Chest Pain in a 15-Year-Old Boy Following Administration of Second COVID-19 Vaccine Dose

Case Report

A 15-year-old boy with no previous medical history presented to a local emergency department 2 days after receiving his second dose of the Pfizer-BioNTech COVID-19 vaccine. History revealed that during the afternoon after he had received the second dose, the patient began feeling general malaise and chills that progressed into headaches. The following day, upon awaking, the patient developed dull, burning, substernal chest pain that radiated to the throat and ears that he described as tightness. The pain was alleviated by leaning forward and exacerbated by deep inspiration. He also had related numbness and tingling in his arms and hands. The patient attempted to relieve his symptoms with the use of acetaminophen, which resulted in mild improvement of symptoms. Persistence of symptoms despite acetaminophen usage prompted the patient to present to the hospital. While at the emergency department, he was afebrile and hemodynamically stable. Laboratory analysis with complete blood count (CBC), chest x-ray (CXR), and electrocardiogram (ECG) revealed normal white blood cell, elevated hemoglobin at 17.8, no acute findings on CXR, and sinus rhythm with reported possible left ventricular hypertrophy on ECG. Troponin was elevated at 0.96 ng/mL (This is a distinct use of the unit “ng/mL.” Later values from Loma Linda University Children’s Health [LLUCH] are reported as “ng/L.”) and C-reactive protein elevated at 3.05 mg/dL with normal erythrocyte sedimentation rate and normal creatine phosphokinase. He was then transferred to LLUCH for further inpatient management.

Final Diagnosis

The final diagnosis was probable myocarditis in the setting of Pfizer-BioNTech COVID-19 vaccination. This patient reported signs and symptoms consistent with myocarditis, including new-onset chest pain and elevated troponins immediately after receiving the Pfizer-BioNTech COVID-19 vaccination. The diagnosis is based on clinical suspicion but was not confirmed with myocardial biopsy or cardiac magnetic resonance imaging.

Hospital Course

Once at LLUCH, troponin levels and ECGs were trended. On hospital day 1, a repeat ECG showed ST elevation in leads II, III, and AVF with mild elevations in other leads. An echocardiogram was negative for acute pericardial effusion or other structural or functional abnormalities. Troponin T levels on the day after admission were 626 ng/L and peaked during hospital day 2 at 1051 ng/L (Figure 1). Due to continually rising troponin levels, cardiology was consulted and colchicine and indomethacin were started for presumed pericarditis. On hospital day 3, troponin levels finally began to downtrend. Colchicine was discontinued on hospital day 4 and indomethacin transitioned to ibuprofen. The patient was subsequently discharged with a final troponin level of 389 ng/L and strict instructions for symptom monitoring. Follow-up was planned at 2 weeks post-discharge with cardiology.

Figure 1.

Serial troponin levels since admission.

Discussion

The rapid development of mRNA vaccines against COVID-19 represents a modern scientific marvel. Widespread availability and administration of these vaccines has led to many lives being saved, particularly in at-risk populations. However, vaccine hesitancy continues to present challenges, particularly among minority populations.¹ Safety is the number 1 driver of vaccine hesitancy, over effectiveness and other factors.² Given the relative novelty of these vaccines, the relationship between COVID-19 vaccination and adverse effects in certain populations remains unclear. Myocarditis in the pediatric population following vaccination is one such example that has garnered more public attention recently.

Recent large clinical studies on COVID vaccine safety have concluded that vaccine-associated myocarditis is rare, occurs mostly after the second vaccine dose, disproportionately affects young men, and is associated with prompt resolution and good short-term prognosis.^3-5 In the general population—based on data from Israel—COVID-19 infection has been found to be associated with myocarditis at 5 times the rate of COVID-19 vaccination.⁵ However, more data regarding COVID vaccine–induced myocarditis in the pediatric population specifically would likely be informative.

