Skip Navigation
Skip to contents

ACC : Acute and Critical Care

OPEN ACCESS
SEARCH
Search
Advanced Search
mobile menu button

Articles

Page Path
HOME > Acute Crit Care > Volume 34(2); 2019 > Article
Case Report
Cardiology Acute fulminant myocarditis following influenza vaccination requiring extracorporeal membrane oxygenation
Youn-Jung Kimorcid, Jun-Il Bae, Seung Mok Ryooorcid, Won Young Kimorcid
Acute and Critical Care 2019;34(2):165-169.
DOI: https://doi.org/10.4266/acc.2017.00045
Published online: November 7, 2018

Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Corresponding author Won Young Kim Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3350 Fax: +82-2-3010-3360 E-mail: wonpia73@naver.com
• Received: January 25, 2017   • Revised: April 29, 2017   • Accepted: May 2, 2017

Copyright © 2019 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • 11,309 Views
  • 199 Download
  • 27 Web of Science
  • 29 Crossref
  • 27 Scopus
prev next
Full Article

Download PDF Download PDF

  • The inactivated influenza vaccination is generally safe with mostly mild side effects. We report a rare but fatal adverse event following influenza vaccination. A previously healthy 27-year-old woman who received the influenza vaccination 3 days before presenting to the emergency department had rapidly aggravating dyspnea and mental deterioration. She was diagnosed as having acute fulminant myocarditis with refractory cardiogenic shock, which was successfully managed with veno-arterial extracorporeal membrane oxygenation. The cardiac function of the patient recovered in 3 weeks.
  • Keywords: adverse event; cardiogenic shock; extracorporeal membrane oxygenation; influenza vaccines; myocarditis
Influenza is an acute respiratory illness caused by the influenza A or B virus, which occurs in distinct annual outbreaks. Influenza causes highly variable clinical manifestations ranging from fever, general myalgia, fatigue, cough, and sore throat to neurologic complications, respiratory failure, shock, and death. The morbidity and mortality caused by influenza are substantial in the general population. Patients who are at high risk of serious complications from influenza include those aged 65 years or older, children aged between 6 and 59 months, those with chronic medical disorders of the respiratory, cardiovascular, hepatic and renal systems, and immunocompromised patients [1]. In Korea, the Korea Centers for Disease Control and Prevention [1] recommends annual influenza vaccinations for these high-risk groups due to their effectiveness in preventing influenza and reducing the burden of complications.
The inactivated influenza vaccination is usually well-tolerated and the side effects are mostly benign local or general reactions, including pain at the injection site, fever, or myalgia [2]. Serious adverse events have been very rarely reported and there have been few case reports of cardiac complications such as pericarditis, myocarditis, and stress-induced cardiomyopathy [3-5]. However, the mechanism of cardiac complications following influenza vaccination is not fully elucidated due its rare incidence. Herein, we report a case of acute fulminant myocarditis occurring after quadrivalent inactivated influenza vaccination (GC Flu Quadrivalent; Green Cross, Yongin, Korea), rescued by extracorporeal membrane oxygenation (ECMO).
The study was performed according to the Helsinki Declaration and approved by the Institutional Review Board of Asan Medical Center (IRB No. 2017-0213), and the informed consent was waived.
A 27-year-old woman without any previous medical history presented to the Emergency Department at Asan Medical Center, Seoul, Korea with a headache, nausea, vomiting, low back pain, and fatigue. Three days before presentation, she received an intramuscular injection against influenza. A quadrivalent inactivated influenza vaccination (GC Flu Quadrivalent, Green Cross) was administered, containing 15 μg hemagglutinin each of the same two A strains per 0.5 mL dose: an A/Christchurch/16/2010 NIB-74xp (H1N1), A/Hongkong/4801/2014 NYMC X-263B (H3N2), B/Brisbane/60/2008, and B/Phuket/3073/2013. Two days later, she developed low back pain, and after ingestion of a nonsteroidal anti-inflammatory drug for pain relief, headache, nausea, and vomiting also developed.
At initial presentation, her vital signs were as follows: blood pressure, 145/101 mmHg; pulse rate, 116 beats per minute; respiratory rate, 20 breaths per minute; body temperature, 37.4°C; and oxygen saturation, 95% on room air (Figure 1). General physical examination revealed unremarkable findings and upon neurological examination; she had no sign of meningismus. However, she developed dyspnea and a cough with pink, frothy sputum after 4 hours of waiting for the laboratory results. Her pulse and respiratory rates had elevated to 169 beats per minute and 30 breaths per minute, respectively. Her oxygen saturation ranged from 83% to 95% despite the constant oxygen supply via an oxygen mask with a reservoir bag and a flow rate of 15 L/min. A chest X-ray also demonstrated significant changes over the 4-hour period, during which she went from having a normal chest to having diffuse ground glass opacities in both lung fields, which suggested pulmonary edema or impending acute respiratory distress syndrome (Figure 2A). Her electrocardiogram demonstrated sinus tachycardia without STsegment changes.
