Acute perimyocarditis is commonly preceded by viral illness and presents with non-specific complaints that can be a manifestation of serious cardiac complications such as arrhythmias and heart failure. While pericarditis is a known complication of thyrotoxicosis, termed \"thyrotoxic pericarditis,\" concomitant new-onset perimyocarditis and Graves\' disease, termed \"thyro-pericarditis,\" has been reported. We present a case of thyro-pericarditis as the initial presentation of undiagnosed and untreated Graves\' disease co-occurring with recent Coxsackievirus A and B infection. A 27-year-old male with a family history of undifferentiated hyperthyroidism presented with acute pleuritic chest pain and shortness of breath. Laboratory testing showed elevated cardiac troponin I with ST elevations and PR depressions on initial ECG. Left heart catheterization was normal, but transthoracic echocardiogram showed right ventricular systolic dysfunction and enlargement. Cardiac MRI demonstrated diffuse pericardial enhancement suggesting pericarditis. Thyroid function testing and thyroid ultrasound suggested auto-immune thyrotoxicosis. Serology noted abnormal Coxsackievirus A and B IgG antibody titers, suggesting prior infection. The patient was treated with colchicine, ibuprofen, methimazole, and metoprolol, with resolution of symptoms. Thyro-pericarditis is a rare concomitant presentation of both Graves\' disease and myopericarditis, and it remains unknown whether there is an increased risk of adverse cardiac outcomes.

Arrhythmias in pericardial syndromes have been poorly investigated and available data are mainly obtained from relevant studies however having different endpoints from arrhythmias. Thus, the incidence and prevalence of any type of arrhythmias may be actually higher than generally considered. Atrial arrhythmias, mainly atrial fibrillation and flutter have been reported as the most common rhythm disturbances in the setting of acute pericarditis. Concerning pathophysiology of atrial arrhythmias, in contrast to earlier hypothesis that they occur exclusively in the presence of an underlying structural heart disease, recent data support an arrhythmogenic potential of acute pericardial inflammation regardless of the presence of heart disease. In cases of myopericarditis, namely primarily pericarditis with evidence of myocardial involvement (i.e., troponin elevation without however overt left ventricular dysfunction and/or segmental wall motion abnormalities), ventricular arrhythmias appear to prevail. With reference to the rest of pericardial syndromes data on arrhythmias development are even more sparce. In particular, in constrictive pericarditis atrial tachyarrhythmias are the most commonly detected and seem to be related to disease severity and possibly to the underlying etiology. In this review we have summarized the available information on the incidence and prevalence of arrhythmias in pericardial syndromes. We wish to emphasize that the clinical significance of arrhythmias in this setting in terms of prognosis and optimal medical treatment (including need and safety of anticoagulation in atrial fibrillation/flutter complicating acute pericarditis), should be further investigated.

UNASSIGNED: Evidence supporting the possible causal association of myopericarditis with the coronavirus disease (COVID-19) vaccine has mainly come from case reports. Epidemiological evidence indicating an increased relative risk for myopericarditis after COVID-19 vaccination is lacking. Therefore, this study aimed to identify and assess all confirmed COVID-19 vaccine- related cases of myopericarditis presenting to major cardiac centers in the Eastern Region of Saudi Arabia, before and after the introduction of the COVID-19 vaccine.
UNASSIGNED: According to case definition, the hospital\'s information system database detected all confirmed cases at two main cardiac centers.
UNASSIGNED: Of the 18 confirmed myocarditis and myopericarditis cases detected after the administration of COVID-19 vaccines, three were possibly related to COVID-19 immunization. The first case was of myopericarditis following a third dose of mRNA-1273. The second case was myocarditis, which occurred seven days after the first dose of AstraZeneca. The third case was myocarditis, which occurred 12 days after the third dose of BNT162b2. A cardiologist carefully evaluated the cases using recognized protocols and case definitions to demonstrate a direct relationship with vaccination consequences rather than coincidence.
UNASSIGNED: We found no difference in the occurrence of myocarditis and myopericarditis after the COVID-19 vaccine compared with the background rate during a similar period (P = 0.9783). The incidences of myocarditis and myopericarditis following immunization were low. The advantages of the COVID-19 vaccination outweigh the risk of myopericarditis.

