Too Much Too Soon? The Catch-22 of Catching COVID-19

INTRODUCTION: Myocarditis has become a well-recognised cardiac complication of SARS-CoV-2 infection. Now, there are growing reports of rare incidences of myocarditis following receipt of mRNA COVID-19 vaccines. CASE REPORT: A previously healthy 35-year-old male tested positive for COVID-19 on 8/12/21. He never required hospitalisation and was thought to have cleared the infection by 9/5/21. Three weeks later he received the first dose of Pfizer-BioNTech BNTT162b2/Comirnaty mRNA COVID-19 vaccine. Five days later he presented to emergency with chest pain alongside myalgia, headache and cough. His troponin-T was below reference range (RR), electrocardiogram showed sinus rhythm with mild, diffuse T-wave flattening, and no evidence of pericardial effusion was seen on bedside transthoracic echocardiogram (TTE) so was discharged. Two days later he represented to hospital with fevers, vomiting, diarrhea and a maculopapular rash. His subsequent admission was complicated by rapid deterioration and his management reflected a diagnostic dilemma with wide differentials. On day 2 of admission he became haemodynamically unstable requiring vasopressor therapy with a high sensitivity (hs) troponin-I of 103ng/L (RR <26ng/L). On day 4 he developed atrial fibrillation, worsening respiratory distress, peak hs troponin-I of 1474ng/L and required intubation, direct-current cardioversion and venoarterial extracorporeal membrane oxygenation (ECMO) for intractable heart failure. TTE here showed severe global systolic impairment with a left ventricular ejection fraction of 15% and small pericardial effusion. His subsequent treatment targeted possible multiorgan sepsis with antibiotics, vaccine-induced myocarditis with immunosuppressive therapy including anakinra and parental corticosteroids, or delayed COVID-19 myocarditis with supportive care. He was later extubated and successfully decannulated from 5 days on ECMO on day 11. Cardiac magnetic resonance imaging on day 12 showed elevated T1 and T2 values consistent with ongoing myocardial edema, but normal ventricular volume, thickness and function. SUMMARY: This is a case of fulminant myocarditis whereby the aetiology is unclear considering recent COVID-19 infection and mRNA vaccination. This raises questions as to the ideal timing of vaccine, type of vaccine and requirement for cardiac screening prior to vaccination in patients who have recovered from COVID-19.