Her initial laboratory findings are presented in Table 1. Cardiac troponin I was elevated at 25.140 ng/mL, as was creatine kinase-MB at 54.2 ng/mL and creatine kinase at 628 IU/L. Brain natriuretic peptide was 1,803 pg/mL (normal <100 pg/mL). Blood and sputum cultures were negative and a respiratory polymerase chain reaction panel to detect common respiratory pathogens also showed unremarkable findings. Bedside transthoracic echocardiogram demonstrated biventricular akinesia of the mid to apical walls, implying biventricular dysfunction. The left ventricular ejection fraction (LVEF), which was estimated using Simpson’s biplane method, was 15%. Mild mitral regurgitation was also detectable via color Doppler analysis.
Respiratory distress and mental deterioration were observed soon after bedside echocardiography, therefore endotracheal intubation was performed. Despite ventilator care and vasopressor infusion, her blood pressure still remained below 60 to 70 mmHg and tissue hypoperfusion, which was reflective of elevated lactic acid levels, was observed. To save the patient from refractory cardiogenic shock, emergency veno-arterial ECMO was performed in the emergency department (Figure 2B).
She was admitted to the emergency intensive care unit, where she gradually recovered. She was successfully weaned from ECMO on the 5th day of hospitalization, and from the mechanical ventilator on the 9th day (Figure 2C), when follow-up echocardiography showed improved left ventricular dysfunction (LVEF, 48%). Cardiovascular magnetic resonance imaging was performed on the 14th day of hospitalization, which demonstrated slightly increased global myocardial T2 values without delayed enhancement in the left ventricular myocardium, indicating an improved status of acute myocarditis (Figure 3). Follow-up echocardiography on the 21st day confirmed the normalized left ventricular function.
We have reported a case of acute fulminant myocarditis in a previously healthy young female following the administration of a quadrivalent inactivated influenza vaccination. Since Streifler et al. [6] described a patient with recurrent pericarditis after influenza vaccination in 1981, a very limited number of patients with cardiac complications following influenza vaccination have been reported. It is still controversial whether myocarditis was causally related to influenza vaccination or merely a serendipitous occurrence. To the best of our knowledge, only one study about adverse events using the Vaccine Adverse Event Reporting System database reported a fatal case of myocarditis in children between 6 to 23 months after administration of a trivalent inactivated influenza vaccine, but the authors concluded the causal relationship between influenza vaccination and development of myocarditis was not certain [7].
It is not possible to prove the hypothetical mechanism of the development of myocarditis after influenza vaccination due to its rarity as well as the associated ethical problems, but one hypothesis suggests that the immune response to compounds in the influenza vaccination and its specific inflammatory cascades may play a major role in the development of cardiovascular compromise [4,8]. It is notable that our patient received an inactivated quadrivalent influenza vaccine without adjuvant (GC Flu Quadrivalent, Green Cross). Previous case [4] reported that their patients received an inactivated trivalent influenza vaccine with MF59 adjuvant (Fluad, Novartis). This implies the possibility that other mechanisms also contribute to the development of cardiovascular compromise after influenza vaccination more so than the autoimmune/inflammatory syndrome induced by adjuvants.
The true incidence of myocarditis after influenza vaccination may be underestimated because of the subclinical and nonspecific clinical manifestations of myocarditis. A prospective study about the incidence of cardiovascular adverse events after smallpox and influenza vaccination revealed that the rate of clinical or subclinical myocarditis and pericarditis after smallpox vaccination was approximately 1:5,500, despite the fact that the rate of troponin elevation was 1:200 [9]. Similarly, 2.6% of the influenza vaccine cohort showed new onset cardiac symptoms, such as chest pain, dyspnea, and palpitation, but no case of clinical or subclinical myocarditis and pericarditis [9].
In this study, we have reported a very rare and serious adverse event following influenza vaccination. In light of this report, influenza vaccination should not be limited; however, physicians should be aware of the possibility of serious cardiovascular complications after influenza vaccination and thus be prepared to provide high-quality intensive care if necessary.

