Acute myopericarditis with focal ECG findings mimicking acute myocardial infarction

Background: Although history, physical examination, laboratory data points, and electrocardiogram (ECG) are helpful, distinguishing among pericarditis, myopericarditis, and myocardial infarction can be difficult. Objectives: This case, which presents as pericarditis with concomitant myocarditis (myopericarditis), illustrates the four evolving ECG stages of pericarditis and highlights some of the potential difficulties in differentiating between myopericarditis and acute myocardial infarction. Case Report: We present the case of a previously healthy 15-year-old boy who presented to the Emergency Department (ED) from his family physician's office for chest pain and presumed pericarditis. The patient's initial ECG showed infero-lateral ST-segment elevation, and his troponin T was elevated at 1.54 ng/mL (ref. < 0.03). Several hours after presentation to the ED, the patient experienced “10/10” chest pain, and a repeat ECG showed ST elevation increased from the prior ECG. After an emergent echocardiogram revealed no regional wall abnormalities, he was transferred to a pediatric cardiac intensive care unit, where a heart catheterization revealed no coronary irregularities. He was discharged 4 days later with the diagnosis of myopericarditis. Conclusion: This case report illustrates some of the difficulties in differentiating among myopericarditis and myocardial infarction in a 15-year-old patient presenting with chest pain.     

Prospective safety surveillance study of ACAM2000 smallpox vaccine in deploying military personnel

ObjectivesTo compare rates of myopericarditis, severe and serious dermatological or neurological events, and other adverse events in deploying US military personnel who received or did not receive ACAM2000® (Smallpox [Vaccinia] Vaccine, Live) vaccine and to evaluate potential risk factors for development of myopericarditis.MethodsProspective observational cohort study enrolling up to 15,000 ACAM2000 recipients (Cohort 1) and up to 5000 persons otherwise eligible for ACAM2000 vaccination but not vaccinated due to recency of vaccination or characteristics of their contacts (Cohort 2). Data and specimens were collected initially and 10 (6–17) days later. Those with clinical or laboratory evidence of possible myopericarditis were referred for further evaluation and adjudication by a blinded independent review committee. The adjusted odds ratio for myopericarditis was determined by a logistic regression model controlling for age, race, gender, and exercise regimen.Results14,667 subjects provided initial data and specimens (Cohort 1, 10,825; Cohort 2, 3842); 12,110 (Cohort 1, 8945; Cohort 2, 3165) completed Visit 2 per-protocol. A total of 125 (Cohort 1, 111; Cohort 2, 14) were referred for myopericarditis adjudication, yielding 54 (Cohort 1, 44, Cohort 2, 10) subclinical myopericarditis, 5 suspected myocarditis, 1 confirmed myocarditis, and 1 suspected pericarditis. Unadjusted myopericarditis rates were: Cohort 1, 5.7/1000 (95% CI, 4.3–7.5); Cohort 2, 3.2/1000 (95% CI, 1.7–5.8). Unadjusted and adjusted odds ratios for myopericarditis were 1.8 (95% CI: 0.9–3.6) and 1.3 (95% CI: 0.6–2.6), respectively. One hundred seventeen subjects (1.1%) in Cohort 1 and 13 (0.3%) in Cohort 2 experienced at least 1 serious adverse event. No instances of serious and severe neurological or dermatological adverse events were reported.ConclusionsIn this carefully screened, generally young and healthy service-member population, ACAM2000 vaccination was associated with modest non-significant increases in the risk of myopericarditis (adjusted OR, 1.3; unadjusted OR, 1.8); all but seven cases were subclinical.Clinical trials registration: ClinicalTrials.gov NCT00928577.     

Caractéristiques et suivi clinique d’une cohorte de patients atteints de myopéricardite confirmée en imagerie par résonance magnétique

IntroductionPericarditis are frequently associated with some degree of concomitant myocardial involvement. Predominant pericarditis with limited myocardial involvement are named myopericarditis. Data regarding myopericarditis are scarce.Patients and methodsRetrospective chart review of all patients admitted between 2002 and 2011 with magnetic resonance imaging confirmed myopericarditis.ResultsTwenty-seven patients were included. Eighty-one percent were men, with median age of 32 years. Infectious disease preceded hospitalization in 55% of cases. Mean left ventricle ejection fraction at admission was 55% with focal myocardial impairment mainly localized in lateral and inferior walls. Coronary angiogram was performed in 37% of cases to rule out an ischaemic aetiology. We identified 5 cases (19%) of myopericarditis preceded by an episode of streptococcus group A throat infection. Non-sustained ventricular tachycardia was observed in 15% of cases. After a 2-year follow-up period, mortality rate was zero and recurrence rate was 15%.ConclusionsIn our series, myopericarditis was a benign disease affecting mostly young men, and prognosis was good. A significant proportion of cases was preceded by group A streptococcus infection.     

Can troponin elevation predict worse prognosis in patients with acute pericarditis?

Introduction

Myopericarditis are common in clinical practice: up to 15% of acute pericarditis have a significant myocardial involvement as assessed by biological markers. This prospective, bicentric study is aimed at describing a myopericarditis population, the clinical and MRI follow-up, and search for prognosis markers.

Patients and methods

Between May 2005 and September 2007, 103 patients hospitalised for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening and cardiac MRI, in case of myopericarditis defined as acute pericarditis with troponin I elevation, were performed. Between December 2007 and July 2008, patients were contacted for new clinical and MRI evaluation.