UNASSIGNED: A rare complication of oesophageal rupture or Boerhaave syndrome is myopericarditis due to leakage of oesophageal contents. This presentation can mimic a myocardial infarction, making diagnosis and management challenging.
UNASSIGNED: We present the case of a middle-aged man presenting with chest pain, who was diagnosed with Boerhaave syndrome complicated by myopericarditis, although the presentation was concerning for acute coronary syndrome.
UNASSIGNED: Through this case, we aim to highlight an unusual alternative aetiology of findings classically seen in myocardial infarction.

BACKGROUND: Numerous reports have described the clinical presentation of cardiac adverse events following immunization (AEFI) with COVID-19 vaccines but long-term outcome studies are limited, especially in the pediatric population.
METHODS: This is a single center retrospective case series of pediatric patients with cardiac AEFI following the Pfizer/BioNTech mRNA COVID-19, diagnosed between May 2021 and May 2022, and managed following a standardized protocol. Follow up information is presented up to 12 months post diagnosis. The incidence rate of cardiac AEFI was estimated for Ottawa residents.
RESULTS: All cases were male (N = 17) with an average age of 16 years (range = 12-17). The majority of cases occurred after the 2nd (12/17) or 3rd vaccine dose (4/17) and were manifested mostly as myopericarditis (15/17). Average interval between the 1st and 2nd vaccine (n = 12) doses was 38 days (21-69 days). All patients improved promptly on non-steroidal anti-inflammatory drugs without recurrence. Five patients reported negative impact on quality of life and mental health, including 2 cases that led to new vaccine hesitancy, not only to COVID-19 vaccine, but also to other routine vaccines. The rate of cardiac AEFI was estimated for residents of the city of Ottawa and found to be 12.01 cases (CI 90 5.98-21.68) per 100,000 doses following the 2nd dose and 16.56 cases (CI 90 5.66-37.90) per 100,000 doses following the 3rd dose for males aged 12 to 17 years.
CONCLUSIONS: Twelve months following the AEFI, all patients clinically recovered from their myopericarditis, but some reported negative impact on quality of life and mental health, including new vaccine hesitancy. This highlights the importance for timely and systematic evaluation of AEFI and the need to provide support, follow up and vaccine counseling in individuals experiencing an AEFI.

UNASSIGNED: Wellens\' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3 (may extend to involve all precordial and lateral limb leads - the type B Wellens\' pattern). A Wellens\' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD). However, there are no reported cases of an association of a Wellens\' EKG pattern with myopericarditis. Here, we present such a rare case.
UNASSIGNED: A thirty-one-year-old female with known essential hypertension and psoriatic arthritis presented with a constant, central chest pain radiating to the shoulders and back. The patient\'s physical examination was unremarkable at presentation other than elevated blood pressure at 170/68 mmHg. An EKG at presentation demonstrated deep symmetric T-wave inversions in anterolateral leads with elevated high-sensitivity troponin, and an elevated erythrocyte sedimentation rate. The patient was referred to the cardiac catheterisation laboratory for concerns of a Wellens\' EKG pattern; however, invasive angiography demonstrated only obtuse marginal branch disease - no LAD disease was noted. Cardiac magnetic resonance (CMR) imaging confirmed the diagnosis of myopericarditis and absence of myocardial infarction. The patient was medically managed and discharged home in a stable condition.
UNASSIGNED: In literature and established clinical practice, the Wellens\' EKG pattern is considered highly concerning for critical ostial/proximal LAD stenosis. However, we now propose that myopericarditis may be considered in a differential diagnosis for this EKG pattern.
CONCLUSIONS: Wellens\' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3.A Wellens\' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD).Association of Wellens\' pattern EKG has been described in association with various other pathologies; however, its association with acute myopericarditis has not been well described.

