key: cord-0904942-1pnkrpgc authors: Marsukjai, Apichai; Theerasuwipakorn, Nonthikorn; Tumkosit, Monravee; Chattranukulchai, Pairoj; Srichomkwun, Panudda; Prechawat, Somchai title: Concomitant myocarditis and painless thyroiditis after AstraZeneca coronavirus disease 2019 vaccination: a case report date: 2022-05-17 journal: J Med Case Rep DOI: 10.1186/s13256-022-03438-z sha: f6e6bdc4445afaffdd9e82a5df872933341f9472 doc_id: 904942 cord_uid: 1pnkrpgc BACKGROUND: Incidence of myocarditis following messenger RNA coronavirus disease 2019 vaccination has been widely described, but this clinical scenario after adenoviral vector coronavirus disease 2019 vaccination has only been rarely reported. In addition, a few case reports of thyroiditis after adenoviral vector coronavirus disease 2019 vaccination have been published. CASE PRESENTATION: A 55-year-old Thai woman presented with palpitation without neck pain 14 days after receiving AstraZeneca coronavirus disease 2019 vaccination. Electrocardiography revealed sinus tachycardia. Her blood tests showed elevation of cardiac troponin and free triiodothyronine with suppressed serum thyroid stimulating hormone, reflecting a hyperthyroid status. Evidence of myocardial inflammation and necrosis from cardiac magnetic resonance imaging supported the diagnosis of recent myocarditis. Laboratory results and imaging findings were consistent with thyroiditis. After 3 weeks of symptomatic treatment, her symptom and blood tests had returned to normal. CONCLUSIONS: This case demonstrates that the adenoviral vector coronavirus disease 2019 vaccine could possibly cause myocarditis and painless thyroiditis. Clinicians should have a high index of suspicion and promptly evaluate these conditions, despite minimal symptoms. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13256-022-03438-z. Since the emergence of the coronavirus disease 2019 (COVID-19)/severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, effective vaccines against COVID-19 have been developed [1] . The Astra-Zeneca COVID-19 vaccine (ChAdOx1-S/nCoV-19 [recombinant], AZD1222), a replication-deficient adenoviral vector vaccine that contains the SARS-CoV-2 spike protein gene, triggers the immune system to generate an immune response against the coronavirus and retain that information in memory immune cells [2, 3] . This vaccine was used for mass vaccination nationally and globally. In Thailand, more than 40 million doses have already been given. The most well-publicized adverse reactions are vaccine-induced thrombosis and thrombocytopenia [4] . However, there are a few published reports regarding thyroiditis and myocarditis following exposure to the AstraZeneca COVID-19 vaccine. We report the case of a patient who developed concomitant myocarditis and painless thyroiditis after receiving the AstraZeneca COVID-19 vaccine. mg/day) and exercise restriction, her symptom and blood tests had returned to normal (Table 1 ). Myocarditis and pericarditis are well-known potential adverse reactions after mRNA-1273 and BNT162b2 vaccine administration [5] . They are not widely recognized as possible adverse reactions of AstraZeneca COVID-19 vaccine, though the incidence of suspected myocarditispericarditis following mRNA and AstraZeneca COVID-19 vaccine from the vaccine adverse event reporting system was similar (1.6-5.0 versus 2.0-3.7 per million doses, respectively) [6] . To date, only a few cases of myocarditis following exposure to the AstraZeneca COVID-19 vaccine have been published [7, 8] . Our patient age was not common for mRNA-induced myocarditis, but the typical age of AstraZeneca COVID-19 vaccinerelated myocarditis has not previously been concluded. Vaccine-related myocarditis usually presented with mild symptoms, which resolved spontaneously with conservative treatment [7, 9] . A severe form presented with cardiogenic shock and need for hemodynamic support had been scarcely reported [8, 10] . Chest pain is the most common presentation; unlike other reports, our case presented with palpitation, which could be a manifestation of myocarditis, thyroiditis, or both [9] . CMR is recommended, in addition to ECG, cardiac markers, and TTE, for myocarditis with minimal symptoms due to noninvasiveness and trustworthy tissue characterization ability [11] . This case highlights the significance of CMR for diagnosis of myocarditis, particularly when the presentation is mild and TTE findings are negative. Post-vaccination thyroiditis, a well-knwon autoimmune/inflammatory syndrome induced by adjuvants (ASIA), has been reported after various types of vaccine, including all COVID-19 vaccine platforms. This condition predominantly affects women in an age range from 26 to 75 years [12] [13] [14] . Symptoms, typically mild and self-resolving without specific treatment, can occur 4-21 days after vaccination. Most patients have neck pain at the onset, while only one case of painless thyroiditis, as in our patient, has been reported [13] . At the onset of presentation, patients can have hyperthyroid (most common), hypothyroid, or euthyroid status [13] . Differential diagnoses of post-vaccination thyrotoxicosis included Graves' disease, and co-occurrence of subacute thyroiditis and Graves' disease was also reported [15] . Thyroid antibodies and iodine-131 uptake should be investigated to clarify the etiology of thyrotoxicosis. AstraZeneca COVID-19 vaccine contains recombinant replication-deficient chimpanzee adenovirus vector encoding the SARS CoV-2 spike protein. Possible mechanisms for post-vaccination myocarditis and thyroiditis are molecular mimicry between SARS CoV-2 spike protein and self-antigens (myocyte protein and thyroid peroxidase) as well as triggering of preexisting dysregulated immune pathways [9, 16, 17] . However, the entire mechanism is unclear. To our knowledge, this is the first case report of concomitant myocarditis and painless thyroiditis following AstraZeneca COVID-19 vaccine administration. The true association cannot be established, although we demonstrate the temporal relationships between vaccine and these conditions. This case demonstrates that the adenoviral vector COVID-19 vaccine could possibly cause myocarditis and painless thyroiditis. Clinicians should have a high index of suspicion and promptly evaluate these conditions. Given a low incidence and minimal symptoms in most cases, the COVID-19 vaccine is recommended in the pandemic situation because the benefit from the vaccine greatly outweighs the risks. 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Thyrotoxicosis after COVID-19 vaccination: seven case reports and a literature review SARS-CoV-2 spike protein impairs endothelial function via downregulation of ACE 2 Reaction of human monoclonal antibodies to SARS-CoV-2 proteins with tissue antigens: implications for autoimmune diseases Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s13256-022-03438-z.Additional file 1. SSFP cine image in basal short-axis (SAX) view demonstrating regional wall motion abnormality.