccine” and specifying “Males” or “Females”, respectively. Inclusion criteria included articles discussing comorbidities and symptomatology. Exclusion criteria included autopsy/postmortem reports, letters to the editor, retrospective studies, and observational studies. In the end, 49 articles were found and included in this review. We found that 27 of 40 pediatric patients with SARS-CoV-2RM presented with gastrointestinal symptoms, and 12 of 40 pediatric patients had no comorbidities. In female cases, eight of 12 patients with SARS-CoV-2RM presented with noncardiac symptoms, and only four of 12 had comorbidities such as asthma, diabetes, and obesity. In male patients with SARS-CoV-2RM, 10 of 12 presented with respiratory and/or cardiac symptoms, and seven of 12 had cardiac and/or diabetic comorbidities. Furthermore, 22 of 31 male patients with SARS-CoV-2VRM presented with chest pain with no previous comorbidities; four of six females with SARS-CoV-2VRM presented with chest pain, and three of six females had no comorbidities; and seven of 11 pediatric patients with SARS-CoV-2VRM had no comorbidities, but 11 of 11 pediatric patients presented with chest pain. In conclusion, males, females, and pediatric patients with previous SARS-CoV-2VRM showed mostly chest pain with no comorbidities. Males presenting with SARS-CoV-2RM showed mostly respiratory and cardiac symptoms with cardiac and diabetic comorbidities. Females with SARS-CoV-2RM described various symptoms from flu-like, respiratory, to cardiac and had no previous comorbidities. The bulk of pediatric patients with SARS-CoV-2RM mainly presented with GI symptoms and no past comorbidities. More studies are needed to determine the clinical presentation and risk factors that lead to SARS-CoV-2RM and SARS-CoV-2VRM.

COVID-19 Vaccine-Related Myocarditis: A Descriptive Study of 40 Case Reports

After the surging rise in the Coronavirus disease 2019 (COVID-19) pandemic, the Food and Drug Administration (FDA) approved emergency approval of vaccinations to prevent life-threatening complications of COVID-19 infection. These vaccines are BNT162b2, mRNA-1273. Later, the FDA also approved JNJ-78436735. COVID-19 vaccination does not have major side effects, but there are some concerning adverse events reported right after vaccination. Myocarditis is one of them. Based on our analysis of 40 case reports, we are presenting the epidemiology and clinical picture of myocarditis related to the COVID-19 vaccine.

Based on our analysis, we found that the majority of cases were seen in males with 90% predominance, and these cases were seen in the age group of 29.13 years old (mean, SD of 14.39 years). In 65% of cases, patients took the BNT162b2 vaccine; 30% of cases were reported with the mRNA-1273 vaccine; and 5% of cases with JNJ-78436735. Of all the cases, 80% of them are reported after the second dose of the vaccine with either Moderna or Pfizer.

The characteristics of COVID-19 vaccine-related myocarditis were analyzed in this study. We identified several findings, ranging from age, gender, type of vaccination, presentation of symptoms, and diagnosis modality. This depicts the picture of COVID-19 vaccine-related myocarditis and what physicians should expect when dealing with the disease. Our analysis showed that more cases were reported after receiving the BNT162b2 vaccine compared to mRNA-1273 and JNJ-78436735 vaccines. Further research needs to be conducted to analyze the underlying cause of this association.

Myocarditis following mRNA Covid-19 vaccination: a pooled analysis

Background

Methods

Results

Conclusions

Recent COVID-19 vaccination has minimal effects on the physiological responses to graded exercise in physically active healthy people

Athletes are advised to receive the COVID-19 vaccination to protect themselves from SARS-CoV-2 infection during major competitions. Despite this, many athletes are reluctant to get the COVID-19 vaccine due to concerns that symptoms of vaccinosis may impair athletic performance. This study aimed to determine the effects of COVID-19 vaccination on the physiological responses to graded exercise. Healthy physically active participants completed a 20-min bout of graded cycling exercise at intensities corresponding to 50%, 60%, 70%, and 80% of the predetermined V̇O2max before and ∼21 days after receiving the COVID-19 vaccine (2-dose Pfizer mRNA or 1-dose Johnson & Johnson). Vaccination had no effect on a large number of physiological responses to exercise measured in blood (e.g., lactate, epinephrine, and cortisol) and by respiratory gas exchange (e.g., oxygen uptake, CO2 production, ventilation, respiratory exchange ratio, predicted V̇O2max, and ventilatory threshold) (P > 0.05). We did, however, find significant elevations in heart rate (∼5 beats/min) and norepinephrine (P = 0.006 and 0.04, respectively) in response to vigorous (i.e., 70%-80% V̇O2max) intensity exercise after vaccination, particularly in those who received the two-shot Pfizer mRNA vaccine regimen. These findings held true when compared with demographically matched controls who completed identical bouts of exercise several weeks apart without receiving a vaccine; delta values for heart rate (P = 0.03) and norepinephrine (P = 0.01) were elevated in the second trial for those who received the Pfizer mRNA vaccine compared with the controls at the 70% and 80% V̇O2max stages, respectively. Recent COVID-19 vaccination has minimal effects on the physiological responses to graded exercise in physically active healthy people. The small elevations in cardiovascular and neuroendocrine responses to exercise after the Pfizer mRNA vaccine regimen could have implications for athletes at the elite level and warrants investigation.NEW & NOTEWORTHY Recent COVID-19 vaccination does not affect a large number of physiological responses to graded exercise, indicating that vaccination is unlikely to impair exercise capacity in normal healthy people. Heart rate and norepinephrine levels were elevated in response to exercise after the two-dose Pfizer mRNA vaccination compared to controls. Small elevations in cardiovascular and neuroendocrine responses to exercise after recent COVID-19 vaccination could have implications for exercise performance in elite athletes and warrants investigation.