A 29-year-old male, otherwise healthy with no past medical history, presented to the hospital after a two-day history of pleuritic chest pain with a fever. He had received his first dose of the mRNA-1273 coronavirus disease (COVID-19) vaccine (Moderna) two months prior without any adverse reactions. He received his second dose approximately 24 hours before symptom onset and hospital presentation. Work-up was unremarkable for respiratory, autoimmune, and rheumatological etiologies. The patient was found to have electrocardiogram features and symptoms in keeping with pericarditis, C-reactive protein elevation, and a peak high-sensitivity troponin level of 9,992 ng/L suggestive of a component of myocarditis. A dilemma arose regarding whether this patient should be diagnosed with perimyocarditis or myopericarditis, terms often used interchangeably without proper reference to the primary pathology, which can ultimately affect management. A subsequent echocardiogram was unremarkable, with a normal left ventricular systolic function, but cardiac resonance imaging revealed myocardial edema suggestive of myocarditis. Without convincing evidence for an alternative explanation after an extensive work-up of ischemic, autoimmune, rheumatological, and infectious etiologies, this patient was diagnosed with COVID-19 mRNA vaccine-induced myopericarditis. The patient fully recovered after receiving a treatment course of ibuprofen and colchicine. This case explores how the diagnosis of COVID-19 vaccine-induced myopericarditis was made and treated using an evidence-based approach, highlighting its differentiation from perimyocarditis.

Acute myocarditis is a serious, likely underdiagnosed condition affecting people of all ages and for which the number of UK hospital admissions is rising. A primary diagnosis of myocarditis accounted for 0.04% (36.5 per 100,000) of all hospital admissions in England between 1998 and 2017, although this is likely to be an underestimate of the true burden of myocarditis. The aetiology is broad, including infective and inflammatory conditions as well as exposure to toxic agents. Clinical features are varied and overlap with other acute cardiac conditions making diagnosis a challenge. Cardiovascular magnetic resonance imaging currently serves as the gold standard non-invasive diagnostic modality. If an underlying aetiological process is identified, then therapy may be directed at the cause; however, for most, treatment is supportive and aimed at managing any complications such as heart failure or arrhythmias. There is emerging evidence for immunosuppressive therapy in certain cases. Prognosis is generally good with recovery in most; however, up to 30% with biopsy-proven myocarditis progress to develop a dilated cardiomyopathy and its potential associated complications. All-cause mortality in the UK for patients presenting to hospital with acute myocarditis is approximately 4%.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a severe disorder characterized by excessive activation of the immune system, leading to hypercytokinemia and damage to multiple organs. We report a rare case of HLH with myopericarditis caused by Campylobacter infection.
METHODS: A 28-year-old male patient with a history of hypertension without medicine control presented at the hospital after a four-day fever, decreasing urine amount, rashes on his trunk and limbs, and other symptoms. He was admitted with a provisional diagnosis of atypical infection and allergic skin rash related to diclofenac. However, his condition deteriorated, and he developed shock, tachycardia, chest distress, and bilateral pleural effusion after admission. Further investigations revealed cardiogenic shock related to myopericarditis, and he was transferred to the ICU. In addition, a stool PCR panel subsequently revealed a positive result for Campylobacter. On day 6, he was diagnosed with HLH. Under Clarithromycin and dexamethasone infusion, leukocytosis, anemia and thrombocytopenia with cardiogenic shock status improved. Then, he was later discharged in stable condition.
CONCLUSIONS: HLH and myopericarditis caused by Campylobacter are very rare. Early detection of Campylobacter-induced HLH and multiple organ failure, as well as prompt use of antibiotics and immunosuppressants, can be helpful for prognosis.

Ulcerative colitis (UC) is an autoimmune disease associated with both intestinal and extraintestinal manifestations. The latter may include heart complications, such as myopericarditis leading to life-threatening arrythmias. Nowadays, UC is commonly treated with biologic medications and infliximab is the first line therapy in an outpatient setting, while it is also used as rescue therapy in acute severe UC. However, it has been associated with severe immunosuppression, cytomegalovirus (CMV) reactivation and drug-induced hepatitis. We report a case of UC flare in a biologic naïve patient admitted with myopericarditis, which was further complicated by positive CMV biopsies and infliximab-induced transaminitis.
CONCLUSIONS: In acute inflammatory bowel disease (IBD) flare presentation with tachycardia and chest pain, an underlying myocardial injury should be investigated.Mucosal healing should be evaluated endoscopically in cases of partial response to biologics.Both cytomegalovirus (CMV) infection and infliximab-induced liver injury may lead to acute hepatitis.