Sex: M
Vaccine: COVID19
Symptoms: Angiogram, Blood pressure measurement, C-reactive protein, Chest X-ray, Electrocardiogram
Clinical narrative: focal myocarditis/chest pain and exertional dyspnea; This is a literature report for the following literature source(s): "STEMI Mimic: Focal Myocarditis in an Adolescent Patient After mRNA COVID-19 Vaccine.",  A 17 year-old male patient received bnt162b2 (BNT162B2), administration date 2021 (Batch/Lot number: unknown) as dose 2, single for covid-19 immunisation. The patient's relevant medical history and concomitant medications were not reported. Vaccination history included: Covid-19 vaccine (first dose; manufacturer unknown), for covid-19 immunisation. The following information was reported: MYOCARDITIS (hospitalization, medically significant) with onset 2021, outcome "unknown", described as "focal myocarditis/chest pain and exertional dyspnea". The patient was hospitalized for myocarditis (hospitalization duration: 1 day(s)). The events "focal myocarditis/chest pain and exertional dyspnea"  were evaluated at the physician office visit and emergency room visit. In June of 2021, a thin, otherwise healthy 17-year-old male presented to the Emergency Department with 3 days of progressively worsening substernal chest pain and exertional dyspnea that began 1 day after his second BNT162b2 vaccination. He had no family history of premature coronary artery disease. Upon presentation, the patient's vitals were within normal limits; blood pressure 119/79 mm Hg, heart rate 90 beats/min, respiration rate 16 breaths/min, and pulse oximetry 97% on room air. His physical examination was benign, including lungs clear to auscultation, no murmurs/rubs/gallops on cardiac examination, and non-reproducible chest pain. The patient's chest x-ray study showed no acute cardiopulmonary abnormalities. The initial electrocardiogram (ECG) showed sub-1-mm lateral ST elevations with sub-1-mm depression in lead III. Bedside ultrasound showed a trace pericardial effusion without wall motion abnormalities. Initial troponin was elevated, at 0.08 ng/mL (normal [nl] < 0.03 ng/mL). Repeat ECG demonstrated 1-mm elevations in leads I and aVL, with reciprocal depression in lead III. At this time, Cardiology was consulted, and a code STEMI was called, given localizing ECG changes meeting STEMI criteria. The patient was given 324 mg of aspirin and sublingual nitroglycerin without improvement in the patient's chest pain. Intra- venous diltiazem was then administered for concerns of possible coronary vasospasm, without improvement in the patient's chest pain or normalization of the patient's ECG. Cardiology elected to obtain a coronary computed tomography angiogram (CCTA), as there was high suspicion for myocarditis and low suspicion for acute coronary syndrome given the patient's age and lack of risk factors. The CCTA showed normal coronary origins with a coronary artery calcium score of 0. Repeat troponin returned at 0.22 ng/mL. The patient was then admitted to the Cardiology service for suspected myocarditis. C-reactive protein was noted to be elevated at 1.9 mg/dL (nl </=0.5 mg/dL), whereas the erythrocyte sedimentation rate was normal at 14 mm/h (nl 0-20 mm/h). Trended troponins continued to rise, with a peak value of 0.39 ng/mL. Cardiac magnetic resonance imaging was performed and showed diffuse, subepicardial delayed gadolinium enhancement of the anterior and lateral wall of the left ventricle, with corresponding heterogeneous T1 signal prolongation and increased short tau inversion recovery signal consistent with a high-risk pattern for myocarditis; left ventricular ejection fraction was preserved at 55%. The patient was monitored on the Cardiology service for 1 day and was discharged after subsequent troponins down trended, with plans for close follow-up with the Cardiology Department. The patient followed up in the  Cardiology clinic 1 month after discharge and endorsed complete resolution of symptoms. No additional laboratory tests or imaging were completed at this time. He was placed on a 6-month activity restriction. Discussion: The mRNA COVID-19 vaccine contains nucleoside-modified messenger RNA that encodes immunogens derived from the spike glycoprotein (S) of SARS-CoV- 2. The body's immune response to these immunogens is believed to cause a suspected hypersensitivity myocarditis, although the mechanism is not yet known. Antibody-mediated responses to the spike proteins have also been theorized. New research suggests that elevated levels of anti-spike immunoglobulin G may be linked to more severe systemic infection. The patient underwent the following laboratory tests and procedures: angiogram: high suspicion for myocarditis, notes: low suspicion for acute coronary syndrome; normal coronary origins, notes: with a coronary artery calcium score of 0; blood pressure measurement: 119/79 mmHg; chest x-ray: no acute cardiopulmonary abnormalities; c-reactive protein (normal high range 0.5): 1.9 mg/dl, notes: elevated; electrocardiogram: sub-1-mm lateral st elevations, notes: with sub-1-mm depression in lead III; reciprocal depression in lead iii, notes: 1-mm elevations in leads I and aVL; heart rate: 90, notes: Beats/min; magnetic resonance imaging: diffuse, notes: subepicardial delayed gadolinium enhancement of the anterior and lateral wall of the left ventricle, with corresponding heterogeneous T1 signal prolongation and increased short tau inversion recovery signal consistent with a high-risk pattern for myocarditis; left ventricular ejection fraction was preserved at 55%; oxygen saturation: 97 %, notes: on room air; physical examination: benign, notes: including lungs clear to auscultation, no murmurs/rubs/gallops on cardiac examination, and non-reproducible chest pain; red blood cell sedimentation rate (0-20): normal at 14, notes: mm/h; respiratory rate: 16, notes: breaths/min; troponin (normal high range 0.03): 0.08 ng/ml, notes: elevated; troponin: 0.39 ng/ml, notes: continued to rise, with a peak value of 0.39 ng/mL; down trended; 0.22 ng/ml; ultrasound scan: trace pericardial effusion, notes: without wall motion abnormalities; vital signs measurement: within normal limits. Therapeutic measures were taken as a result of myocarditis.   No follow-up attempts are possible; information about lot/batch number cannot be obtained. No further information is expected.; Sender's Comments: Based on the current information available and considering drug-event temporal association a possible contributory role of the suspect BNT162B2 for the reported event of Myocarditis cannot be completely excluded. The case will be reassessed further upon receipt of additional information. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to RAs, Ethics Committees, and Investigators, as appropriate.