Case Presentation: 45 year old female with history of pulmonary embolism seven years ago not on anticoagulation presented with chest pain of 4 weeks. Chest pain was sharp, retrosternal, radiating to left upper extremity, neck & back. Chest pain was also positional, worse laying flat but improved on sitting up. It started 48-72 hours of receiving first dose of BNT162b2 (Pfizer–BioNTech) vaccine. Pain had been waxing and waning since then but worsened after the second dose of the same vaccine three weeks later. No reports of fevers, chills or symptoms of recent respiratory tract infections. Vitals were stable. CVS exam revealed normal S1, S2 with a friction rub & no JVD. Rest of the physical exam was normal. Initial EKG showed ST-segment elevation in the inferior leads as shown in the Image 1. Routine screening of SARS-CoV-2 was negative. Chest X-ray showed normal cardiomediastinal silhouette without infiltrates or effusion. Patient was initially diagnosed with ST-elevation Myocardial infarction (STEMI) of the inferior wall & underwent urgent coronary angiogram which revealed right dominant system but no evidence of thrombus, dissection or bridging. Troponin HS was less than 2.3 (N: 0-15 pg/ml). Serum myoglobin level was 14.4 (0-69ng/ml). CT angiography of chest was negative for pulmonary embolism. She was then diagnosed with acute pericarditis given the pleuritic and positional nature of the chest pain, pericardial rub despite the absence of typical diffuse ST-segment elevation. Further studies were supportive of the diagnosis of acute pericarditis with elevated inflammatory markers such as C-reactive protein (CRP) at 4.2mg /dl (N: < 1 mg/dl) & ESR at 43 mm/hr (N: <20 mm/hr). TTE revealed normal left ventricular function with no wall motion abnormalities, small pericardial effusion with thickened pericardium. Antinuclear antibody was negative and Thyroid Stimulating Hormone was normal 0.85 (N: 0.34-5.6 mIU/ml). Patient showed significant improvement of symptoms with high dose Ibuprofen at 800 mg three times a day along with colchicine 0.6 mg twice daily.

Discussion: COVID-19 vaccines are generally well-tolerated. However, some of rare side effects such as cerebral sinus venous thrombosis (Vaccine-induced thrombocytopenia with thrombosis), Guillain-Barré syndrome, capillary leak syndrome, pericarditis & myocarditis are also reported [1-4]. Most cases of pericarditis & myocarditis occured in male adolescents, typically within several days of COVID-19 vaccination & more commonly after the second dose. [1a] Molecular mimicry and an aberrant activation of immune system leading to its dysregulation are implicated in the pathogenesis of immune medicated diseases post mRNA vaccination. [5a] The index patient lacked typical EKG changes for pericarditis such as diffuse ST segment elevation or PR segment depression but focal ST-elevations in inferior leads leading to false initial impression of STEMI. The findings of pericardial rub, elevated inflammatory markers in the setting of pleuritic chest pain that gets better sitting upright and thickened pericardium favors acute pericarditis. Although temporal association does not prove causation, but the short duration between vaccination and symptom onset suggests vaccine induced pericarditis.

Conclusions: It is important to note that the COVID-19 vaccines have been effective in reducing the hospitalizations & deaths. Rare side effects such as pericarditis, myocarditis can still occur but the benefits of vaccines continue to outweigh the risks associated.

IMAGE 1: Electrocardiogram (EKG) showing Sinus Rhythm with ST Elevations in the Inferior Leads