typical COVID19 vaccine-induced myocarditis; cardiac sarcoidosis; autonomic dysfunction; This is a literature report.   CASE PRESENTATION: This is a case of a 65-year-old male presenting to the emergency department (ED) for abrupt-onset dizziness that started about an hour prior to arrival. On presentation the patient was found to be in monomorphic VT with two unsuccessful defibrillation attempts, after which amiodarone and lidocaine drips were used to control his rhythm. He was also notably in shock even after the resolution of his ventricular tachyarrhythmias, requiring norepinephrine, vasopressin, milrinone and midodrine. There was no clear evidence of decompensated heart failure, infection, or adrenalin sufficiency. TTE showed normal biventricular function and normal valvular function. Given his refractory shock, the patient was taken for left and right heart catheterization, revealing normal coronaries, normal right sided and PA pressures, along with moderately elevated left filling pressures. Ultimately, he underwent PET scan, which showed mild uptake in the proximal septum and proximal lateral wall, suspicious for active cardiac sarcoidosis. Of note, the patient reported taking his second COVID mRNA vaccine (Tozinameran; Pfizer-BioNTech) 10 days prior to presentation. Patient was subsequently started on methylprednisolone 1 gram daily for 3 days, followed by prednisone 60 mg daily, methotrexate 20 mg weekly, and folic acid 1 mg daily. Patient exhibited clinical improvement and was discharged on corticosteroids with plans for close cardiology follow up. DISCUSSION: The current patient qualified for the diagnosis of clinical cardiac sarcoidosis via the 2014 HRS criteria, and while myocarditis was in the differential, the patient presented uniquely from the typical COVID 19 vaccine-induced myocarditis patient. Sustained VT is not a frequently reported feature of COVID 19 vaccine induced myocarditis; amongst 139 adolescents diagnosed with vaccine induced myocarditis, zero patients developed sustained VT, and non-sustained VT was rare (5%). To date, there are 5 published case reports on patients developing sarcoidosis in close time proximity to COVID-19 mRNA vaccination. This case is one of two published cases on cardiac sarcoidosis in the absence of systemic radioactive PET scan uptake in the setting of COVID-19 vaccination as a potential trigger. Furthermore, the initial presentation of autonomic dysfunction and sustained monomorphic VT presents a truly complex and unique clinical picture. CONCLUSIONS: For patients who develop unexplained sustained ventricular arrhythmias following COVID 19 vaccination, particularly in the presence of autonomic instability, exacerbation of cardiac sarcoidosis should be considered. More studies and data are needed to assess the possible mechanism of this potential unmasking of sarcoidosis.; Sender's Comments: The causal association between the reported event Myocarditis and suspect drug cannot be totally excluded, based on known drug safety profile.Based on the temporal relation, the association between the event Cardiac Sarcoidosis , autonomic Dysfunction , Myocarditis and the suspect product cannot be completely ruled out. The impact of this report on the benefit/risk profile of the Pfizer drug 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 Regulatory Authorities, Ethics Committees, and Investigators, as appropriate.,Linked Report(s) : US-PFIZER INC-202300319518 same article/drug/event and different patient;US-PFIZER INC-202300319561 same article/drug/event and different patient;US-PFIZER INC-202300319563 same article/drug/event and different patient;