No potential conflict of interest relevant to this article was reported.

Figure 1.
Serial changes of vital signs and lactic acid level for 10 hours after emergency department (ED) presentation. ECMO: extracorporeal membrane oxygenation; ICU: intensive care unit.
acc-2017-00045f1.jpg
Figure 2.
Serial chest X-rays during hospitalization. (A) Chest X-ray showed diffuse ground glass opacities on both lung fields at 4 hours after emergency department presentation. (B) Chest X-ray after insertion of extracorporeal membrane oxygenation and intubation at emergency department. (C) Chest X-ray after recovery on the 9th day of hospitalization.
acc-2017-00045f2.jpg
Figure 3.
Representative cardiovascular magnetic resonance findings in a patient with acute myocarditis. (A) Short-axis T2 map revealed an increased global myocardial T2 value of 68–72 ms in this patient. (B) Late gadolinium enhancement shows mild diffuse midwall enhancement in the left ventricular (LV) myocardium.
acc-2017-00045f3.jpg
Table 1.
Serial changes of laboratory findings
Variable Hospitalization day
#1 #2 #3 #4 #5
White blood cell (/μL) 27,300 23,500 16,200 15,900 13,200
C-reactive protein (mg/dL) 4.27 14.22 24.03 18.66 9.97
Creatine kinase (IU/L) 628 869 18,220 21,085 15,350
Creatine kinase-MB (ng/mL) 54.2 25.5 74.6 50.0 56.2
Troponin I (ng/mL) 25.14 16.53 12.45 6.03 2.71
  • 1. Korea Centers for Disease Control and Prevention. Korea Centers for Disease Control and Prevention (KCDC) web [Internet]. Cheongju, Korea Centers for Disease Control and Prevention; 2017 [cited 2017 Oct 19]. Available from: http://cdc.go.kr/CDC/mobile/intro/CdcKrIntro0505.jsp?menuIds=HOME001-MNU1154-MNU2557-MNU2487&cid=76303
  • 2. Nichol KL, Margolis KL, Lind A, Murdoch M, Mc-Fadden R, Hauge M, et al. Side effects associated with influenza vaccination in healthy working adults: a randomized, placebocontrolled trial. Arch Intern Med 1996;156:1546-50.ArticlePubMed
  • 3. de Meester A, Luwaert R, Chaudron JM. Symptomatic pericarditis after influenza vaccination: report of two cases. Chest 2000;117:1803-5.ArticlePubMed
  • 4. Cheng MP, Kozoriz MG, Ahmadi AA, Kelsall J, Paquette K, Onrot JM. Post-vaccination myositis and myocarditis in a previously healthy male. Allergy Asthma Clin Immunol 2016;12:6. ArticlePubMedPMC
  • 5. Singh K, Marinelli T, Horowitz JD. Takotsubo cardiomyopathy after anti-influenza vaccination: catecholaminergic effects of immune system. Am J Emerg Med 2013;31:1627. e1-4.Article
  • 6. Streifler JJ, Dux S, Garty M, Rosenfeld JB. Recurrent pericarditis: a rare complication of influenza vaccination. Br Med J (Clin Res Ed) 1981;283:526-7.Article
  • 7. Rosenberg M, Sparks R, McMahon A, Iskander J, Campbell JD, Edwards KM. Serious adverse events rarely reported after trivalent inactivated influenza vaccine (TIV) in children 6-23 months of age. Vaccine 2009;27:4278-83.ArticlePubMed
  • 8. Lanza GA, Barone L, Scalone G, Pitocco D, Sgueglia GA, Mollo R, et al. Inflammation-related effects of adjuvant influenza A vaccination on platelet activation and cardiac autonomic function. J Intern Med 2011;269:118-25.ArticlePubMed
  • 9. Engler RJ, Nelson MR, Collins LC Jr, Spooner C, Hemann BA, Gibbs BT, et al. A prospective study of the incidence of myocarditis/pericarditis and new onset cardiac symptoms following smallpox and influenza vaccination. PLoS One 2015;10:e0118283. ArticlePubMedPMC

