Age: 22.0
Sex: M
Vaccine: COVID19
Symptoms: Heart rate, International normalised ratio, Magnetic resonance imaging heart, Physical examination, Renal infarct
Clinical narrative: cardiogenic shock; renal infarct; cardiomyopathy; New-onset acute systolic heart failure with a left ventricular ejection fraction; This literature-non-study case was reported in a literature article and describes the occurrence of CARDIOMYOPATHY (cardiomyopathy), CARDIAC FAILURE (New-onset acute systolic heart failure with a left ventricular ejection fraction), CARDIOGENIC SHOCK (cardiogenic shock) and RENAL INFARCT (renal infarct) in a 22-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 prophylaxis.   The patient's past medical history included Diabetes mellitus (It was managed conservatively as an outpatient with no known complications.) in January 2020, COVID-19 and Left ventricular assist device insertion. Concurrent medical conditions included Morbid obesity.   On 19-May-2021, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 07-Oct-2021, received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. In November 2021, the patient experienced CARDIOMYOPATHY (cardiomyopathy) (seriousness criteria hospitalization and medically significant), CARDIAC FAILURE (New-onset acute systolic heart failure with a left ventricular ejection fraction) (seriousness criteria hospitalization and medically significant) and RENAL INFARCT (renal infarct) (seriousness criteria hospitalization and medically significant). On an unknown date, the patient experienced CARDIOGENIC SHOCK (cardiogenic shock) (seriousness criteria hospitalization and medically significant). The patient was hospitalized on sometime in November 2021 due to CARDIAC FAILURE, CARDIOMYOPATHY and RENAL INFARCT. The patient was treated with MILRINONE ongoing since an unknown date at an unspecified dose and frequency. At the time of the report, CARDIOMYOPATHY (cardiomyopathy), CARDIAC FAILURE (New-onset acute systolic heart failure with a left ventricular ejection fraction), CARDIOGENIC SHOCK (cardiogenic shock) and RENAL INFARCT (renal infarct) outcome was unknown.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): In November 2021, Angiocardiogram: Due to the concern for a low output state and for further evaluation of the cardiomyopathy, he underwent a coronary angiogram, his coronaries were without any significant atherosclerosis.. In November 2021, Blood creatinine: 1.56 mg/dl. In November 2021, Blood pressure measurement: 140/84 mmHg. In November 2021, Body mass index: 45.4 kilogram per square metre. In November 2021, Body temperature: 36.5 degree Celsius. In November 2021, Cardiac index: 1.48 litre per minute per square metre. In November 2021, Cardiac output: 3.11 litre per minute. In November 2021, Catheterisation cardiac: 33 mmHg Due to the concern for a low output state and for further evaluation of the cardiomyopathy, he underwent right heart catheterization showed a right atrial pressure., 70/52 mmHg Due to the concern for a low output state and for further evaluation of the cardiomyopathy, he underwent right heart catheterization showed pulmonary artery pressure. and 30 mmHg Due to the concern for a low output state and for further evaluation of the cardiomyopathy, he underwent right heart catheterization showed wedge pressure.. In November 2021, Computerised tomogram pelvis: The patient underwent computed tomography (CT) scan of the abdomen/pelvis, which demonstrated a new infarction of the left kidney.. In November 2021, Echocardiogram: To further evaluate for an embolic source and elevated troponin, a transthoracic echocardiogram was obtained, which showed new-onset acute systolic heart failure with a left ventricular ejection fraction (LVEF) of 10%. Parasternal long and four-chamber apical view demonstrating severely dilated left ventricle (LV), dilated left atrium (LA), right ventricular (RV) dysfunction, the right atrium (RA), and the aorta (AO).. In November 2021, Ejection fraction: 10 % left ventricular ejection fraction.. In November 2021, Heart rate: 116 beats per minute. In November 2021, International normalised ratio: 1.2. In November 2021, Physical examination: Patient examination demonstrated a regular rate and tachycardia, with clear lungs. His abdomen was soft and non-tender to palpation without guarding.. In November 2021, Respiratory rate: 18 breaths per minute. In November 2021, Troponin: 0.06 mg/dl. On an unknown date, Blood thyroid stimulating hormone: 0.72 mIU/L level. On an unknown date, Magnetic resonance imaging heart: Showed a severely dilated left ventricle (left ventricular end-diastolic volume index (LVEDVI): 195 mL/m2 ) with severely reduced function (quantitative LVEF: 13%). Small focal infarcts were noted in the lateral apical and mid-septal segments, which were likely embolic.  