Images of COVID-19 Vaccination

Rozin AP and Yalonetsky S

Published on: 1970-01-01

Abstract

A 62-year old man is on chronic dialysis 5 years due to chronic renal failure. He has 40-year FMF history treated with colchicine without pericarditis events. The patient had severe fatigue, extreme weakness, abdominal pain and hypotension on admission. Eight days before he got the first Covid-19 vaccine. Then he felt well. Last dialysis was 2 days before current hospitalization. He indicated heart rate 120 per minute, blood pressure 90/40, respiratory distress, muffled heart tones, low lung dullness, and decreased inspiration sounds. The CT angiogram showed large pericardial effusion and mild to moderate pleural effusion. Transthoracic echocardiography (ECHO) showed large pericardial effusion with collapsed right heart. His 12 leads ECG showed low voltage with electrical alternance and old inferior scar post myocardial infarction. Urgent pericardiocenthesis disclosed 700 ml sero-sanguinose fluid with 600 leucocytes/mm3, most polymorphonuclears.  No bacterial, viral pathogens or malignant cells observed in the pericardial fluid. Immuno-serology was negative for infection and autoimmune diseases. Control ECHO twice showed no return of pericardial effusion and the drain evacuated on the 3-rd day without additional therapy. FMF pericarditis as the first and very late manifestation of the patient treated with colchicine seems unlikely. General practitioner was informed and second vaccine canceled as life threatening.  Multiple reports about corona virus induced cardiac tamponade bring for consideration of possible S-protein-immune system competetion. Lifesaving COVID-19 vaccination may be dangerous for very ill and debilitated patients. We should be ready to choose appropriate population for vaccination and to diagnose life-threatening complications early.

Keywords

Covid-19 Vaccination; Cardiac Tamponade; FMF; Pericardiocenthesis; Chronic Renal Failure

Clinical Image

Although Edwin Klebs first saw the bacillus causing diphtheria in 1883, Friedrich Loeffler isolated the Corynebacterium diphtheriae. Trying to explain fatal disease without spread of the microbes, he proposed toxin release, found by Emile Roux. On basis of the toxin, Emil Behring created anti-toxin serum, which saved milllions children during diphteria epidemic. How far have we moved away from that era? Novel COVID-19 pandemic have brought a challenge to humanity. Viral S-protein is a part of aggressive mechanism of corona virus. This attaches to tissues starting damage. Sinthezied by m-RNA modified lymphocyte S-protein induces immune response, but it is similar viral! Response defense by antibodies and immune cells impairs S-protein expansion providing tissue resistance. However, what happens if response defense is incompetent in elderly and severe ill patients? Aggressive properties of the S-protein are probably going to wake up! Here our case illustrates this way of thinking. A 62-year old man is on chronic dialysis 5 years due to chronic renal failure. He has 40-year FMF history treated with colchicine without pericarditis events. The patient developed severe fatigue, extreme weakness, abdominal pain and hypotension. Eight days before he got first Covid-19 vaccine. Then he felt well. Last dialysis was 2 days before current hospitalization. He indicated heart rate 120 per minute, blood pressure 90/40, respiratory distress, muffled heart tones, low lung dullness, and decreased inspiration sounds on admission. COVID-19 RT-PCR was negative. The CT angiogram showed large pericardial effusion and mild to moderate pleural effusion (Figure 1). Transthoracic echocardiography (ECHO) showed large pericardial effusion with collapsed right heart (Figure 2).

Figure 1: CT angiogram of chest: large pericardial effusion (PF), collapsed right heart (contrast) and pleural effusion are seen.

Figure 2:  Transthoracic echocardiography in the subcostal view.

Panel A: large concentric pericardial effusion (marked by arrows).

Panel B: After pericardial tap just trace pericardial effusion is visualized (marked by arrow).

His 12 leads ECG showed low voltage with electrical alternance and old inferior scar post myocardial infarction. Urgent pericardiocenthesis disclosed 700 ml sero-sanguinose fluid with 600 leucocytes/mm3, most polymorphonuclears.  No bacterial, viral pathogens or malignant cells observed in the pericardial fluid. Immuno-serology was negative for infection and autoimmune diseases, apart from increased IGA (648, N<350 mg/dl). Control ECHO twice showed no return of pericardial effusion and the drain was removed on the 3-rd day without additional therapy. FMF pericarditis as the first and very late manifestation of the patient treated with colchicine seems unlikely. General practitioner was informed and second vaccine canceled as life threatening.  Last year multiple publications about cardiac tamponade due to active COVID19 infection described at all ages [1-11]. Most of the reports indicate development of aggressive pericardial effusion 8 day (1-29) after first symptoms of the disease. Our case came 8 days after vaccination too. All reports showed pericardicentesis as single life-saving curable procedure without need of additional therapy like that of our case. Norway physicians reconsidered population for corona vaccines excluding severe ill and late elderly group after 33 cases of fatal events. Our case takes back: the S-protein may be dangerous in very debilitated and compromised patients. Antibody production might be delated and not to come at term and tissue damage follows. Hypersensitivity may be another mechanism of inflammation (See competition scheme Figure 3).

Figure 3: Competition of immunity [2] and S-protein [1] for neutralisation or induction of tissue damage.

Diphtheria toxin and S-protein of corona should be neutralized by antibody and cell mediated immunity! Beck's triad (jugular vein distention, hypotension and muffled heart tones) should be red signal of cardiac tamponade! We do not detail origin of our vaccine. We are sure it does not matter! It may happened with each acting vaccine. The authors of this message have got the same vaccine and convinced that it is great life protection prophylaxis. Recently Maccabi Health provider in Israel informed about 0.02% mild corona infection cases after 28 days since completion of two-dose vaccination (20 of 128000)! The problem is how we are ready: to choose appropriate population for vaccination and to diagnose life-threatening complications early. "The decision is always based on a risk-benefit assessment", said Christian Bogdan, director of the Institute for Clinical Microbiology, Immunology and Hygiene at Erlangen University Hospital, who is also a member of the Standing Committee on Vaccination (STIKO) at the Robert Koch Institute (RKI). To the German Press Agency, he made the following calculation: "If an elderly person has a 20% chance of dying from a Corona infection, and at the same time the risk of getting a severe side effect of the vaccination is 1:50,000 or even less, I would accept that risk," he said [12].

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