Unraveling the Mystery of COVID-19 Postvaccination Myocarditis: A Systematic Review of Current Cases

From the early stages of the pandemic, the development and mass production of a safe and effective vaccine seemed like the greatest tool, to win the fight against the virus. In the present study, we comprehensively conducted a systematic review of all current cases worldwide to better understand whether there is a link between COVID-19 vaccination and one of the most devastating complications, cardiac Inflammation. Our search retrieved over 250 results, of which 130 met the inclusion criteria, and their respective data were extracted. The results suggest that postvaccination myocarditis and pericarditis are more likely to be seen in male, younger, and mRNA-vaccinated individuals. Most affected patients experienced symptoms following the second shot, and complaint of chest pain was the most prevalent presentation. Currently, no direct link can be drawn between the vaccines and the risk of cardiac inflammation.

Current view on novel vaccine technologies to combat human infectious diseases

Inactivated and live attenuated vaccines have improved human life and significantly reduced morbidity and mortality of several human infectious diseases. However, these vaccines have faults, such as reactivity or suboptimal efficacy and expensive and time-consuming development and production. Additionally, despite the enormous efforts to develop vaccines against some infectious diseases, the traditional technologies have not been successful in achieving this. At the same time, the concerns about emerging and re-emerging diseases urge the need to develop technologies that can be rapidly applied to combat the new challenges. Within the last two decades, the research of vaccine technologies has taken several directions to achieve safe, efficient, and economic platforms or technologies for novel vaccines. This review will give a brief overview of the current state of the novel vaccine technologies, new vaccine candidates in clinical trial phases 1-3 (listed by European Medicines Agency (EMA) and Food and Drug Administration (FDA)), and vaccines based on the novel technologies which have already been commercially available (approved by EMA and FDA) with the special reference to pandemic COVID-19 vaccines. KEY POINTS: • Vaccines of the new generation follow the minimalist strategy. • Some infectious diseases remain a challenge for the vaccine development. • The number of new vaccine candidates in the late phase clinical trials remains low.

Cardiac complications following mRNA COVID-19 vaccines: A systematic review of case reports and case series

There have been several local and systemic adverse events associated with mRNA COVID-19 vaccines. Pericarditis, myocarditis and myocardial infarction are examples of cardiac complications related to these vaccines. In this article, we conducted a systematic review of case reports and case series to identify the clinical profile, investigations, and management of reported cardiac complications post-mRNA COVID-19 vaccines. We systematically searched PubMed, Scopus, Web of Science, and Google Scholar, as well as the medRxiv preprint server, with terms including: 'SARS-CoV-2', 'COVID-19', 'messenger RNA vaccine*', 'mRNA-1273 vaccine', 'BNT162 vaccine', 'myocarditis', 'pericarditis', 'stroke' and 'Myocardial Ischemia' up to 25 September 2021. Studies were excluded if they were not case reports or case series, or reported cases from non-mRNA vaccines. Case reports and case series were included that investigated the potential cardiac complications associated with mRNA COVID-19 vaccines. The JBI checklist was used to assess quality and data synthesis was conducted using a qualitative methodology called narrative synthesis. Sixty-nine studies, including 43 case reports and 26 case series, were included. Myocarditis/myopericarditis and pericarditis were the most common adverse events among the 243 reported cardiac complications, post mRNA COVID-19 vaccination. Males with a median age of 21 years had the highest frequency of myocarditis. Almost three quarters (74.4%) of cases with myocarditis had received the BNT162b2 vaccine and 87.7% had received the second dose of the vaccine. Chest pain (96.1%) and fever (38.2%) were the most common presentations. CK-MB, troponin, and NT-proBNP were elevated in 100%, 99.5% and 78.3% of subjects, respectively. ST-segment abnormality was the most common electrocardiogram feature. Cardiac magnetic resonance imaging, which is the gold-standard approach for diagnosing myocarditis, was abnormal in all patients diagnosed with myocarditis. Non-steroidal anti-inflammatory drugs were the most prescribed medication for the management of myocarditis. Apart from inflammatory conditions, some rare cases of Takotsubo cardiomyopathy, myocardial infarction, myocardial infarction with non-obstructive coronary arteries, and isolated tachycardia were also reported following immunisation with mRNA COVID-19 vaccines. We acknowledge that only reviewing case reports and case series studies is one potential limitation of our study. We found that myocarditis was the most commonly reported adverse cardiac event associated with mRNA COVID-19 vaccines, which presented as chest pain with a rise in cardiac biomarkers. Further large-scale observational studies are recommended.

