Age: 86.0
Sex: M
Vaccine: FLUX
Symptoms: Pleural effusion, Pulmonary oedema, Troponin increased, White blood cell count increased
Clinical narrative: Acute Pericarditis; sudden onset retrosternal chest pain with radiation to his back/had a distinct postural element which was worse lying flat, but asymptomatic when semi-recumbent with some reproducibility on palpation of the right chest wall; trace pericardial effusion; pleural effusions; mild pulmonary edema; Initial information received on 23-Sep-2024 via Other Health Care Professional regarding an unsolicited valid serious case issued from a literature article:    This case involves a 86-year-old male patient who experienced acute pericarditis while receiving vaccine Influenza vaccine (Latency: unspecified).  The patient's past medical treatment(s), vaccination(s) and family history were not provided.  Patient with a history of hypertension, hyperlipidemia, type-2 diabetes, a remote history of Corona Virus Disease 2019 (COVID-19) infection.  On an unknown date, patient was recently immunized for influenza, received a dose of suspect Influenza vaccine produced by unknown manufacturer lot number not reported via unknown route in unknown administration site.   On an unknown date, patient presented to author emergency department (ED) with sudden onset retrosternal chest pain with radiation to his back (chest pain). Electrocardiogram (ECG or EKG) on arrival was notable for new ST-elevations in II, III, arteriovenous fistula (AVF). Initial troponin was 0.01 ng/ml. He was loaded with aspirin 324mg and was started on a heparin infusion. Given his risk factors, STEMI (ST-Segment Elevation Myocardial Infarction) alert was called, and the patient was transported for emergent coronary catheterization. Cardiology noted diffusely patent coronary vasculature. Following PCI, he was transferred to the ICU and his troponin increased to 0.06 ng/ml with a peak of 0.23 ng/ml. His chest pain changed in character and had a distinct postural element which was worse lying flat, but asymptomatic when semi-recumbent with some reproducibility on palpation of the right chest wall. His subsequent EKGs began to show diffuse ST elevations. Additionally, his labs were notable for C-reactive protein (CRP) of 234 mg/L, white blood cells (WBC) 11.9, creatinine 1.35 mg/dl. Computed tomography (CT) chest/abdomen/pelvis with contrast showed trace pericardial effusion (pericardial effusion), pleural effusions (pleural effusion), and mild pulmonary edema (pulmonary oedema). He underwent transthoracic echocardiography which showed Left ventricular ejection fraction (LVEF) 60-65% with no wall abnormality. He was treated with colchicine and prednisone. Over the following days his symptoms completely resolved, and he was discharged home after 2-days in hospital.   Author stated that: Acute pericarditis (pericarditis) can be difficult to differentiate from acute myocardial infarction (MI) due to overlapping similarities in clinical presentation. Acute pericarditis is typically characterized by pleuritic, positional radiating chest pain, with diffuse ST segment elevations and PR depressions in most EKG leads. Typical findings an acute MI include substernal pressure radiating to the left jaw, neck, and arm region with the possibility of ST elevations, T wave inversions, and troponin elevations. Treatment for an acute MI is typically percutaneous coronary intervention (PCI), while pericarditis is typically treated with NSAIDs and colchicine. Due to overlapping similarities and atypical presentation, acute pericarditis can be mistaken, and even treated as acute MI. Differentiation between acute pericarditis and acute MI can be challenging in the emergent setting. The decision to provide reperfusion therapy to patients presenting with chest pain and ST-elevation can be difficult because of mimickers of MI causing ST- segment elevation. Some factors associated with a higher likelihood for urgent PCI include typical anginal symptoms, ST-segment elevation on ECG, history of previous PCI, elevated troponin, diaphoresis, and male sex; In one study, 16.8% of patients with a final diagnosis of acute pericarditis were referred for PCI. Treatment of pericarditis as an MI with anticoagulation or thrombolytics can be dangerous given potential for hemorrhagic transformation and tamponade. Ultimately it is a multifactorial decision balancing risks/benefits of false alarm with the consequence of delaying myocardial reperfusion. Causes for pericarditis in this case include COVID-19 pericarditis and post-vaccination pericarditis. Dini et al concluded attributed a high prevalence of acute pericarditis in patients with long covid-19 syndrome. Similarly, though rare, post-influenza vaccination pericarditis cannot be overlooked and may be underreported.   Seriousness criteria: medically significant and hospitalization for the event acute pericarditis. Action taken: not applicable for Influenza vaccine. Corrective treatment: aspirin, colchicine and prednisone for the event acute pericarditis. Outcome: Recovered / Resolved for the event acute pericarditis. Reporter's causality: Related; Sender's Comments: Sanofi company comment on dated 26-Sep-2024: This case involves a 86-year-old male patient who experienced acute pericarditis while receiving vaccine Influenza vaccine. Based on the limited information received the causal role of VACCINE cannot be excluded due to compatible temporal relationship of ADR to the VACCINE. Further information regarding concurrent condition during vaccination, previous vaccination, tolerance, allergic history, latency, excluding alternative etiologies for the reported event are needed to fully assess this case. Furthermore, the role of concurrent conditions COVID-19 infection cannot be excluded either and assessing the individual role of vaccine in isolation is not possible. Based upon the reported information, the role of vaccine cannot be assessed completely.