Age: 18.0
Sex: M
Vaccine: COVID19
Symptoms: C-reactive protein, Chest X-ray, Ejection fraction, Electrocardiogram, Epistaxis
Clinical narrative: Myocarditis; Nose bleeding; This literature-non-study case was reported in a literature article and describes the occurrence of MYOCARDITIS (Myocarditis) in an 18-year-old male patient who received mRNA-1273 (Spikevax) for COVID-19 prophylaxis. The occurrence of additional non-serious events is detailed below.   The patient's past medical history included SARS-CoV-2 infection (Patient had two previous episodes of COVID-19 infections, eight months, and two months prior of the COVID-19 vaccine.).    On an unknown date, the patient received first dose of mRNA-1273 (Spikevax) (unknown route) 1 dosage form. On an unknown date, the patient experienced MYOCARDITIS (Myocarditis) (seriousness criteria hospitalization and medically significant) and EPISTAXIS (Nose bleeding). The patient was treated with PARACETAMOL (TYLENOL) at an unspecified dose and frequency. At the time of the report, MYOCARDITIS (Myocarditis) was resolving and EPISTAXIS (Nose bleeding) outcome was unknown.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Angiogram: (Negative) CT angiography (CTA) of the chest was negative for any acute changes.. On an unknown date, Blood creatine phosphokinase (39-308 U/L): 900 U/L. On an unknown date, Blood creatine phosphokinase MB (0.0-3.6 ng/mL): 73.3 ng/mL and 8.1. On an unknown date, Blood pressure measurement: 128/88 mmHg. On an unknown date, Body temperature: 98.2 Degrees Fahrenheit (°F).. On an unknown date, C-reactive protein (0-10 milligram per litre): 160 milligram per litre. On an unknown date, Chest X-ray: Negative. On an unknown date, Ejection fraction: The echocardiogram revealed an ejection fraction (EF) of 60-65%.. On an unknown date, Electrocardiogram: EKG showed normal sinus rhythm with ST-segment elevation in some lateral leads.. On an unknown date, Fibrin D dimer (0.00-0.40 microgram per millilitre): 0.70 microgram per millilitre. On an unknown date, Heart rate: 88 beats per minute. On an unknown date, Heart sounds: The precordium was quiet, first and second heart sounds were heard with no added sounds.. On an unknown date, Lipids: The lipid panel was performed, no abnormal results were noted.. On an unknown date, Magnetic resonance imaging heart: Cardiac MRI revealed patchy mural delayed myocardial enhancement with relative sparing of the endocardium within the septum, and inferior and lateral walls at the cardiac base. Cardiac MRI was suggested of myocarditis. On an unknown date, Myocardial necrosis marker: Cardiac enzymes were noted to be elevated. On an unknown date, Oxygen saturation: 98 % on room air.. On an unknown date, Physical examination: On examination, the patient appeared to be an obese male in acute painful distress.. On an unknown date, Respiratory rate: 18 cycles per minute. On an unknown date, Right ventricular systolic pressure: The echocardiogram revealed, right ventricular systolic pressure (RVSP) of 30-35 mmHg.. On an unknown date, SARS-CoV-2 test: (Negative) On admission. On an unknown date, Troponin (0.00-0.01 ng/mL): 1.39 ng/mL. On an unknown date, White blood cell count (5.0-10.0): 11.0 K/ul.     The action taken with mRNA-1273 (Spikevax) (Unknown) was unknown.   For mRNA-1273 (Spikevax) (Unknown), the reporter considered MYOCARDITIS (Myocarditis) to be related. No further causality assessment was provided for EPISTAXIS (Nose bleeding).    No concomitant medication was reported. Patient was presented sudden onset of chest pain that had started about 8 hours after receiving the first dose of the Moderna vaccine. Patient had chest pain with fever, cough, and shortness of breath after the vaccine. He also had other symptoms such as fatigue, nausea, diarrhea, and nose bleeds, which may likely have been the other side effects of the vaccine. Reported that precordium was quiet. The patient was managed with steroids and Tylenol as needed for pain management. He was also placed on telemetry for rhythm monitoring. It was reported that cardiac enzymes were monitored over the course of the hospitalization and were seen to have plateaued. Therefore, with the resolution of symptoms and the decreasing need for analgesics, the patient was discharged. He was followed up 1 month later and was found to be stable. The patient had to visit the clinic in six months and subsequently every year, provided he continued to remain at baseline. Author stated that the susceptibility to developing these likely stems from the possible production of antibodies to the viral antigen from previous COVID-19 infections. Furthermore, patient developed symptoms eight hours after receiving the vaccine suggests a possible additive effect of antibodies produced from the two previous COVID-19 infections. This case report suggested that individuals repeatedly infected with COVID-19 may be at increased risk of myocarditis following the administration of the Moderna vaccine. Author concluded that COVID-19 vaccines can lead to myocarditis in rare cases. Although most cases occur after the second dose of vaccination, a high index of suspicion was needed when patients with previous COVID-19 infections present with symptoms suggestive of myocarditis, even after the first dose of vaccine. Also, the onset of myocarditis within 24 hours post first dose of vaccination should be anticipated in individuals with two or more previous COVID-19 infections.  