To the Editor:
We read with interest the report by Minocha et al,1 in which the authors describe a case of a 17-year-old male patient with recurrent myocarditis. The second episode began 48 hours after he received the Pfizer-BioNTech coronavirus disease 2019 mRNA vaccine. This occurred 4 months after a previous episode of idiopathic myocarditis.
During the first episode of myocarditis, a cardiac magnetic resonance imaging scan demonstrated 2 small areas of subepicardial late gadolinium enhancement in the lateral mid- and apical segments. The patient recovered from this acute episode, but then returned 4 months later with a similar presentation.
lthough the symptomatology, electrocardiogram changes, and troponin rise recorded during the second presentation are all consistent with active myocarditis, the cardiac magnetic resonance imaging findings described in this report are not confirmatory of acute myocardial inflammation. The distribution late gadolinium enhancement described during the second episode of myocarditis is the same as in the first episode. Given that these changes were previously present, the late gadolinium enhancement seen during the second episode could represent old scar tissue, and therefore does not confirm an active inflammatory process.
T2 mapping is highly sensitive for myocardial edema and is often elevated in acute myocarditis. T2 mapping is particularly useful in cases in which an area of late gadolinium enhancement is present, but it is unclear whether this is due to an acute myocardial injury or the result of residual scar from a previous insult.2, 3, 4 Therefore, in cases of recurrent myocarditis, we suggest T2 mapping should be used to compliment the late gadolinium enhancement images.
Footnotes
The authors declare no conflicts of interest.
References
- 1.Minocha P.K., Better D., Singh R.K., Hoque T. Recurrence of acute myocarditis temporally associated with receipt of the mRNA coronavirus disease 2019 (COVID-19) vaccine in a male adolescent. J Pediatr. 2021;238:321–323. doi: 10.1016/j.jpeds.2021.06.035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kim H.W., Jenista E.R., Wendell D.C., Azevedo C.F., Campbell M.J., Darty S.N., et al. Patients with acute myocarditis following mRNA COVID-19 vaccination. JAMA Cardiol. 2021;6:1196–1201. doi: 10.1001/jamacardio.2021.2828. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Puntmann V.O., Carerj M.L., Wieters I., Fahim M., Arendt C., Hoffmann J., et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19) JAMA Cardiol. 2020;5:1265–1273. doi: 10.1001/jamacardio.2020.3557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.von Knobelsdorff-Brenkenhoff F., Schüler J., Dogangüzel S., Dieringer M.A., Rudolph A., Greiser A., et al. Detection and monitoring of acute myocarditis applying quantitative cardiovascular magnetic resonance. Circ Cardiovasc Imaging. 2017;10:e005242. doi: 10.1161/CIRCIMAGING.116.005242. [DOI] [PubMed] [Google Scholar]