Partially Resolving Myocardial Fibrosis Five Months Following the mRNA COVID-19 Vaccine: An MRI Based Case Report
Keywords:
Cardiac magnetic resonance imaging, CMR, Fibrosis, Covid Vaccine, MyocarditisAbstract
Introduction: Myocarditis is a disease that has varying severity and its diagnosis or management can pose as a challenge to
clinicians. With over 250 million people receiving the mRNA covid vaccine, there have been rare reports of myocarditis or
other cardiovascular involvement.Case: We report a 30-year-old healthy male who was hospitalized for chest pain 3 days after receiving the second dose of the covid-19 vaccination. He had high cardiac laboratory markers (cardiac troponin I peak of 22 ng/mL, normal <0.03 ng/mL) with dynamic ST segment elevations in the inferior and lateral leads. He had a subsequent coronary angiogram and echocardiogram that were normal with elevated inflammatory markers and hence, was diagnosed with myocarditis. He had a cardiac
magnetic resonance (CMR) study approximately 8 weeks later (from the date of his second covid vaccine dose) that showed
prominent mid to epicardial lateral wall fibrosis corresponding to similar ECG territory with normal T1 and T2 mapping. A
repeat CMR was performed 5 months later (from the second vaccine dose) that showed persistent, though partially resolving
fibrosis, despite the full resolution of all symptoms and biomarkers.Conclusion: This case demonstrates acute myocarditis following the second dose of the mRNA covid-19 vaccination with evidence of persistent fibrosis on CMR 2 months later and on follow-up CMR scan 5 months from administration of the second dose of the vaccine. Furthermore, it demonstrates correlation of scar territory on CMR with initial ECG changes and lingering natural course and an insidious recovery as well as the utility of CMR in clinical management.
References
Olimulder, MA., van Es, J., Galjee, MA. (2009) The importance of cardiac MRI as a diagnostic tool in viral myocarditis-induced cardiomyopathy. Neth Heart J, 17(12): 481- 486.
Montgomery, J., Ryan, M., Engler, R., Hoffman, D., McClenathan, B., Collins, L., et al. Myocarditis Following Immunization with mRNA COVID-19 Vaccines in Members of the US Military. JAMA Cardiol, 6(10): 1202-1206.
Wise, J. (2021) Covid-19: Should we be worried about reports of myocarditis and pericarditis after mRNA vaccines? BMJ, 373: n1635.
Tschöpe, C., Ammirati, E., Bozkurt, B., Caforio, AL., Cooper, LT., Felix, LT., et al. (2021) Myocarditis and inflammatory cardiomyopathy: current evidence and future directions. Nat Rev Cardiol, 18(3): 169-193.
Caforio, AL., Mahon, NJ., Tona, F., McKenna, WJ. (2002) Circulating cardiac autoantibodies in dilated cardiomyopathy and myocarditis: pathogenetic and clinical significance. Eur J Heart Fail, 4(4): 411-417.
Myocarditis and Pericarditis Following mRNA COVID-19 Vaccination | CDC
Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination | JAMA Cardiology | JAMA Network
Oster, ME., Shay, DK., Su, JR., Gee, J., Creech, CB., Broder, KR., et al. (2022) Myocarditis Cases Reported After mR- NA-Based COVID-19 Vaccination in the US From December 2020 to August 2021. JAMA, 327(4): 331–340.
Mahrholdt, H., Goedecke, C., Wagner, A., Meinhardt, G., Athanasiadis, A., Vogelsberg, H., et al. (2004) Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation, 109(10):1250-1258.
Shay, DK., Shimabukuro, TT., DeStefano, F. (2021) Myocarditis Occurring After Immunization with mRNA-Based COVID-19 Vaccines. JAMA Cardiol, 6(10): 1115-1117.
Amsterdam, E., Wenger, N., Brindis, R., Casey Jr, DE., Ganiats, GT., Holmes, DR., et al. (2014) 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am CollCardiol, 64(24): e139–e228.
