Age: 39.0
Sex: M
Vaccine: COVID19
Symptoms: Angiogram, Antinuclear antibody, Blood pressure measurement, Body temperature, Brain natriuretic peptide
Clinical narrative: Myocarditis-like illness; This literature-study case was reported in a literature article and describes the occurrence of MYOCARDITIS (Myocarditis-like illness) in a 39-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination.   LITERATURE REFERENCE: Myocarditis temporally associated with COVID-19 vaccination. Circulation. 2021;144(6):502-5     No Medical History information was reported.   On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date,  after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced MYOCARDITIS (Myocarditis-like illness) (seriousness criteria hospitalization and medically significant). The patient was hospitalized for 3 days due to MYOCARDITIS. At the time of the report, MYOCARDITIS (Myocarditis-like illness) had resolved.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Angiogram: normal (normal) No obstructive coronary artery disease; proximal circumflex; mild 30% stenosis. On an unknown date, Antinuclear antibody: negative (Negative) Negative. On an unknown date, Blood pressure measurement: 103/70 mm hg at the time of presentation. On an unknown date, Body temperature: 36.9 °c (normal) at the time of presentation. On an unknown date, Brain natriuretic peptide: 97 pg/ml 97 pg/mL. On an unknown date, C-reactive protein: 11.70 mg/dl (High) 11.70 mg/dL (peak). On an unknown date, Chest X-ray: normal (normal) No detectable active cardiopulmonary disease. On an unknown date, Echocardiogram: 1.0 cm, none, normal (normal) Intraventricular septal diastolic thickness (2D): 1.0 cm.  Regional wall motion abnormalities: None  Diastolic function: Normal (4 days postvaccine). On an unknown date, Ejection fraction: 52% 52%, no regional wall motion abnormalities (5 days postvaccine) and 61% 61% (4 days postvaccine). On an unknown date, Electrocardiogram: normal (normal) No acute ST segment changes and normal sinus rhythm. On an unknown date, Heart rate: 79 bpm at the time of presentation. On an unknown date, Magnetic resonance imaging heart: abnormal (abnormal) Suboptimal T2 WI secondary to banding artifact and respiratory motion (5 days postvaccine) and abnormal (abnormal) Multifocal subepicardial and midmyocardial LGE; prominence of the pericardium overlying the anterior wall with enhancement (5 days postvaccine). On an unknown date, Red blood cell sedimentation rate: 23 mm/h (High) 23 mm/h (peak). On an unknown date, Respiratory rate: 16 per min at the time of presentation. On an unknown date, Respiratory viral panel: negative (Negative) Negative except mycoplasma IgG; Coxsackie B1, B2, B3 (IgG 1:8) and B4, B5, B6 (IgG 1:16)  Respiratory viral panel was performed using the FilmArray BioFire Respiratory Panel 2.1 and contains qualitative detection of respiratory pathogen nucleic acid for the following viruses: adenovirus, coronavirus 229E, coronavirus HKU1, coronavirus NL63, coronavirus OC43, SARS-CoV-2, human metapneumovirus, human rhinovirus/enterovirus, influenza A, influenza A/H1, influenza AH1 2009, influenza A/H3, influenza B, parainfluenza virus 1, parainfluenza virus 2, parainfluenza virus 3, parainfluenza virus 4, respiratory syncytial virus, Bordetella pertussis, Bordetella parapertussis, Chlamydophila pneumoniae, and Mycoplasma pneumoniae.. On an unknown date, SARS-CoV-2 antibody test: positive (Positive) Positive (performed using LIAISON SARS-CoV-2 S1/S2 IgG assay). On an unknown date, SARS-CoV-2 test: negative (Negative) The patient denied history of previous COVID-19 infection.. On an unknown date, Troponin I: 3.41 ng/ml (High) 3.41 ng/mL (normal: <0.04 ng/mL)  at presentation, 13.00 ng/ml (High) 13.00 ng/mL (normal: <0.04 ng/mL)  peak value and 0.037 ng/ml (normal) 0.037 ng/mL (normal: <0.04 ng/mL)  postdischarge. On an unknown date, Ventricular internal diameter: 4.4 cm 4.4 cm (4 days postvaccine). On an unknown date, White blood cell count: 8.28 8.28 (5 days postvaccine).     For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter considered MYOCARDITIS (Myocarditis-like illness) to be possibly related.    Concomitant medications were not provided.  The symptoms at the time of presentation included fever, chills, shortness of breath, and chest heaviness/pain symptoms.  Days from administration to presentation was 4 days.  The patient was hemodynamically stable and did not have a pericardial friction rub or rash, no evidence of obstructive coronary artery disease.  Multifocal subepicardial late gadolinium enhancement was present. No palpitation was reported, and there was no evidence of sustained arrhythmias. No evidence of an active viral illness or autoimmune disease.  The patient was treated with Intravenous (IV) steroids for 3 days.; Sender's Comments: Based on the current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.