Four-chamber view demonstrated markedly dilated right and left ventricle. Four-chamber delayed enchantment imaging demonstrating multiple areas of fibrosis. Arrows showed embolic infarction.  No evidence of infiltration, inflammation, or other areas of infarction were noticed on cardiac MRI..     For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered CARDIOMYOPATHY (cardiomyopathy) to be related. No further causality assessments were provided for CARDIAC FAILURE (New-onset acute systolic heart failure with a left ventricular ejection fraction), CARDIOGENIC SHOCK (cardiogenic shock) and RENAL INFARCT (renal infarct).    No concomitant medication was reported. Patient was presented one month after the booster vaccine dose to the hospital complaining of left lower quadrant abdominal pain. It was reported that six months following the COVID-19 infection, he received the COVID-19 initial and booster vaccines. Patient's family history was unremarkable for cardiomyopathy or heart disease. He was transferred to a quaternary care referral center for further evaluation and treatment. He underwent a thorough evaluation for his cardiomyopathy. evaluation for infectious source, and metabolic workup, which were all unrevealing. Patient hospital course was complicated by decompensated heart failure and persistent cardiogenic shock initially requiring ionotropic support and ultimately mechanical support with placement of a right axillary Impella device. Despite 43 days of mechanical and ionotropic support, his cardiomyopathy was not improved and required placement of a durable mechanical support device (LVAD). The patient had left ventricular assist device implantation during hospitalization which showed in the cardiac ultrasound as four-chamber apical view and parasternal long view demonstrating severely dilated left ventricle function with LVAD in place extending from the left ventricle, dilated left atrium, right ventricular dysfunction, and the right atrium. Patient postoperative course was complicated by right ventricular dysfunction, which required milrinone, and he was discharged on milrinone. He was discharged to a rehabilitation center with follow-up in the clinic. It was reported that patient had COVID-19 infection first and was later vaccinated. Cardiomyopathy was likely a result of the inflammatory process associated with SARS-CoV-2 infection and the subsequent cytokine storm from the vaccination. Author concluded that patients who had COVID-19 infection and were later given the vaccines may develop irreversible cardiomyopathy, necessitating mechanical cardiovascular support.  CC: This is a literature non-study case concerning a 22-year-old male patient, with past medical history of morbid obesity, diabetes mellitus and previous COVID-19, who experienced the unexpected and serious (hospitalization and medically significant) AESI of cardiomyopathy, cardiac failure and cardiogenic shock, and the unexpected serious (hospitalization and medically significant) event of RENAL INFARCT. Six months following the infection, he obtained the mRNA-1273 vaccine initial and booster dose. A month after the booster vaccine dose he presented complaining of left lower quadrant abdominal pain. The examination on revealed a temperature of 36.5°C, pulse rate of 116 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 140/84 mmHg. His examination demonstrated a regular rate and tachycardia, with clear lungs. His abdomen was soft and non-tender to palpation without guarding. His blood work showed creatinine of 1.56 mg/dL, INR of 1.2, and troponin of 0.06 mg/dL. A computed tomography scan of the abdomen-pelvis, demonstrated a new infarction of the left kidney. To further evaluate for an embolic source and elevated troponin, a transthoracic echocardiogram was obtained, which showed new-onset acute systolic heart failure with a left ventricular ejection fraction of 10%. He underwent a coronary angiogram and right heart catheterization without any significant atherosclerosis; however, his right heart catheterization showed a right atrial pressure of 33 mmHg, pulmonary artery pressure of 70/52 mmHg, wedge pressure of 30 mmHg, cardiac output of 3.11 L/m, and cardiac index of 1.48 L/m/m2. He was ultimately transferred to a quaternary care referral center for further evaluation and treatment. He underwent a thorough evaluation for his cardiomyopathy, including thyroid-stimulating hormonal (0.72 mIU/L) level, evaluation for infectious source, and metabolic workup, which were all unrevealing. A cardiac