Kim, HW., Jenista, ER., Wendell, DC., Azevedo, CF., Campbell, MJ., Darty, SN., et al. (2021) Patients with Acute Myocarditis Following mRNA COVID-19 Vaccination. JAMA Cardiol, 6(10): 1196-1201.
Abu Mouch, S., Roguin, A., Hellou, E., Ishai, A., Shoshan, U., Mahamid, L., et al. (2021) Myocarditis following COVID-19 mRNA vaccination. Vaccine, 39(29): 3790-3793.
Hazebroek, MR., Everaerts, K., Heymans, S. (2014) Diagnostic approach of myocarditis: strike the golden mean. Neth Heart J, 22(2): 80-84.
Richardson, P., McKenna, W., Bristow, M., Maisch, B., Mautner, B., O'Connell, J., et al. (1996) Report of the 1995 world health organization/international society and federation of cardiology task force on the definition and classification of cardiomyopathies. Circulation, 93(5): 841–842.
Kindermann, I., Barth, C., Mahfoud, F., Ukena, C., Lenski, M., Yilmaz, A., et al. (2012) Update on myocarditis. J Am Coll Cardiol, 59(9): 779-792.
Baughman, KL. (2006) Diagnosis of myocarditis: death of Dallas criteria. Circulation, 113(4): 593-595.
Pan, JA., Lee, YJ., Salerno, M. (2018) Diagnostic Performance of Extracellular Volume, Native T1, and T2 Mapping Versus Lake Louise Criteria by Cardiac Magnetic Resonance for Detection of Acute Myocarditis: A Meta-Analysis. Circ Cardiovasc Imaging, 11(7): e007598.
Friedrich, MG., Sechtem, U., Schulz-Menger, J., Holmvang, G., Alakija, P., Cooper, LT., et al. (2009) International Consensus Group on Cardiovascular Magnetic Resonance in Myocarditis. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol, 53(17): 1475-1487.
h-Ici, DO., Jeuthe, S., Al-Wakeel, N., Berger, F., Kuehne, T., Kozerke, S., et al. (2014) T1 mapping in ischaemic heart disease. European Heart Journal - Cardiovascular Imaging, 15(6): 597-602.
Kim, PK., Hong, YJ., Im, DJ., Suh, YJ., Park, CH., Kim, JY., et al. (2017) Myocardial T1 and T2 Mapping: Techniques and Clinical Applications. Korean J Radiol, 18(1): 113-131.
Messroghli, DR., Moon, JC., Ferreira, VM., Grosse-Wortmann, L., He, T., Kellman, P., et al. (2017) Clinical recommendations for cardiovascular magnetic resonance mapping of T1, T2, T2* and extracellular volume: A consensus statement by the Society for Cardiovascular Magnetic Resonance (SCMR) endorsed by the European Association for Cardiovascular Imaging (EACVI). J Cardiovasc Magn Reson, 19(1): 75.
Montant, P., Sigovan, M., Revel, D., Douek, P. (2015) MR imaging assessment of myocardial edema with T2 mapping. Diagn Interv Imaging, 96(9): 885-890.
Karamitsos , TD., Arvanitaki, A., Karvounis, H., Neubauer, S., Ferreira, VM. (2020) Myocardial Tissue Characterization and Fibrosis by Imaging. JACC Cardiovasc Imaging, 13(5): 1221-1234.
Yelgec, NS., Dymarkowski, S., Ganame, J., Bogaert, J. (2007) Value of MRI in patients with a clinical suspicion of acute myocarditis. Eur Radiol, 17(9): 2211-2217.
Law, YM., Lal, AK., Chen, S., Čiháková, D., Cooper, LT., Jr, Deshpande, S., et al. (2021) American Heart Association Pediatric Heart Failure and Transplantation Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young and Stroke Council. Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association. Circulation, 144(6): e123-e135.
Yelgec, NS., Dymarkowski, S., Ganame, J., Bogaert, J. (2007) Value of MRI in patients with a clinical suspicion of acute myocarditis. Eur Radiol, 17(9): 2211–2217.