Results

Among the initial population of 103 patients admitted for acute pericarditis, 14 myopericarditis and 38 pericarditis were included. Compared with pericarditis, the myopericarditis group was associated with the following features: younger age (34.9 years [95% CI 28.3-41.2]; p = 0.01), ST-segment elevation (nine patients between 14; p = 0.03), higher troponin I (7.3 μg/L [95% CI 4.4-10.2]; p < 10^-4) and lower systemic inflammation (CRP peak 38.1 mg/L [95% CI 7-69.2]; p = 0.01). In the case of myopericarditis, infectious etiologies were predominant (12 patients among 14; p = 0.002) and patients stayed longer in hospital (5.8 days [95% CI 4.7-6.8]; p = 0.01). Follow-up showed no difference in terms of functional status (p = 0.3) and global complications (p = 0.9) between paired myopericarditis and pericarditis. Nevertheless, cardiac mortality was higher for myopericarditis (p = 0.04). MRI follow-up showed myocardial sequelae without clinical impact.

Conclusion

Myopericarditis significantly distinguished from pericarditis. Three years follow-up showed no difference in terms of global complications but a higher cardiac mortality for myopericarditis. MRI myocardial lesions did not develop into symptomatic sequelae.     

Cytomegalovirus hepatitis and myopericarditis

Cytomegalovirus （CMV） infection in inmunocompetent hosts generally is asymptomatic or may present as a mononucleosis syndrome but rarely can lead to severe organ complications. We report a case of simultaneous hepatic and pericardic CMV infection in a 36-year old immunocompetent man. He was admitted to coronary unit with fever, chest pain radiated to shoulders, changes on electrocardiogram with diffuse ST elevation and modest laboratory elevations in the MB fraction of creatine kinase （CK-MB） of 33.77 μg/L （0.1-6.73）, serum cardiac troponin T of 0.904 ng/mL （0-0.4）, creatine kinase of 454 U/L （20-195） and myoglobin of 480.4 μg/L （28-72）. Routine laboratory test detected an elevation of aminotransferase level： alanine aminotransferase 1445 U/L, aspartate aminotransferase 601 U/L. We ruled out other causes of hepatitis with normal results except IgM CMV. The patient was diagnosed with myopericarditis and hepatitis caused by cytomegalovirus and started symptomatic treatment with salicylic acid. In few days the laboratory findings became normal and the patient was discharged.     

Possible autoimmune reactions following smallpox vaccination: The biologic false positive test for syphilis

Due to the threat of bioterrorism, large-scale clinical trials of a new cell culture smallpox vaccine were conducted. Biologically false positive (BFR) serological reactions to viruses (hepatitis B and C, HIV) and syphilis were evaluated. BPR rapid reagin tests (RPR) to syphilis occurred in 19% and false positive tests for antibody to hepatitis B in 3.3% of 90 healthy adults undergoing primary vaccination. Most subjects (94%) were RPR-positive on Day 15 after vaccination and all seroreverted within 2 months thereafter. One subject with myocarditis was RPR-negative. One RPR-positive and 1 RPR-negative subject had elevated CK-MB enzymes without other evidence for myocarditis.     

Concomitant acute myopericarditis and multiple systemic arteriovenous thrombosis as a rare manifestation of post-COVID-19 syndrome

Initially recognized as a respiratory system disease, COVID-19 has been found to be more of a systemic illness with multiorgan involvement. Recently, there are increasing reports of persistent and prolonged effects after acute COVID-19 infection, mainly on the cardiovascular system. Here, we report the case of a young man with myopericarditis and multiple systemic arteriovenous thrombosis developing several weeks after flu-like symptoms, with antigens indicating a past COVID-19 infection. This case highlights the multisystemic involvement of SARS-CoV-2, raising the possibility of concomitant myopericarditis and multiple systemic thrombosis after a COVID-19 non-severe infection. To our knowledge, there are no previous reports of such a case.     

Incidence of myopericarditis after mRNA COVID-19 vaccination: A meta-analysis with focus on adolescents aged 12–17 years

BackgroundThe incidence of myopericarditis after mRNA COVID-19 vaccination among adolescents aged 12–17 years remains unknown. Therefore, we conducted a study to pool the incidence of myopericarditis following COVID-19 vaccination in this age group.MethodsWe did a meta-analysis by searching 4 electronic databases until February 6, 2023. The following main keywords were used: “COVID-19”, “vaccines”, “myocarditis”, “pericarditis”, and “myopericarditis”. Observational studies reporting on adolescents aged 12–17 years who had myopericarditis in temporal relation to receiving mRNA COVID-19 vaccines were included. The pooled incidence of myopericarditis and 95 % confidence interval (CI) were calculated using a single-group meta-analysis.ResultsFifteen studies were included. The pooled incidences of myopericarditis after mRNA COVID-19 vaccination among adolescents aged 12–17 years were 43.5 (95 % CI, 30.8–61.6) cases per million vaccine doses for both BNT162b2 and mRNA-1273 (39 628 242 doses; 14 studies), and 41.8 (29.4–59.4) cases for BNT162b2 alone (38 756 553 doses; 13 studies). Myopericarditis was more common among males (66.0 [40.5–107.7] cases) than females (10.1 [6.0–17.0] cases) and among those receiving the second dose (60.4 [37.6–96.9] cases) than those receiving the first dose (16.6 [8.7–31.9] cases). The incidences of myopericarditis did not differ significantly when grouped by age, type of myopericarditis, country, and World Health Organization region. None of the incidences of myopericarditis pooled in the current study were higher than those after smallpox vaccinations and non-COVID-19 vaccinations, and all of them were significantly lower than those in adolescents aged 12–17 years after COVID-19 infection.ConclusionsThe incidences of myopericarditis after mRNA COVID-19 vaccination among adolescents aged 12–17 years were very rare; they were not higher than other important reference incidences. These findings provide an important context for health policy makers and parents with vaccination hesitancy to weight the risks and benefits of mRNA COVID-19 vaccination among adolescents aged 12–17 years.