Presentation
A 22-year-old male with past medical history of Coxsackie myocarditis in
2019 presented to the emergency department with acute chest pressure and
diaphoresis. He described his chest pain as squeezing with radiation to
the back. The patient denied dyspnea, edema, and lightheadedness.
Physical examination and vital signs were within normal limits.
Cardiovascular exam showed regular rate, normal rhythm, S1, S2 sounds,
and no pericardial rub. He was taking no medications and had received
his second dose of the Pfizer (BNT162b2) mRNA Coronavirus-19 disease
(COVID-19) vaccine 3 days prior to symptoms onset. Laboratory
examination showed high sensitivity C-reactive protein (hs-CRP) (3.15
mg/L), troponin (126 ng/mL) and brain natriuretic peptide (105 pg/mL)
levels were all elevated. Severe acute respiratory
syndrome-Coronavirus-2 (SARS-CoV-2) IgG test was positive indicative of
prior infection with COVID-19. Electrocardiogram (ECG) showed diffuse
ST-segment elevation suggestive of pericarditis. CXR was negative.
Bedside echocardiography (Echo) demonstrated mildly reduced ejection
fraction (EF) (45%). Cardiac magnetic resonance imaging (CMR)
identified a small pericardial effusion, and profound basal
inferolateral and lateral myocardial involvement (Figure 1A).Given his clinical and imaging findings, he was diagnosed with
perimyocarditis secondary to COVID-19 vaccination. He was prescribed
Aspirin 650 mg TID, colchicine 0.6 mg BID, and 1 month prednisone taper
(30 mg). At 6 week follow-up, the patient noted his pain was
significantly improved. The patient had completed his steroid taper and
discontinued aspirin therapy due to gastrointestinal distress.
Laboratory markers and ECG were normal. Echo showed EF recovery(Video 1). Repeat CMR demonstrated interval improvement in
pericardial effusion and delayed enhancement (Figure 1B) . His
colchicine was tapered to 0.6 mg daily and he was told to follow up in 4
months.