Figure & Data

References

    Citations

    Citations to this article as recorded by  
    • Clinical Characteristics and Mechanisms of Acute Myocarditis
      Stephane Heymans, Sophie Van Linthout, Sarah Mignon Kraus, Leslie T. Cooper, Ntobeko A.B. Ntusi
      Circulation Research.2024; 135(2): 397.     CrossRef
    • Endosomal Toll-Like Receptors intermediate negative impacts of viral diseases, autoimmune diseases, and inflammatory immune responses on the cardiovascular system
      Fatemeh Sadat Tabatabaei, Melika Shafeghat, Amirali Azimi, Ashley Akrami, Nima Rezaei
      Expert Review of Clinical Immunology.2024; : 1.     CrossRef
    • Clinical Manifestations and Adverse Cardiovascular Events in Patients with Cardiovascular Symptoms after mRNA Coronavirus Disease 2019 Vaccines
      William D. Kim, Min Jae Cha, Subin Kim, Dong-Gil Kim, Jae-Jin Kwak, Sung Woo Cho, Joon Hyung Doh, Sung Uk Kwon, June Namgung, Sung Yun Lee, Jiwon Seo, Geu-ru Hong, Ji-won Hwang, Iksung Cho
      Yonsei Medical Journal.2024; 65(11): 629.     CrossRef
    • Active surveillance for adverse events of influenza vaccine safety in elderly cancer patients using self-controlled tree-temporal scan statistic analysis
      Na-Young Jeong, Chung-Jong Kim, Sang Min Park, Ye-Jee Kim, Joongyub Lee, Nam-Kyong Choi
      Scientific Reports.2023;[Epub]     CrossRef
    • The Incidence of Myocarditis Following an Influenza Vaccination: A Population-Based Observational Study
      Wen-Hwa Wang, Kai-Che Wei, Yu-Tung Huang, Kuang-Hua Huang, Tung-Han Tsai, Yu-Chia Chang
      Drugs & Aging.2023; 40(2): 145.     CrossRef
    • Comparison of COVID-19 Vaccine-Associated Myocarditis and Viral Myocarditis Pathology
      Kamron Reza Hamedi, Gannett Loftus, Lawson Traylor, Richard Goodwin, Sergio Arce
      Vaccines.2023; 11(2): 362.     CrossRef
    • Myocarditis and autoimmunity
      Akira Matsumori
      Expert Review of Cardiovascular Therapy.2023; 21(6): 437.     CrossRef
    • Cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) imaging in the diagnosis and follow-up of patients with acute myocarditis and chronic inflammatory cardiomyopathy
      Federico Caobelli, Jordi Broncano Cabrero, Nicola Galea, Philip Haaf, Christian Loewe, Julian A. Luetkens, Giuseppe Muscogiuri, Marco Francone
      The International Journal of Cardiovascular Imaging.2023; 39(11): 2221.     CrossRef
    • Clinical Syndromes Related to SARS-CoV-2 Infection and Vaccination in Pediatric Age: A Narrative Review
      Maria Vincenza Mastrolia, Camilla De Cillia, Michela Orlandi, Sarah Abu-Rumeileh, Ilaria Maccora, Valerio Maniscalco, Edoardo Marrani, Ilaria Pagnini, Gabriele Simonini
      Medicina.2023; 59(11): 2027.     CrossRef
    • Acute Lymphocyte Myocarditis Associated with Influenza Vaccination
      Ryo Nakamura, Shin-ichi Ando, Seiya Kato, Toshiaki Kadokami
      Internal Medicine.2022; 61(15): 2307.     CrossRef
    • Clinically Suspected Myocarditis Temporally Related to COVID-19 Vaccination in Adolescents and Young Adults: Suspected Myocarditis After COVID-19 Vaccination
      Dongngan T. Truong, Audrey Dionne, Juan Carlos Muniz, Kimberly E. McHugh, Michael A. Portman, Linda M. Lambert, Deepika Thacker, Matthew D. Elias, Jennifer S. Li, Olga H. Toro-Salazar, Brett R. Anderson, Andrew M. Atz, C. Monique Bohun, M. Jay Campbell, M
      Circulation.2022; 145(5): 345.     CrossRef
    • Myocarditis following rAd26 and rAd5 vector‐based COVID‐19 vaccine: case report
      Farah Naghashzadeh, Shadi Shafaghi, Atosa Dorudinia, Seyed Alireza Naji, Majid Marjani, Ahmad Amin, Arezoo Mohamadifar, Sima Noorali, Babak Sharif Kashani
      ESC Heart Failure.2022; 9(2): 1483.     CrossRef
    • Myocarditis following COVID-19 vaccination in adolescents and adults: a cumulative experience of 2021
      Onyedika J. Ilonze, Maya E. Guglin
      Heart Failure Reviews.2022; 27(6): 2033.     CrossRef
    • Chest Pain and Suspected Myocarditis Related to COVID-19 Vaccination in Adolescents—A Case Series
      Da-Eun Roh, Hyejin Na, Jung-Eun Kwon, Insu Choi, Yeo-Hyang Kim, Hwa-Jin Cho
      Children.2022; 9(5): 693.     CrossRef
