Discussion
COVID-19 vaccination efforts have been increasing resulting in many
receiving mRNA vaccines. The COVID-19 mRNA vaccine encodes for the spike
glycoprotein of the virus. The vaccine’s liquid suspension particles
allow for direct delivery of mRNA into host cells. Once intracellular,
the mRNA upregulates ribosomal activity to create the spike
glycoprotein.1 The spike glycoprotein is then
presented on the surface of the cell, this subsequently triggers the
immune system to produce antibodies specific to the spike
protein.1,2 COVID-19 vaccine side effects are
typically mild and may involve local injection site pain, myalgia, and
fatigue. Serious adverse effects are rare, but recent reports have
suggested that mRNA COVID-19 vaccines may cause myocarditis,
pericarditis, and myopericarditis. As of June 11th 2021, the Centers for
Disease Control (CDC) have identified 323 cases of myocarditis,
pericarditis, and myopericarditis in the United
States.3 CDC findings suggest that afflicted patients
are more likely to be male, younger with a median age of 19 years, and
experience symptoms within two days after
vaccination.3 The most common presenting symptoms
include chest pain (85%-95%), fever (65%) dyspnea (19%-49%), and
syncope (6%).4 The CDC also determined that patients
were more likely to be hospitalized, but clinical course was mild as
most patients recover fully .3,5 While no consensus
mechanism has been elucidated, vaccine component hypersensitivity,
inflammatory reaction, and inappropriate immune system activation have
been mentioned as potential causes.4 Perimyocarditis
diagnosis requires fulfillment of 2 out of 4 major criteria: pleuritic
chest pain, auscultation of pericardial rub, ECG changes, and effusion
on imaging.6 Additionally, patients must also have
elevated biomarkers suggestive of myocardial injury (troponin) and
reduced left ventricular function.4 Our patient
presented with pleuritic chest pain, characteristic ECG changes,
effusion on imaging, minor LV dysfunction, and biomarker elevation.
Imaging with Echo and CMR are useful for diagnosis and informing
clinical course. Echo can identify the presence of effusion as well as
be used for risk stratification in patients with cardiac
tamponade.7 Findings of pericarditis on CMR include
T1-weighted enhancement of the thickened pericardium, T2-weighted
increased pericardial intensity, and presence of pericardial edema on
delayed hyperenhancement (DHE).8 Notably, CMR findings
of DHE in patients who develop non-vaccine myocarditis is associated
with increased risk of cardiac complications.9Therefore, assessing the long term risk of complications in patients who
have DHE on CMR after vaccination is paramount.9 While
much is still unknown about management of perimyocarditis in patients
after COVID-19 vaccination, patients are treated using current
guidelines for pericarditis management (non-steroidal anti-inflammatory
drugs, colchicine, and/or steroids). Luckily, our patient was able to
achieve clinical improvement on this regimen alone. Biologics
(rilonacept) are indicated in patients who develop dependence on NSAIDs,
colchicine, and steroids.10To our knowledge, this is one of the first reports of perimyocarditis
after COVID-19 vaccination. Fortunately, these patients seem to
experience mild disease courses. However, further observational studies
are required to understand the side effects associated with COVID-19
vaccination.