Case Presentation: A 28-year-old male patient presented to the hospital with central, non-radiating, moderate-intensity chest pain that started four days after his second dose of Pfizer-BioNTech COVID-19 vaccine. The patient had neither any prior history of SARS-COV2 infection nor known exposure to a symptomatic patient. He denied any fever, chills, diaphoresis, upper or lower respiratory tract infection symptoms, nausea, vomiting, diarrhea, arthralgia, myalgia, or skin rash. The patient had no history of tobacco, alcohol or drug abuse, recent vaccinations other than for COVID-19, insect bites, foreign travel outside the United States or exposure to any medications. Initial vitals were within normal limits. Physical exam was unremarkable. EKG showed normal sinus rhythm and nonspecific ST-T changes. Chest X-ray showed no acute pathology. Initial labs showed elevated Troponin I (9.944 ng/ml) and inflammatory markers like C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Creatinine Phosphokinase (CPK), Lactate Dehydrogenase (LDH) (Table 1). Troponin I peaked at 11.8 ng/ml, 6 hours after initial presentation and then trended down. Echocardiogram showed normal ejection fraction of 60% and no regional wall motion abnormalities. SARS-COV 2 reverse transcriptase polymerase chain reaction (RT-PCR) was negative for an active infection. The patient had no personal history, family history or risk factors for premature coronary artery disease. He did not have any viral prodrome that would suggest other viral etiologies for myocarditis. Our patient’s presentation is similar to previously reported cases of myocarditis post mRNA vaccination against COVID-19. We made the diagnosis of post-COVID-19 vaccine myocarditis in our patient based on medical history, laboratory data, temporal association with vaccination, and available medical literature. Chest pain resolved after administration of one dose of 600 mg of ibuprofen. The patient was monitored in the hospital overnight. The patient did not have any other symptoms. Telemetry did not show any arrhythmias. The patient was discharged home the next day.
Discussion: According to CDC vaccine adverse effects reporting system (VAERS), as of October 18th, 2021, 1990 cases of myocarditis have been reported post-vaccination for COVID-19[1]. Myocarditis has been reported in the past following vaccination for smallpox and influenza as well[1]. Post-vaccination myocarditis is predominantly seen in young males[2]. The pathophysiology is indeterminate but is postulated to be secondary to hypersensitivity myocarditis as the incidence is predominantly seen after the second dose and young individuals[2]. Endomyocardial biopsies in two patients have shown myocardial infiltration with macrophages, T-cells, eosinophils, B-cells, and plasma cells[3]. Typical changes of myocarditis can be seen on cardiac MRI[4]. Evidence suggests that the condition has a good prognosis[2]. Clinicians need to be vigilant about the condition and monitor adolescents and young adults who present with chest pain following the COVID-19 vaccination. Extensive and expensive investigations may not be necessary for these patients as the condition has a good prognosis.
Conclusions: Post-vaccination myocarditis is predominantly seen in young males. Most cases present with chest pain, elevated troponin, and inflammatory markers. The condition carries a good prognosis and expensive investigations may not be necessary for diagnosis.
