Radiotherapy-induced acute myopericarditis
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Introduction: A case of acute myopericarditis related to radiotherapy is presented. Incidence is difficult to affirm but chronic presentation is much more common. Diagnosis is challenging and a high suspicion level is important to establish it.Keywords:
Myopericarditis
Presentation (obstetrics)
Myopericarditis occurs in 15% of patients with pericarditis. Recurrent myopericarditis occurs in 15% to 30% of patients after partial or complete recovery from acute myopericarditis. Relapse often occurs within 1 month of an initial episode. The standard of care for pericarditis or myopericarditis is initial treatment with nonsteroidal anti-inflammatory drugs for 10 to 14 days. Colchicine is often administered for 3 to 6 months for residual chest pain due to myopericarditis. The authors present a case of seasonal recurrent myopericarditis in a 32-year-old man who presented with severe chest pain in nearly the same month for 4 consecutive years. The authors conducted an extensive review of the literature but found no other case reports of seasonal recurrent myopericarditis. If a patient presents with severe chest pain requiring hospitalization, physicians should consider prescribing nonsteroidal anti-inflammatory drugs or colchicine before seasonal symptom recurrence.
Myopericarditis
Colchicine
Pleurisy
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Abstract Myopericarditis is a condition, which primarily involves the pericardium, with minimal myocardial involvement. In myopericarditis, chest pain, elevated cardiac enzymes, and electrocardiographic changes occur. Although COVID-19 mRNA vaccines significantly contribute to preventing the COVID-19 disease, rarely myocarditis and/or pericarditis may develop due to these vaccines. We present a previously healthy 14-year-old male patient who developed myopericarditis after receiving the second dose of the COVID-19 mRNA vaccine.
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Myopericarditis has occasionally been reported as a side effect of mesalamine in patients with inflammatory bowel disease. We present a 20-year-old woman with ulcerative colitis admitted with chest pain. After thorough investigation she was diagnosed with myopericarditis potentially related to mesalamine. There was complete clinical and laboratorial recovery following drug withdrawal. Although uncommon, the possibility of myopericarditis should be considered in patients with inflammatory bowel disease presenting with cardiac complaints. Early recognition can avoid potential life-threatening complications.
Myopericarditis
Adult-onset Still's disease
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To counter the possibility of smallpox being used as a biological weapon, in 2002 the US government restarted a smallpox vaccination campaign. Myopericarditis is a possible cardiac complication of smallpox vaccination. We report 2 cases of vaccine-associated myopericarditis in military recruits who were treated at our facility. Chest pain, shortness of breath, and electrocardiographic changes of pericarditis, with a recent history of smallpox vaccination, were useful in making the diagnosis of probable post-vaccinial myopericarditis. Nonsteroidal, anti-inflammatory drugs (NSAIDs) were used to manage myopericarditis. Both patients had complete resolution of symptoms and electrocardiographic changes and subsequently returned to active duty.Myopericarditis should be suspected when patients with recent history of smallpox vaccination present with chest pain or shortness of breath. Nonsteroidal anti-inflammatory drugs are useful in the management of post-vaccinial myopericarditis.
Myopericarditis
Smallpox vaccine
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Inflammation of the myocardium (myocarditis) or pericardium (pericarditis) or both (myopericarditis) as side effects of mesalamine, a drug widely used in the treatment of inflammatory bowel disease, is a rare, but potentially lethal complication. We report a case of myopericarditis occurring in a young Caucasian woman 14 days following initiation of mesalamine therapy for treatment of a newly diagnosed ulcerative colitis (UC). She presented with pleuritic chest pain, elevated troponin levels and pre-syncope. The diagnosis of myopericarditis was made based on the clinical features, electrocardiogram (EKG) and cardiac magnetic resonance, which showed trace pericardial effusion. The patient's symptom and condition were dramatically improved upon discontinuing mesalamine, and a full recovery was achieved. Mesalamine-induced inflammation of the myocardium (myocarditis) or pericardium (pericarditis) or both (myopericarditis) is rare, but has fatal side effects. Early recognition of these side effects by clinicians and patients is important to prevent progression of the inflammation. Furthermore, patients should be educated to seek urgent medical attention if cardiac symptoms arise.
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Myopericarditis is a rare consequence of COVID-19 infection. Although extremely rare, COVID-19 can present without pulmonary involvement, and there have been reports of isolated cardiac involvement in one prior case We report a case of a young African American man presenting with myopericarditis following a recently recovered COVID-19 infection. Complicated by ICU admission requiring vasopressors; with eventual resolution following initiation of aspirin and colchicine for myopericarditis. Life threatening myopericarditis can occur following resolution of COVID-19 disease. The degree of cardiac involvement correlates poorly to the severity of pulmonary involvement.
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Myopericarditis is a rare extraintestinal manifestation of Crohn's disease (CD). Myopericarditis has also been attributed to treatment with mesalamine and heart failure to tumor necrosis factor inhibitor (TNFi) use. When a patient with CD, controlled on these medications, presents with myopericarditis and/or heart failure, it can confound both the differential diagnosis and management of such patients. Our case is acute myopericarditis in a 34-year-old male, with a history of CD controlled with mesalamine and infliximab, who had been off TNFi therapy for over six months due to loss of insurance coverage and had been intermittently using leftover mesalamine. He presented to the ED complaining of a one-day history of abdominal pain with bloody diarrheal stools, chest discomfort, and fever. A colonoscopy performed two days back had demonstrated active colonic CD. Findings included ECG evidence of pericarditis, elevated cardiac biomarkers, and reduced left ventricular function on ventriculography consistent with myopericarditis. We present the differential, diagnostic and management challenges encountered in this situation, review the pertinent literature, and discuss decision making in what appears to be myopericarditis attributed to an extraintestinal manifestation of active GI Crohn's.
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Vaccination is important for the prevention of coronavirus-induced disease 2019 (COVID-19) caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and to protect persons with a high risk for complications. There have been reports of myopericarditis following COVID-19 vaccination, especially in adolescent males and young adults. Breakthrough infections, such as the Delta or Omicron variant of SARS-CoV-2, have raised great concern about the necessity for repeated doses of the vaccine. A case of myopericarditis after the second dose of COVID-19 mRNA-1273 (Moderna) vaccine in a 23-year-old man with a prior episode of viral myopericarditis is presented. He received the second dose of the COVID-19 mRNA vaccine, after which he developed persistent midsternal chest pain and he was subsequently transferred to our emergency department. An echocardiogram showed a trivial inferior pericardial effusion with diffuse left ventricular systolic dysfunction. He was treated with colchicine from the first day of hospitalization with a diagnosis of myopericarditis. His chest pain had resolved by the third day, and left ventricular wall motion was dramatically improved by the seventh day of hospitalization. A strong response to the second vaccination in the present case suggests that the prior history of myopericarditis is evidence of strong congenital or acquired immunological features in this individual. Individuals with such a strong immune response may be more likely to develop myopericarditis after mRNA vaccination. Immunization against COVID-19 is currently recommended from a risk-benefit standpoint. We advised the patient to avoid additional COVID-19 mRNA vaccines because of this episode. The risk of COVID-19 weighed against myopericarditis associated with the mRNA vaccination should be considered on a case-by-case basis. This case may help us better understand the mechanism of myopericarditis following COVID-19 mRNA vaccination.
Myopericarditis
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Non-typhoidal salmonella (NTS) is a rare, but well-established cause of myopericarditis. Presenting symptoms may be varied, however often revolve around the dual presentation of both myopericarditis and infectious diarrhoea. Given the rarity of NTS related myopericarditis, we conducted a systematic review of the literature, identifying 41 previously reported cases.We present the case of an otherwise healthy 39-year old male, presenting with chest pain in the setting of documented Salmonella typhimurium infection. After further investigation with echocardiogram and laboratory blood tests, a diagnosis of NTS associated myopericarditis was made, and the patient received antibiotic treatment with an excellent clinical outcome. Overall, myopericarditis is rare in NTS. Although treatment for myopericarditis has not been well established, there are guidelines for the treatment of NTS infection. In our review, we found that the majority of NTS cases has been pericarditis (27/42, 64.3%), with an average age of 48.3 years, and 71.4% being male. The average mortality across all cases was 31%.Myopericarditis is a rare, but potentially serious complication of NTS infection, associated with an increased morbidity and mortality.
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De Giorgi et al reviewed the association between Takotsubo cardiomyopathy (TC) and various infectious etiologies. However, the authors did not describe any report suggesting an association between viral myopericarditis and TC. There is increasing evidence suggesting an association between viral myopericarditis and TC. Myopericarditis may either precede the stress-induced cardiomyopathy or develop as one of its complications. When myopericarditis is the primary pathology, it has been suggested that an intense perimyocardial inflammation-induced chest discomfort may trigger an exaggerated sympathetic stimulation or somatic stress resulting in a reversible left ventricular dysfunction/TC. Alternatively, in cases where TC is the initial stressor, pericarditis may result from an extension of myocardial inflammation to the overlying epicardium suggesting an inflammatory hypothesis to TC. In these instances, findings on imaging are often disproportionate to credibly explain the regional dysfunction caused by myopericarditis and thus support the coexistence of these 2 conditions. Due to an increased understanding of stress-induced cardiomyopathy, its diagnostic criteria have evolved with time. In fact, previously proposed criteria by various medical societies, which emphasized excluding patients with myocarditis or myopericarditis from the diagnosis of TC now appear to be outdated and modified versions have been recently proposed. Recent studies suggest that these 2 entities can coexist and are not mutually exclusive. Cardiac magnetic resonance imaging may be useful in such clinical scenarios where the delayed gadolinium enhancement—not plausible to explain the segmental wall-motion abnormalities—will be suggestive of myopericarditis and TC association. When exploring the infectious etiopathogenesis for stressinduced cardiomyopathy, viral myopericarditis is a differential diagnosis to consider. This association can have diagnostic and therapeutic implications, especially the cautionary use of anticoagulants and glycoprotein IIb/IIIa inhibitors when TC and myopericarditis association is suspected to prevent lifethreatening complications such as hemorrhagic tamponade.
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Etiology
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