Letter by Kounis et al Regarding Article, "Biopsy-Proven Giant Cell Myocarditis Following the COVID-19 Vaccine".

Abstract

HomeCirculation: Heart FailureVol. 15, No. 10Letter by Kounis et al Regarding Article, “Biopsy-Proven Giant Cell Myocarditis Following the COVID-19 Vaccine” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Kounis et al Regarding Article, “Biopsy-Proven Giant Cell Myocarditis Following the COVID-19 Vaccine” Nicholas G. Kounis, Ioanna Koniari, Virginia Mplani, Dimitrios Velissaris and Panagiotis Plotas Nicholas G. KounisNicholas G. Kounis https://orcid.org/0000-0002-9751-6710 Department of Cardiology (N.G.K., P.P.), University of Patras Medical School, Greece. Search for more papers by this author , Ioanna KoniariIoanna Koniari Department of Cardiology, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom (I.K.). Search for more papers by this author , Virginia MplaniVirginia Mplani Intensive Care Unit (V.M.), University of Patras Medical School, Greece. Search for more papers by this author , Dimitrios VelissarisDimitrios Velissaris Department of Internal Medicine (D.V.), University of Patras Medical School, Greece. Search for more papers by this author and Panagiotis PlotasPanagiotis Plotas Department of Cardiology (N.G.K., P.P.), University of Patras Medical School, Greece. Search for more papers by this author Originally published10 Oct 2022https://doi.org/10.1161/CIRCHEARTFAILURE.122.009826Circulation: Heart Failure. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 10, 2022: Ahead of Print To the Editor:We read with interest the article by Sung et al1 which describes a 63-year-old man who developed, 2 weeks after the second dose of the BNT162b2 vaccine, clinical heart failure with reduced ejection fraction to 35%, biventricular hypertrophy, apical hypokinesis on echocardiography, and elevated filling pressures with cardiac index of 1.8 L/min per M2 on left and right heart catheterization necessitating aortic balloon pump was placement. The endomyocardial biopsy revealed lymphocytes, eosinophils, and giant cells compatible with giant cell myocarditis. The patient was treated with steroids and immunosuppressives and his condition is improving. This report raises issues on delayed myocarditis, etiology, and perspectives to prevent myocarditis. The delayed occurrence of postvaccination reactions is not new. Such reactions have been associated with vaccines containing antimicrobial agents and ingredients, such as thimerosal and aluminum, and with Japanese encephalitis and rabies vaccines.2 These reactions are antibody independent, cell-mediated, stemming from overstimulation of T lymphocyte–mediated infiltration, as correctly emphasized by the authors, and monocytes/macrophages and cytokine release that further cause inflammation, cell death, and tissue damage. The types of myocarditis are classified by clinicopathological, causative, and histological criteria. The latter include eosinophilic, giant cell, histiocytic, granulomatous, and lymphocytic myocarditis. The giant cells are multinucleate cells that constitute a mass formed by the union of several distinct cells, such as histiocytes and eosinophils. The histiocyte cytoplasm is eosinophilic and contains variable amounts of lysosomes. Therefore, eosinophilic, giant cell, and histiocytic myocarditis are types of hypersensitivity myocarditis or drug-induced myocarditis that have been firstly described by one of the authors of this letter.3 Several cases of giant cell myocarditis due to drug hypersensitivity with a notably devastating clinical course, including heart transplantation, have been described recently.4 Compared with lymphocytic myocarditis that is mainly viral, giant cell myocarditis is much more severe, with much more rapid progression, as in the described case, presumably due to multiple cell involvement. Drug-induced hypersensitivity myocarditis is particularly difficult to recognize clinically because the clinical features characteristic of hypersensitivity reaction—including nonspecific skin rash, malaise, fever, and eosinophilia—are not always present. Most patients respond well to steroid and/or immunosuppressive administration or drug removal. COVID-19 vaccines, including the BNT162b2 vaccine, dispose recipients that could be potential antigens able to induce hypersensitivity such as polyethylene glycol. However, creams, ointments, lotions, cosmetics, and dental materials, which are usually used by women and young individuals contain also polyethylene glycol, whereas 1% to 5.4% of the general population has been sensitized to cosmetics or dental materials. Therefore, such recipients could induce hypersensitivity and consequently hypersensitivity myocarditis. Indeed, there are suggestions of alternative recipients if vaccine component-induced hypersensitivity is confirmed by systematic future investigations. Hypersensitivity to such recipients constitutes risk to patients with allergy to polyethylene glycol. COVID-19 vaccines could be offered to most patients, but according to new suggestions, susceptible patients should wait for new vaccines containing different recipients.5 Myocarditis post–COVID-19 vaccination is very rare while the benefits of vaccination should be counterbalanced and continue to be recommended to all eligible individuals.Article InformationDisclosures None.FootnotesFor Disclosures, see page 1004.