Background: Acute myocarditis is a rare complication of messenger RNA (mRNA) COVID-19 vaccination. Case: A 36-year-old female with hypertension, smoking, prior alcohol use, chronic pancreatitis and prior COVID-19 infection was transferred for surgical intervention for median arcuate ligament syndrome (MALS). She noted abdominal pain, chest discomfort, dyspnea, orthopnea, and lower extremity edema which began 5 days after the second dose of BNT162b2 COVID-19 vaccine. Physical exam revealed rales, abdominal distention and pitting edema. 12 lead ECG showed a nonspecific ST abnormality. Troponins were 19,222 ng/L (ref < 17 ng/L). Brain natriuretic peptide level was 4734 pg/mL (ref<100 pg/mL). Testing for active COVID-19 infection was negative. Chest x-ray demonstrated a right pleural effusion. Transthoracic echocardiogram revealed apical wall akinesis. Cardiac catheterization showed normal coronary vasculature. Cardiac MRI showed late gadolinium enhancement (LGE) in the basal anterolateral, mid-anterior and midanterolateral walls. Decision-making: Myocarditis should be suspected with elevated cardiac biomarkers, new unexplained heart failure and normal coronary angiography. Despite apical dysfunction, Takutsubo (stress) cardiomyopathy was less likely given CMR findings of LGE. Acute COVID-19 infection is well known to be associated with acute myocarditis but testing was negative. Testing for other potential etiologies (HIV, EBV, toxicology) was also negative. There was no history of collagen-vascular disease. Surgical and gastrointestinal consultations noted symptoms were consistent with acute heart failure rather than MALS. Timing was most consistent with vaccine induced myocarditis given onset within days of second injection with an mRNA vaccine. Based on the above findings decision was made to begin the patient on guideline directed medical therapy (GDMT) with diuretics, ace inhibition and beta blockade. Conclusion: While most common in young males, myocarditis following shortly after mRNA vaccine administration should be considered in patients without another etiology and with appropriate timing of symptom development. Most patients will improve with GDMT.
MYOCARDITIS MASQUERADING AS MEDIAN ARCUATE LIGAMENT SYNDROME: VACCINE-INDUCED MYOCARDITIS IN A YOUNG FEMALE