    • Cardiac Adverse Events after Vaccination—A Systematic Review
      Kanak Parmar, Sai Subramanyam, Gaspar Del Rio-Pertuz, Pooja Sethi, Erwin Argueta-Sosa
      Vaccines.2022; 10(5): 700.     CrossRef
    • A case of myocarditis after COVID-19 vaccination: incidental or consequential?
      Leona S. Alizadeh, Vitali Koch, Ibrahim Yel, Leon D. Grünewald, Daniel Mathies, Simon Martin, Thomas J. Vogl, Dominic Rauschning, Christian Booz
      Heliyon.2022; 8(6): e09537.     CrossRef
    • COVID-19 Vaccination and the Rate of Immune and Autoimmune Adverse Events Following Immunization: Insights From a Narrative Literature Review
      Naim Mahroum, Noy Lavine, Aviran Ohayon, Ravend Seida, Abdulkarim Alwani, Mahmoud Alrais, Magdi Zoubi, Nicola Luigi Bragazzi
      Frontiers in Immunology.2022;[Epub]     CrossRef
    • COVID-19 vaccination and carditis in children and adolescents: a systematic review and meta-analysis
      Oscar Hou In Chou, Jonathan Mui, Cheuk To Chung, Danny Radford, Simon Ranjithkumar, Endurance Evbayekha, Ronald Nam, Levent Pay, Danish Iltaf Satti, Sebastian Garcia-Zamora, George Bazoukis, Göksel Çinier, Sharen Lee, Vassilios S. Vassiliou, Tong Liu, Gar
      Clinical Research in Cardiology.2022; 111(10): 1161.     CrossRef
    • Myopericarditis after vaccination, Vaccine Adverse Event Reporting System (VAERS), 1990–2018
      John R. Su, Michael M. McNeil, Kerry J. Welsh, Paige L. Marquez, Carmen Ng, Ming Yan, Maria V. Cano
      Vaccine.2021; 39(5): 839.     CrossRef
    • Sipuleucel‐T associated inflammatory cardiomyopathy: a case report and observations from a large pharmacovigilance database
      Melissa Y.Y. Moey, Rahim A. Jiwani, Kotaro Takeda, Karyn Prenshaw, R. Wayne Kreeger, John Inzerillo, Darla K. Liles, C. Bogdan Marcu, Bénédicte Lebrun‐Vignes, D. Lynn Morris, Sivakumar Ardhanari, Joe‐Elie Salem
      ESC Heart Failure.2021; 8(4): 3360.     CrossRef
    • Myocarditis following COVID-19 vaccination
      Elisabeth Albert, Gerard Aurigemma, Jason Saucedo, David S. Gerson
      Radiology Case Reports.2021; 16(8): 2142.     CrossRef
    • Myocarditis and Other Cardiovascular Complications of the mRNA-Based COVID-19 Vaccines
      Mahesh K Vidula, Marietta Ambrose, Helene Glassberg, Neel Chokshi, Tiffany Chen, Victor A Ferrari, Yuchi Han
      Cureus.2021;[Epub]     CrossRef
    • Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination
      Han W. Kim, Elizabeth R. Jenista, David C. Wendell, Clerio F. Azevedo, Michael J. Campbell, Stephen N. Darty, Michele A. Parker, Raymond J. Kim
      JAMA Cardiology.2021; 6(10): 1196.     CrossRef
    • Acute myocarditis following Comirnaty vaccination in a healthy man with previous SARS-CoV-2 infection
      Anna Patrignani, Nicolò Schicchi, Francesca Calcagnoli, Elena Falchetti, Nino Ciampani, Giulio Argalia, Antonio Mariani
      Radiology Case Reports.2021; 16(11): 3321.     CrossRef
    • Myocarditis and pericarditis after vaccination for COVID‐19
      Blake Hudson, Ryan Mantooth, Matthew DeLaney
      Journal of the American College of Emergency Physicians Open.2021;[Epub]     CrossRef
    • Myocarditis, Pericarditis and Cardiomyopathy After COVID-19 Vaccination
      Salvatore Pepe, Ann T. Gregory, A. Robert Denniss
      Heart, Lung and Circulation.2021; 30(10): 1425.     CrossRef
    • Cardiac Manifestations of Multisystem Inflammatory Syndrome in Children (MIS-C) Following COVID-19
      Eveline Y. Wu, M. Jay Campbell
      Current Cardiology Reports.2021;[Epub]     CrossRef
    • Hemodynamic Collapse After Influenza Vaccination: A Vaccine-Induced Fulminant Myocarditis?
      Nobutaka Nagano, Toshiyuki Yano, Yugo Fujita, Masayuki Koyama, Ryo Hasegawa, Jun Nakata, Ryo Nishikawa, Naoto Murakami, Takefumi Fujito, Atsushi Mochizuki, Hidemichi Kouzu, Atsuko Muranaka, Nobuaki Kokubu, Tetsuji Miura
      Canadian Journal of Cardiology.2020; 36(9): 1554.e5.     CrossRef
    • Fatal influenza myocarditis with incessant ventricular tachycardia
      Nidhi Saraiya, Supriya Singh, Marilou Corpuz
      BMJ Case Reports.2019; 12(7): e228201.     CrossRef