Company comment:This is a literature non-study case concerning an 18-year-old male patient, with two previous episodes of COVID-19 infections, eight months and two months prior vaccination, who experienced the expected and serious (hospitalization and medically significant) AESI of myocarditis 8 hours after receiving the first dose of mRNA-1273 vaccine. He presented with a complaint of sudden onset of chest pain, rated it as a 7/10 in its worse form. He described it as being sharp, pressure-like, and squeezing, radiating to the back and worse with inhalation and coughing. The chest pain was associated with fever, cough, shortness of breath, fatigue, diarrhea, and vomiting. He reported a history of nose bleeding that had started about the same time and resolved without any intervention (non-serious). On examination, he appeared to be an obese male in acute painful distress with a temperature of 98.2°F, blood pressure of 128/88 mmHg, pulse rate of 88 beats per minute, respiratory rate of 18 cycles per minute, and oxygen saturation of 98% on room air. The precordium was quiet, and first and second heart sounds were heard with no added sounds. Cardiac enzymes were elevated: troponin of 1.39 ng/mL (0.00-0.01), total creatine kinase of 900 U/L (39-308), creatine kinase-MB of 73.3 ng/mL (0.0-3.6) and a creatine kinase-MB index of 8.1 (0.0-2.8). A lipid panel showed no abnormal results. The EKG showed normal sinus rhythm with ST-segment elevation in some lateral leads. White blood cell count, C-reactive protein, and D-dimer were elevated at 11.0 K/ul (5.0-10.0), 160 mg/L (0-10), and 0.70 ug/mL (0.00-0.40) respectively. The echocardiogram revealed an ejection fraction of 60-65% and a right ventricular systolic pressure of 30-35 mmHg. Chest X-ray and CT angiography of the chest were negative for any acute changes. He tested negative for COVID-19 on admission. Cardiac MRI revealed patchy mural delayed myocardial enhancement with relative sparing of the endocardium within the septum, and inferior and lateral walls at the cardiac base. He was managed with steroids and paracetamol and placed on telemetry for rhythm monitoring. Cardiac enzymes were monitored over the course of the hospitalization and were seen to have plateaued. He was discharged home due to the resolution of symptoms and the decreasing need for analgesics. He was followed up a month later and was found to be stable. The reporter assessed that this is the first reported case of vaccine-induced myocarditis following the first dose of the Moderna vaccine in a patient with two previous COVID-19 infections. The susceptibility to developing myocarditis after the first dose of vaccination was likely due to the antibodies developed against the viral antigen from previous infections. No further clinical information was available for medical review. The benefit-risk relationship of mRNA-1273 is not affected by this report.   Most recent FOLLOW-UP information incorporated above includes: On 16-Nov-2022: Follow up received by safety on 17-Nov-2022 has Email with FTA and contains significant information: Reporter information, medical history, lab data, treatment medications and events were updated.; Sender's Comments: This is a literature non-study case concerning an 18-year-old male patient, with two previous episodes of COVID-19 infections, eight months and two months prior vaccination, who experienced the expected and serious (hospitalization and medically significant) AESI of myocarditis 8 hours after receiving the first dose of mRNA-1273 vaccine. He presented with a complaint of sudden onset of chest pain, rated it as a 7/10 in its worse form. He described it as being sharp, pressure-like, and squeezing, radiating to the back and worse with inhalation and coughing. The chest pain was associated with fever, cough, shortness of breath, fatigue, diarrhea, and vomiting. He reported a history of nose bleeding that had started about the same time and resolved without any intervention (non-serious). On examination, he appeared to be an obese male in acute painful distress with a temperature of 98.2°F, blood pressure of 128/88 mmHg, pulse rate of 88 beats per minute, respiratory rate of 18 cycles per minute, and oxygen saturation of 98% on room air. The precordium was quiet, and first and second heart sounds were heard with no added sounds. Cardiac enzymes were elevated: troponin of 1.39 ng/mL (0.00-0.01), total creatine kinase of 900 U/L (39-308), creatine kinase-MB of 73.3 ng/mL (0.0-3.6) and a creatine kinase-MB index of 8.1 (0.0-2.8). A lipid panel showed no abnormal results. The EKG showed normal sinus rhythm with ST-segment elevation in some lateral leads. White blood cell count, C-reactive protein, and D-dimer were elevated at 11.0 K/ul (5.0-10.0), 160 mg/L (0-10), and 0.70 ug/mL (0.00-0.40) respectively. The echocardiogram revealed an ejection fraction of 60-65% and a right ventricular systolic pressure of 30-35 mmHg. Chest X-ray and CT angiography of the chest were negative for any acute changes. He tested negative for COVID-19 on admission. Cardiac MRI revealed patchy mural delayed myocardial enhancement with relative sparing of the endocardium within the septum, and inferior and lateral walls at the cardiac base. He was managed with steroids and paracetamol and placed on telemetry for rhythm monitoring. Cardiac enzymes were monitored over the course of the hospitalization and were seen to have plateaued. He was discharged home due to the resolution of symptoms and the decreasing need for analgesics. He was followed up a month later and was found to be stable. The reporter assessed that this is the first reported case of vaccine-induced myocarditis following the first dose of the Moderna vaccine in a patient with two previous COVID-19 infections. The susceptibility to developing myocarditis after the first dose of vaccination was likely due to the antibodies developed against the viral antigen from previous infections. No further clinical information was available for medical review. The benefit-risk relationship of mRNA-1273 is not affected by this report.