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COVID-19 Vaccine-Related eConsults: Case 1

eConsult Clinical Question

My patient received the Pfizer COVID-19 vaccine. Three weeks later, she presented to emergency department (ED) for evaluation of squeezing chest pain and shortness of breath that developed, and then awoke her from sleep two days prior. Pain was worse with deep breathes, lying flat, and leaning forward and improved with rest and ibuprofen. 

She had a negative d-dimer in the ED and her echocardiogram was unremarkable. The ED diagnosed her with pericarditis and told her to follow-up with PCP about when and whether to receive second shot. Would you recommend second shot and if so, would you consider having her monitored for extra time?

eConsult Response

  1. Recommendations: Hold off on second dose until the symptoms of pericarditis have resolved. Would not recommend pretreating with nonsteroidal anti-inflammatory drugs (NSAIDs), but rather treat as needed. Would like to see if the symptoms are reproducible because the COVID vaccine are probably going to be a routine part of health care going forward. Wait 30-minute post injection of second dose. Have NSAIDs available as needed. There are case reports of myocarditis/pericarditis post COVID vaccine administration, but this is not a contraindication for the COVID vaccine. The bigger question is whether the vaccine and acute event of pericarditis are related. While there is limited data on incidence of pericarditis, it has been reported in up to 5% of patients admitted to the ED with nonischemic chest pain. If symptoms are reproducible with the second dose of the vaccine, then we can establish such as association for this patient. If that is the case, we would recommend a different COVID vaccine in the future. 
  2. Contingency plan: Receive a different brand of COVID vaccine for second dose.

These real-life examples have some limitations. Given the evolving recommendations and guidance on COVID-19 care, these cases should not be considered complete or definitive and may not reflect the most up-to-date guidance.