    • PubReader PubReader
    • ePub LinkePub Link
    • Cite
      CITE
      export Copy
      Close
      Download Citation
      Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.
      Format:
      • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
      • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
      Include:
      • Citation for the content below
      Acute fulminant myocarditis following influenza vaccination requiring extracorporeal membrane oxygenation
      Acute Crit Care. 2019;34(2):165-169.   Published online November 7, 2018
      DOI: https://doi.org/10.4266/acc.2017.00045
      Close
    • XML DownloadXML Download
    Figure
    • 0
    • 1
    • 2
    Related articles
    Acute fulminant myocarditis following influenza vaccination requiring extracorporeal membrane oxygenation
    Image Image Image
    Figure 1. Serial changes of vital signs and lactic acid level for 10 hours after emergency department (ED) presentation. ECMO: extracorporeal membrane oxygenation; ICU: intensive care unit.
    Figure 2. Serial chest X-rays during hospitalization. (A) Chest X-ray showed diffuse ground glass opacities on both lung fields at 4 hours after emergency department presentation. (B) Chest X-ray after insertion of extracorporeal membrane oxygenation and intubation at emergency department. (C) Chest X-ray after recovery on the 9th day of hospitalization.
    Figure 3. Representative cardiovascular magnetic resonance findings in a patient with acute myocarditis. (A) Short-axis T2 map revealed an increased global myocardial T2 value of 68–72 ms in this patient. (B) Late gadolinium enhancement shows mild diffuse midwall enhancement in the left ventricular (LV) myocardium.

    Figure 1.

    Figure 2.

    Figure 3.

    Acute fulminant myocarditis following influenza vaccination requiring extracorporeal membrane oxygenation
    Variable Hospitalization day
    #1 #2 #3 #4 #5
    White blood cell (/μL) 27,300 23,500 16,200 15,900 13,200
    C-reactive protein (mg/dL) 4.27 14.22 24.03 18.66 9.97
    Creatine kinase (IU/L) 628 869 18,220 21,085 15,350
    Creatine kinase-MB (ng/mL) 54.2 25.5 74.6 50.0 56.2
    Troponin I (ng/mL) 25.14 16.53 12.45 6.03 2.71
    Table 1. Serial changes of laboratory findings

    Table 1.

    ACC : Acute and Critical Care
    © The Korean Society of Critical Care Medicine.
    TOP