Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination

Abstract

Importance: Vaccine-associated myocarditis is an unusual entity that has been described for the smallpox vaccine, but only anecdotal case reports have been described for other vaccines. Whether COVID-19 vaccination may be linked to the occurrence of myocarditis is unknown.

Objective: To describe a group of 7 patients with acute myocarditis over 3 months, 4 of whom had recent messenger RNA (mRNA) COVID-19 vaccination.

Design, setting, and participants: All patients referred for cardiovascular magnetic resonance imaging at Duke University Medical Center were asked to participate in a prospective outcomes registry. Two searches of the registry database were performed: first, to identify patients with acute myocarditis for the 3-month period between February 1 and April 30 for 2017 through 2021, and second, to identify all patients with possible vaccine-associated myocarditis for the past 20 years. Once patients with possible vaccine-associated myocarditis were identified, data available in the registry were supplemented by additional data collection from the electronic health record and a telephone interview.

Exposures: mRNA COVID-19 vaccine.

Main outcomes and measures: Occurrence of acute myocarditis by cardiovascular magnetic resonance imaging.

Results: In the 3-month period between February 1 and April 30, 2021, 7 patients with acute myocarditis were identified, of which 4 occurred within 5 days of COVID-19 vaccination. Three were younger male individuals (age, 23-36 years) and 1 was a 70-year-old female individual. All 4 had received the second dose of an mRNA vaccine (2 received mRNA-1273 [Moderna], and 2 received BNT162b2 [Pfizer]). All presented with severe chest pain, had biomarker evidence of myocardial injury, and were hospitalized. Coincident testing for COVID-19 and respiratory viruses provided no alternative explanation. Cardiac magnetic resonance imaging findings were typical for myocarditis, including regional dysfunction, late gadolinium enhancement, and elevated native T1 and T2.

Conclusions and relevance: In this study, magnetic resonance imaging findings were found to be consistent with acute myocarditis in 7 patients; 4 of whom had preceding COVID-19 vaccination. Further investigation is needed to determine associations of COVID-19 vaccination and myocarditis.

Figure 1.. Patients With Cardiac Magnetic Resonance Imaging Findings Consistent With Acute Myocarditis

The total number of patients with acute myocarditis is highest for 2021 with 4 associated with recent COVID-19 vaccination. Only 1 patient had myocarditis associated with acute COVID-19 infection.

Figure 2.. Cardiac Magnetic Resonance Imaging in Patients With Acute Myocarditis Following COVID-19 Vaccination

Late gadolinium enhancement (LGE) images and T1 maps are shown in 4 patients who recently received COVID-19 vaccine. Patients 1, 2, and 4 demonstrate epicardial LGE, and patient 3 demonstrates patchy, diffuse LGE (pink arrowheads), which are consistent with myocarditis. T1 maps demonstrate abnormal (elevated) native T1 in the regions with LGE (blue arrowheads).