Clinical Presentation and Outcomes of Myocarditis Post mRNA Vaccination: A Meta-Analysis and Systematic Review

BACKGROUND

Myocarditis is being increasingly reported as a potential complication of both Pfizer-BioNTech and Moderna vaccines for COVID-19. One thousand five hundred and twenty-two cases were reported as of September 02, 2021, as per CDC's (Centers for Disease Control) vaccine adverse event reporting system. Most of the published data is available in the form of case reports and series. There is a need to compile the demographic data, clinical features, and outcomes in these patients.  Methods: A systematic search was conducted in PubMed, Embase, Web of science, and google scholar for published literature between January 01, 2020, and July 17, 2021. Individual data of 69 patients were pooled from 25 qualifying case reports and case series.

RESULTS

The median age of onset was 21 years. 92.7% of the patients were male. 76.8% of patients received the Pfizer-BioNTech vaccine, and 23.2% received the Moderna vaccine. 88.5% developed symptoms after the second dose. Patients were admitted to the hospital a median of three days post-vaccination. All the patients had chest pain and elevated troponin. The myocarditis was confirmed on cardiac MRI in 87% of the patients. Most of the patients had late gadolinium enhancement on MRI. The median length of stay was four days. All the reported patients recovered and were discharged.

CONCLUSION

Post-mRNA vaccination myocarditis is seen predominantly in young males within a few days after their second dose of vaccination. The pathophysiology of myocarditis is not well known. The prognosis is good as all the reported patients recovered. The presence of late gadolinium enhancement on cardiac MRI indicated myocardial necrosis/fibrosis and further studies are needed to establish the long-term prognosis of the condition.

A Case Report for Myopericarditis after BNT162b2 COVID-19 mRNA Vaccination in a Korean Young Male

Mass vaccination with the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine (BNT162b2) in Korea has resulted in many reported adverse effects. These side effects are the object of much scrutiny in the medical community. We report the case of a 29-year-old male who was diagnosed with myopericarditis after his second dose of Pfizer-BioNTech COVID-19 vaccine. This patient is the second recognized case of Pfizer-BioNTech COVID-19 vaccine induced myopericarditis in Korea and the first to have recovered from it. He originally presented with chest discomfort and exertional chest pain. Lab tests revealed elevated cardiac marker levels and echocardiographic findings displayed minimal pericardial effusion, prompting diagnosis as myopericarditis. We decided on two weeks of outpatient treatment with non-steroidal anti-inflammatory drugs (NSAIDs) due to the patient's mild symptoms and his occupation in the military. When this proved insufficient, we shifted to combination therapy with low dose corticosteroids and NSAIDs. After two weeks of treatment, the patient's symptoms and pericardial effusion had improved, and he was recovered completely 37 days after the onset.

Familial hypercholesterolemia and COVID-19: A menacing but treatable vasculopathic condition

SARS-CoV-2 infection continues to cause increased morbidity and mortality, and due to the slow pace of vaccination COVID-19 will probably remain a global burden to health systems for a long time. Unfortunately, the necessary prevention and treatment strategies of COVID-19 have led to restriction measures that are hampering the routine care of common chronic metabolic conditions like hypercholesterolemia. It is of particular concern that during the acute phase of COVID-19, the control of pre-existing metabolic diseases tends to get worse which again increases the risk for complications and a poor outcome in these patients. A significant contributor to these complications is endothelial dysfunction which is associated with COVID-19. This Commentary will discuss the impact of COVID-19 on endothelial function particularly in patients with familial hypercholesterolemia (FH), a metabolic inherited disease known to in itself adversely affect endothelial function. There should be no hesitation to continue with statin therapy in severe hypercholesterolemic patients with COVID-19. We argue that in FH patients with COVID-19 the clinicians need even consider intensifying statin therapy as well as the addition of other lipid-lowering agents, such as proprotein convertase subtilisin/kexin type 9(PCSK9) inhibitors. In contrast to statins, the PCSK9 inhibitors lower lipoprotein(a) [Lp(a)] level, and, accordingly, these latter drugs need to be considered particularly in FH patients with an elevated level of Lp(a). This call applies to the in-hospital stay and also beyond. When considering that the vasculopathic effects of COVID-19 may persist, a long-term follow-up of individualized therapies in FH patients is warranted.