magnetic resonance imaging showed a severely dilated left ventricle with severely reduced function and small focal infarcts were noted in the lateral apical and mid-septal segments, which were likely embolic. No evidence of infiltration, inflammation, or other areas of infarction were noticed on cardiac MRI. His hospital course was complicated by decompensated heart failure and persistent cardiogenic shock initially requiring ionotropic support and ultimately mechanical support with placement of a right axillary Impella device. Despite 43 days of mechanical and ionotropic support, his cardiomyopathy did not improve and required placement of a durable mechanical support device. His postoperative course was complicated by right ventricular dysfunction, which required milrinone, and he was discharged on milrinone. He was discharged to a rehabilitation center with follow-up in the clinic. The reporter assessed that cardiomyopathy was likely a result of the inflammatory process associated with SARSCoV-2 infection and the subsequent cytokine storm from the vaccination and it may be the cause of severe myocardial injury. Patient´s past medical history of morbid obesity, diabetes mellitus and previous COVID-19 could be confounders for cardiomyopathy and eventually cardiac failure and cardiogenic shock. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Sender's Comments: This is a literature non-study case concerning a 22-year-old male patient, with past medical history of morbid obesity, diabetes mellitus and previous COVID-19, who experienced the unexpected and serious (hospitalization and medically significant) AESI of cardiomyopathy, cardiac failure and cardiogenic shock, and the unexpected serious (hospitalization and medically significant) event of RENAL INFARCT. Six months following the infection, he obtained the mRNA-1273 vaccine initial and booster dose. A month after the booster vaccine dose he presented complaining of left lower quadrant abdominal pain. The examination on revealed a temperature of 36.5°C, pulse rate of 116 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 140/84 mmHg. His examination demonstrated a regular rate and tachycardia, with clear lungs. His abdomen was soft and non-tender to palpation without guarding. His blood work showed creatinine of 1.56 mg/dL, INR of 1.2, and troponin of 0.06 mg/dL. A computed tomography scan of the abdomen-pelvis, demonstrated a new infarction of the left kidney. To further evaluate for an embolic source and elevated troponin, a transthoracic echocardiogram was obtained, which showed new-onset acute systolic heart failure with a left ventricular ejection fraction of 10%. He underwent a coronary angiogram and right heart catheterization without any significant atherosclerosis; however, his right heart catheterization showed a right atrial pressure of 33 mmHg, pulmonary artery pressure of 70/52 mmHg, wedge pressure of 30 mmHg, cardiac output of 3.11 L/m, and cardiac index of 1.48 L/m/m2. He was ultimately transferred to a quaternary care referral center for further evaluation and treatment. He underwent a thorough evaluation for his cardiomyopathy, including thyroid-stimulating hormonal (0.72 mIU/L) level, evaluation for infectious source, and metabolic workup, which were all unrevealing. A cardiac magnetic resonance imaging showed a severely dilated left ventricle with severely reduced function and small focal infarcts were noted in the lateral apical and mid-septal segments, which were likely embolic. No evidence of infiltration, inflammation, or other areas of infarction were noticed on cardiac MRI. His hospital course was complicated by decompensated heart failure and persistent cardiogenic shock initially requiring ionotropic support and ultimately mechanical support with placement of a right axillary Impella device. Despite 43 days of mechanical and ionotropic support, his cardiomyopathy did not improve and required placement of a durable mechanical support device. His postoperative course was complicated by right ventricular dysfunction, which required milrinone, and he was discharged on milrinone. He was discharged to a rehabilitation center with follow-up in the clinic. The reporter assessed that cardiomyopathy was likely a result of the inflammatory process associated with SARSCoV-2 infection and the subsequent cytokine storm from the vaccination and it may be the cause of severe myocardial injury. Patient´s past medical history of morbid obesity, diabetes mellitus and previous COVID-19 could be confounders for cardiomyopathy and eventually cardiac failure and cardiogenic shock. The benefit-risk relationship of mRNA-1273 is not affected by this report.