ARCHIVES OF PATHOLOGY AND LABORATORY MEDICINE - James R. Gill, MD;
Randy Tashjian, MD; Emily Duncanson, MD - Volume 146, Issue 8 - AUGUST 2022
Context.—
Myocarditis in adolescents has been diagnosed clinically following the administration of the second dose of an mRNA vaccine for coronavirus disease 2019 (COVID-19). Autopsies were conducted on two teenage boys, one in Connecticut and one in Michigan, who died within a few days of their second dose of Pfizer's Covid vaccine. One boy had ADD and the other was obese. The post-death examinations showed that both had "global myocardial injury."
Objective.—
To examine the autopsy microscopic cardiac findings in adolescent deaths that occurred shortly following administration of the second Pfizer-BioNTech COVID-19 dose to determine if the myocarditis described in these instances has the typical histopathology of myocarditis.
Design.—
Clinical and autopsy investigation of 2 teenage boys who died shortly following administration of the second Pfizer-BioNTech COVID-19 dose.
Results.—
The microscopic examination revealed features resembling a catecholamine-induced injury, not typical myocarditis pathology.
Conclusions.—
The myocardial injury seen in these postvaccine hearts is different from typical myocarditis and has an appearance most closely resembling a catecholamine-mediated stress (toxic) cardiomyopathy. Understanding that these instances are different from typical myocarditis and that cytokine storm has a known feedback loop with catecholamines may help guide screening and therapy.
Myocarditis in adolescents (particularly teenage boys) has been reported following the second dose of the Pfizer-BioNTech COVID-19 vaccine.1–7 Since cardiac biopsies are rarely performed in these instances with clinically stable patients, the myocardial pathology has not been clearly elucidated.8 Myocarditis is rarely diagnosed at autopsy in deaths due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.9,10 The incidence of myocarditis, although low, has been shown to increase after the receipt of the BNT162b2 vaccine, particularly after the second dose among young male recipients.11 In addition, the first week after the second vaccine dose was found to be the main risk window.11 The clinical presentation of myocarditis after vaccination was usually mild.11
We report the autopsy results, including microscopic myocardial findings, of 2 teenage boys who died within the first week after receiving the second Pfizer-BioNTech COVID-19 dose. The microscopic findings are not the alterations seen with typical myocarditis. This suggest a role for cytokine storm, which may occur with an excessive inflammatory response, as there also is a feedback loop between catecholamines and cytokines.12
MATERIALS AND METHODS
The Connecticut Office of the Chief Medical Examiner and the Michigan Institute of Forensic Science and Medicine investigate all unexpected and unnatural deaths in their respective jurisdictions: Connecticut and the Michigan counties of Alcona, Gladwin, Huron, Lapeer, Ogemaw, and Saginaw.
Standard medicolegal autopsies were performed including gross, microscopic, and toxicologic testing. SARS-CoV-2 nasal swab testing was performed by reverse transcriptase–polymerase chain reaction assay. Tissues were sent to the National Center for Emerging and Zoonotic Infectious Diseases branch of the Centers for Disease Control and Prevention for molecular studies.
Cardiac molecular testing with sequence analysis and deletion/duplication testing of the 100 genes listed in Invitae's arrhythmia and cardiomyopathy comprehensive panel was performed.
RESULTS
The results of autopsies for 2 teenage boys who were found dead in bed 3 and 4 days after receiving the second dose of the Pfizer-BioNTech COVID-19 vaccine are presented (Table). Both boys were pronounced dead at home without attempted resuscitation.