First Identified Case of Fatal Fulminant Necrotizing Eosinophilic Myocarditis Following the Initial Dose of the Pfizer-BioNTech mRNA COVID-19 Vaccine (BNT162b2, Comirnaty): an Extremely Rare Idiosyncratic Hypersensitivity Reaction

Abstract

Rationale Transient myopericarditis has been recognised as an uncommon and usually mild adverse event predominantly linked to mRNA-based COVID-19 vaccines. These have mostly occurred in young males after the second dose of mRNA COVID-19 vaccines. Objectives Fulminant necrotising eosinophilic myocarditis triggered by a variety of drugs or vaccines is an extremely rare hypersensitivity reaction carrying a substantial mortality risk. Early recognition of this medical emergency may facilitate urgent hospital admission for investigation and treatment. Timely intervention can lead to complete cardiac recovery, but the non-specific clinical features and rarity make early diagnosis challenging. Findings The clinical and pathological observations from a case of fatal fulminant necrotising myocarditis in a 57-year-old woman, following the first dose of the Pfizer-BioNTech vaccine, are described. Other causes have been discounted with reasonable certainty. Conclusion These extremely rare vaccine-related adverse events are much less common than the risk of myocarditis and other lethal complications from COVID-19 infection. The benefits of vaccination far exceed the risks of COVID-19 infection.

First Identified Case of Fatal Fulminant Eosinophilic Myocarditis Following the Initial Dose of the Pfizer-BioNTech mRNA COVID-19 Vaccine (BNT162b2, Comirnaty): an Extremely Rare Idiosyncratic Necrotizing Hypersensitivity Reaction Different to Hypersensitivity or Drug-Induced Myocarditis

“…It can be classified by causative (viral, bacterial, protozoal, trypanosomal, toxic, hypersensitivity or drug induced), histological (eosinophilic, giant cell, granulomatous, lymphocytic), and clinicopathological (fulminant, acute, chronic active, chronic persistent, myopericarditis) criteria. The authors of the above report [1] correctly characterized this unique case of fulminant eosinophilic myocarditis as an extremely rare idiosyncratic necrotizing hypersensitivity reaction because it is clearly differentiated from hypersensitivity myocarditis. It seems that the combination of fulminant, eosinophilic, necrotizing, hypersensitivity, and idiosyncratic elements of this myocarditis constitute a new type of the disease that follows COVID-19 vaccination.…”

“…We read with interest the report published in the Journal of Clinical Immunology [1] describing an extremely rare vaccine-related fatal fulminant necrotizing eosinophilic myocarditis, in a female patient, following the initial dose of the Pfizer-BioNTech mRNA COVID-19 Vaccine (BNT162b2, Comirnaty) with abundant eosinophils and focal myocyte necrosis at autopsy and we like to comment on the confusion related to classification of myocarditis following COVID-19 vaccination.…”

Fulminant necrotizing eosinophilic myocarditis after COVID‐19 vaccination survived with mechanical circulatory support

“…16 Patients of COVID-19 vaccination-associated myocarditis in older ages have been reported to progress to fatal outcome. 5,6 There have been only one report of NEM after COVID-19 vaccination, in which the patient was found deceased at home and the autopsy confirmed the diagnosis. 6 In the present case, the patient did not show the evidence of infection of any viruses or other microorganisms and did not have a history of exposure to any new drugs potentially causing hypersensitivity reaction.…”

Myocarditis following COVID-19 vaccination: incidence, mechanisms, and clinical considerations

“…Few published cases have undergone extensive immunologic testing, and reports including histopathological analysis are few, perhaps due to the generally low severity of COVID-19 vaccine-associated myocarditis [ 56 ]. Of the few autopsy reports published, most cases demonstrate a lymphocyte predominance, with some cases also describing an accompanying neutrophil population [ 46 , 56 , 57 ]. This finding is mirrored by the lymphocyte-predominant immune infiltrates seen in cases where endomyocardial biopsy is used [ 58–62 ].…”

“…This finding is mirrored by the lymphocyte-predominant immune infiltrates seen in cases where endomyocardial biopsy is used [ 58–62 ]. While some reports describe eosinophilic myocarditis in patients with severe vaccine-associated myocarditis, this is a very rare finding with unclear implications [ 57 , 63 ]. In contrast to vaccine-associated myocarditis, the multifactorial cardiac inflammation seen with SARS-CoV-2 infection is believed to be indirectly driven by circulating cytokines, with true myocarditis being uncommon [ 64 , 65 ].…”