Acute Myocarditis Following the Third Dose of SARS-CoV-2 Vaccine; A Case Report


 BackgroundCOVID-19 pandemic has led to the development and use of the SARS-CoV-2 vaccine. In this study, we report a case with a history of multiple sclerosis that experienced acute Myocarditis following the third dose of the SARS-CoV-2 vaccine. Case presentation A 20-year-old man with a history of multiple sclerosis was admitted to the hospital to visit due to recent retrosternal chest pain four days after the third dose of SARS-COV-2 vaccine (AstraZeneca vaccine). Initial electrocardiogram showed ST-Segment elevation in the inferior limb and precordial leads. However, Echocardiography was normal without any wall motion abnormality. Cardiac Magnetic Resonance (CMR) confirmed acute myocarditis. After treatment and monitoring, Echocardiography, cardiac troponin, CBC, ESR, and CRP were normal, without any symptoms two weeks later. ConclusionsConsequently, vaccine-associated myocardial damage should be considered in the differential diagnosis in patients who have recently been vaccinated against COVID-19. Individuals with chest pain should be monitored regardless of their age and encouraged to perform relevant tests and at least an electrocardiogram.


Background
According to the World Health Organization (WHO), as of November 21, 2021, more than 219 million people have been infected by , and more than 4.5 million of these people have died from the disease. Approximately 3.2 billion people worldwide have been fully vaccinated against the COVID-19 (1). Cardiac disorders such as Myocarditis, as a rare side effect, can be reported after vaccination, which could be a severe and signi cant complication (2). Numerous responses to this complication have been proposed, such as secondary nonspeci c systemic in ammatory response to vaccination or molecular mimicry between cardiac structures and SARS-CoV-2 viral proteins (3), or possibly due to greater systemic and immunological reactivity of mRNA vaccines compared to others (4).

Case Presentation
A 20-year-old man with a history of multiple sclerosis (clinically isolated syndrome-CIS) with a BMI of 22.4 kg/m 2 was admitted to the hospital to visit due to recent retrosternal chest pain (2 episodes of 30 minutes in the morning and evening), 4 days after the third dose of SARS-COV-2 vaccine (AstraZeneca vaccine). Moreover, he had received the rst and second dose of the SARS-COV-2 vaccine (Sinopharm vaccine) 5 and 4 months before.
The patient's medical history was as follows: He did not have a history of recent traveling, allergy, or reaction to the vaccine. At the time of admission, he had chest pain and was physically examined, and his vital sign was normal. Initial electrocardiogram showed ST-Segment elevation in the inferior limb and precordial leads. (Figure 1) Echocardiography was normal without any wall motion abnormality.
Laboratory blood tests con rmed evidence of myocardial injury and systemic in ammation. (Table 1)   The patient was started on supportive therapy for his symptoms, Beta-blockers for palpitation, and Colchicine and Nonsteroidal anti-in ammatory drugs (NSAIDs) began.
He was discharged home after 3 days of monitoring without any evidence of electrical or hemodynamic instability. Two weeks later, Echocardiography, cardiac troponin, CBC, ESR, and CRP were normal, without any symptoms.

Discussion
Studies on the effects of vaccination on the heart (disorders), especially after vaccination with various coronavirus vaccines, are limited. However, studies have shown that some vaccines, including mRNA vaccines, cause Myocarditis (5, 6). Furthermore, most of these studies report that this complication occurs in younger men a few days after the second vaccination dose (7,8).
This complication has been reported rarely, and the possibility of a severe reaction after Covid-19 vaccination has not been reported (9). However, in our reported case, the patient was referred to the hospital and hospitalized for a few days. At the time of admission, the electrocardiogram showed STsegment elevation in the inferior limb and precordial leads. However, there was no sign of chest pain after hospitalization, but troponin was mildly increased and his vital signs were normal. However, a similar study reported clinical manifestations, including chest pain, electrocardiogram ndings, and abnormal troponin levels and lymphadenopathy following vaccine-associated Myocarditis (10).
In addition, in another study of 4 patients with acute Myocarditis occurring within days of COVID-19 mRNA vaccination, the diagnosis of acute Myocarditis was so simple that the symptom was (the onset of) acute severe chest pain, and myocardial damage was detected by increasing troponin levels in all patients. CMR imaging abnormalities have been observed in several techniques and cannot be attributed to image artifacts. In addition, matching ndings were reported to be typical for acute Myocarditis (11).
While in our patient vital signs and Echocardiography were normal without any wall motion abnormality.
In general, it cannot be stated with certainty that youth vaccination leads to Myocarditis because its prevalence has been reported to be very low. However, according to the results of similar studies in this eld, post-vaccination monitoring and drug care for mRNA-related vaccine-induced myocardial injury should be encouraged during ongoing vaccination (8).

Conclusions
Consequently, vaccine-associated myocardial damage should be considered in the differential diagnosis in patients recently vaccinated against COVID-19 presented with chest pain. Therefore, individuals should be monitored regardless of their age and encouraged to perform relevant tests such as Troponin in the case of chest pain and at least an electrocardiogram. The study is not funded

Con icts of interest/Competing interests
The authors declare no competing interests.

Ethics approval
This study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences.

Consent to participate
Written informed consent was obtained for participation in the study from participant.

Consent for publication
Written informed consent was obtained for publication of data from participant.

Availability of data and material
All our study-related information is stored in secure folders with limited access. Electronic data les are stored on a le system with access restricted to designated researchers and data managers. The dataset is available from the corresponding author at Shahid Beheshti University of Medical Sciences.
Code availability Not applicable.
Authors' contributions MR searched the literature, collected the data, performed the statistical analyses, and wrote the manuscript; MSh and AM contributed to conception, design, data interpretation, and supervision of the study. All authors read and approved the nal manuscript.