Coronary Vasospasm in a Pediatric Patient with Myopericarditis After COVID-19 Vaccine

Introduction: The COVID-19 vaccine was approved for use in adolescents ages 12-17 on May 10, 2021. There have since been case reports of myocarditis shortly after the COVID-19 vaccine, mostly in adolescent males. Among these cases, coronary vasospasm has not been described.

Case Description: A 16 year old previously healthy male presented with two days of chest pain and subjective fevers three days after receiving the second dose of the Pfizer COVID-19 vaccine. High-sensitivity troponin I was 10,819 ng/L (reference range: 3-57), and ECG showed mild diffuse ST segment elevations (Image 1). He was admitted for suspected myopericarditis and treated with ketorolac, prednisone, and IVIG. Shortly after admission, he experienced sudden crushing, substernal chest pain. An ECG obtained during the episode showed striking ST segment elevation in the inferolateral leads (Image 2). He was started on a nitroglycerin drip, supplemental oxygen, low dose aspirin and received 3 doses of morphine. The acute chest pain responded rapidly to these measures, and the nitroglycerin drip was stopped after 24 hours without recurrence of symptoms. An echocardiogram was normal. Cardiac MRI showed subepicardial enhancement without evidence of acute infarction. He was discharged on hospital day #4, chest pain free for 24 hours with downtrending troponin.

Discussion: Our patient’s initial presentation of chest pain with elevated troponin and mild diffuse ST segment elevation is consistent with myopericarditis, similar to described cases occurring after the COVID-19 vaccine. During an acute, more severe, episode of chest pain, there was further localized ST segment elevation consistent with myocardial ischemia. Serial ECGs demonstrated improvement as the chest pain resolved, suggesting acute coronary artery vasospasm. Intravenous nitroglycerin, the mainstay of treatment for coronary vasospasm, was therapeutic with no recurrence of chest pain. Interestingly, our patient’s acute inferolateral ST segment elevations during the episode of severe chest pain correlated with the distribution of myocardial enhancement noted on cardiac MRI, implicating subepicardial myocarditis as the likely cause. This complication has been reported in adults with viral myocarditis.

Conclusion: This case highlights the importance of recognizing coronary vasospasm as a potential complication of COVID vaccine-induced myopericarditis.