The clinical management of myocarditis in the pediatric population is determined by the severity of signs and symptoms that range from asymptomatic disease to acute heart failure with cardiogenic shock.⁶ Some cases of myocarditis like the one presented here are mild and may require only bed rest, supplemental oxygen, and diuretics.⁷ More studies are needed to support the use of intravenous immunoglobulin (IVIG) for the treatment of severe myocarditis in the pediatric population. Although IVIG tends to be used in sicker patients, current studies do not show statistically significant benefit for survival regardless of the patient’s severity.^8,9 Immunosuppression is another option in the treatment of pediatric myocarditis. One trial evaluating the use of conventional therapies alone or with 24-week regimens of prednisone and cyclosporine or prednisone and azathioprine found improvement in left ventricular ejection fraction at 28 weeks in all groups but no statistically significant difference between groups.⁹ For severe cases of myocarditis with systolic dysfunction and left ventricular ejection fraction of 40% or less, randomized controlled trials suggest a regimen of angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone.⁶

Benefits of vaccination should be weighed against risks when advising parents and patients. Two-dose vaccination with the Pfizer-BioNTech COVID-19 vaccine has been shown to be 91% effective (95% confidence interval = 78%-97%) against development of multisystem inflammatory syndrome in children (MIS-C) aged 12 to 18 years. In this same analysis by Zambrano et al,¹⁰ although no deaths were reported in either the vaccinated or unvaccinated groups, none of the 38 individuals with MIS-C who needed life support were vaccinated.

Much attention has been given to the quantity and validity of VAERS (Vaccine Adverse Event Reporting System) reports related to COVID-19 vaccination.^11,12 A note should be made that VAERS reports may be submitted by both healthcare practitioners and the public at large and do not represent causation on the part of the vaccine but rather only correlation; they are unconfirmed reports representing a possible side effect. We do not wish to enter the debate surrounding aggregate validity of the reports but rather desire to point out the disproportionate quantity of reports based on age and sex.

If the assumption is made that these data, at least in ratios, roughly approximate the incidence of myocarditis caused by vaccination, intriguing trends may be seen. The VAERS data (see Table 1) show men below 30 years of age—including the pediatric population (shown in red text)—as having an increased likelihood of experiencing myocarditis associated with vaccination when compared with the general population. This disproportionate risk becomes much less apparent in groups greater than 30 years of age.¹³

Table 1.

Vaccine Adverse Event Reporting System Reports of Myocarditis Following Administration of COVID-19 Vaccine.

Age group	Sex	Number and percentage of events reported (total = 2589)
3-5 years	Female	0 (0.00%)
	Male	2 (0.08%)
	Total	2 (0.08%)
6-17 years	Female	62(2.39%)
	Male	490 (18.93%)
	Unknown	4 (0.15%)
	Total	556 (21.48%)
18-29 years	Female	159 (6.14%)
	Male	668 (25.80%)
	Unknown	2 (0.08%)
	Total	829 (32.02%)
30-49 years	Female	210 (8.11%)
	Male	396 (15.30%)
	Unknown	2 (0.08%)
	Total	608 (23.48%)
50+ years	Female	193 (7.45%)
	Male	188 (7.26%)
	Unknown	4 (0.15%)
	Total	385 (14.87%)
Unknown age	Total	209 (8.07%)

Pediatric males in denoted in red.

Conclusion

This case is unique in that the age of the patient is younger than many of the other incidences reported in literature. The risk of myocarditis following administration of the Pfizer-BioNTech COVID-19 vaccine appears to be greatly increased in men below the age of 30 compared with older segments of the population.⁸ Given the potential for disproportionate incidence, studies describing the risk of myocarditis in the population as an aggregate are likely not generalizable to men younger than 30, including pediatric males. Further investigation is warranted to determine the risk of vaccine-related myocarditis in this subset of the population. We believe this clinical case is of importance because vaccine hesitancy has become a common point of contention between providers and patients, especially toward the novel COVID-19 vaccines. An open and honest discussion between providers and patients is a matter of public health and safety, and the ability to discuss and appreciate adverse outcomes will lead to better, more informed decisions.

Author Contributions

VG: Contributed to conception and design; contributed to acquisition and interpretation; drafted and critically revised the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy.

NB: Contributed to conception; contributed to acquisition; drafted the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy.

DL: Contributed to conception and design; drafted and critically revised the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy.

CW: Contributed to conception; drafted the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy.

AC: Contributed to conception; critically revised the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy.

SH: Contributed to acquisition and interpretation; critically revised the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy.