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Association of Myocarditis With BNT162b2 Vaccine in Children
Quick Takes
- Myocarditis typically occurred in male patients after the second dose of the COVID-19 vaccine.
- All patients in this series had a benign course; none required ICU admission and all were discharged alive from the hospital within 5 days.
- Larger studies with longer-term follow-up are indicated to inform future recommendations for COVID-19 vaccination in children.
Study Questions:
What are the results of comprehensive cardiac imaging in children with myocarditis after receiving the BNT162b2 (Pfizer-BioNTech) messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccine?
Methods:
The investigators conducted a case series of children <19 years old hospitalized with myocarditis within 30 days of BNT162b2 mRNA COVID-19 vaccine. The setting was a single-center pediatric referral facility, and admissions occurred between May 1 and July 15, 2021. All patients underwent cardiac evaluation including an electrocardiogram, echocardiogram, and cardiac magnetic resonance imaging (CMR). CMR assessment included left ventricular ejection fraction (LVEF), T2-weighted myocardial imaging, LV global native T1, LV global T2, extracellular volume fraction, and late gadolinium enhancement (LGE). Descriptive statistics were calculated for all study variables. Quantitative variables were summarized as median and range and categorical variables as frequencies and percentages.
Results:
Fifteen patients (14 male patients [93%]; median age, 15 years [range, 12-18 years]) were hospitalized for management of myocarditis after receiving the BNT162b2 vaccine. Symptoms started 1-6 days after receipt of the vaccine and included chest pain in 15 patients (100%), fever in 10 patients (67%), myalgia in eight patients (53%), and headache in six patients (40%). Troponin levels were elevated in all patients at admission (median, 0.25 ng/ml [range, 0.08-3.15 ng/ml]) and peaked 0.1-2.3 days after admission. By echocardiographic examination, decreased LVEF was present in three patients (20%), and abnormal global longitudinal or circumferential strain was present in five patients (33%). No patient had a pericardial effusion. CMR findings were consistent with myocarditis in 13 patients (87%) including LGE in 12 patients (80%), regional hyperintensity on T2-weighted imaging in two patients (13%), elevated extracellular volume fraction in three patients (20%), and elevated LV global native T1 in two patients (20%). No patient required intensive care unit (ICU) admission, and median hospital length of stay was 2 days (range 1-5). At follow-up 1-13 days after hospital discharge, 11 patients (73%) had resolution of symptoms. One patient (7%) had persistent borderline low LV systolic function on echocardiogram (EF 54%). Troponin levels remained mildly elevated in three patients (20%). One patient (7%) had nonsustained ventricular tachycardia on ambulatory monitor.
Conclusions:
The authors concluded that myocarditis was diagnosed in children after COVID-19 vaccination, most commonly in boys after the second dose, and had a benign short-term course.
Perspective:
This case series reports that myocarditis typically occurred in male patients after the second dose of the COVID-19 vaccine. Furthermore, all patients in this series had a benign course; none required ICU admission and all were discharged alive from the hospital within 5 days. Of note, the long-term risks associated with post-vaccination myocarditis remain unknown at this time. Larger studies with longer-term follow-up are indicated to inform future recommendations for COVID-19 vaccination in this population.
Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Prevention, SCD/Ventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging
Keywords: Chest Pain, Child, Coronavirus, COVID-19, Diagnostic Imaging, Echocardiography, Electrocardiography, Gadolinium, Heart Failure, Intensive Care Units, Length of Stay, Magnetic Resonance Imaging, Myalgia, Myocarditis, Patient Discharge, Pediatrics, Pericardial Effusion, RNA, Messenger, Secondary Prevention, Stroke Volume, Tachycardia, Ventricular, Troponin, Vaccination, Ventricular Function, Left
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