Severe Acute Myocarditis after the Third (Booster) Dose of mRNA COVID-19 Vaccination

Figures

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  Figure 1. Electrocardiograms (EKG) on presentation. (A) EKG on presentation showing monomorphic ventricular tachycardia. (B) EKG after cardioversion showing sinus rhythm with poor R wave progression in precordial leads without significant PR or ST segment changes. Left heart Catheterization (C–E) show normal coronary arteries. (Table 1B).

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  Figure 2. Cardiac MRI (1.5T) at presentation. (A) A short axis view of late gadolinium enhancement (LGE) image showing transmural LGE in the lateral and inferolateral wall (red arrow). (B) A T2 mapping image showing myocardial edema with regionally increased T2 values (78 milliseconds) in the lateral and inferolateral wall. (C) A T1 mapping image showing myocardial injury with increased native T1 values (1288 milliseconds) in the lateral and inferolateral walls.

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  Figure 3. Histopathological Findings from Endomyocardial Biopsies. Hematoxylin-eosin stains of heart-tissue specimens showed inflammatory infiltrates composed of mononuclear cells with foci of severe interstitial edema and multifocal cardiomyocyte damage consistent with the diagnosis of definitive acute myocarditis (Panels A and B). Immunostaining demonstrated predominant inflammatory infiltration of lymphocytes (Panel C, CD3 immunostaining for T-lymphocytes, and Panel D, CD20 immunostaining for B-lymphocytes) and, to a lesser extent, macrophages (Panel E, CD68 immunostaining). A repeated endomyocardial biopsy 3 months later showed a complete resolution of myocarditis without evidence of inflammation or cardiomyocyte damage (Panel F, hematoxylin-eosin stains). Original magnification, ×200; scale bars, 100 µm (Panels A, and D–F) and original magnification, ×400; scale bars, 50 µm (Panel B).

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  Figure 4. Two-lead recording from a wearable cardioverter-defibrillation (LifeVest) demonstrating a sustained monomorphic ventricular tachycardia event lasting for 94 s, which was ultimately terminated by a successful electrical shock, about 2 weeks after the index hospitalization. The figure illustrates the onset (time 17 s) and termination of the ventricular tachycardia event (time 111 s).