"Case Description
A previously well 57-year-old woman received the first Pfizer-BioNTech vaccine in July 2021. The following day she experienced increasing lethargy and had to leave work early because of worsening fatigue. She had one episode of breathlessness and complained of a stiff neck as well as upper limb pain. She had a sore throat but pointed to her sternum. During the remainder of the day, she became increasingly unwell. The following day she consulted her primary care physician with a sore throat, back pain, fatigue and an episode of haematuria, which had occurred the previous night. She had difficulty getting out of the car and experienced a fall at the family physician’s surgery. She did not complain of palpitations.
On day 2... she was noted to have an increased C-reactive protein (CRP). She had a raised ferritin and alanine transaminase (ALT)... On the third day, she was diagnosed with an Escherichia coli urinary tract infection, which was treated with trimethoprim. During that night, she was found deceased in bed...
Autopsy findings
... On internal examination, the most striking finding was a tan, solid lobulated mass originating from the mediastinum and situated in the left pleural cavity. This mass was 130 × 120 × 90 mm and weighed 710 g...
Histology and Ancillary Tests
Histological examination of the heart sections showed fulminant necrotizing eosinophilic myocarditis...
Discussion
Fulminant necrotizing eosinophilic myocarditis is an extremely rare hypersensitivity syndrome caused by a variety of drugs and vaccines. This life-threatening idiosyncratic reaction specifically targets the myocardium. The cardiac injury is likely to be mediated by the highly toxic contents of granules including eosinophilic cationic protein, eosinophil major basic protein, eosinophil peroxidase and eosinophil-derived neurotoxin. In mice, eosinophil-derived IL4 plays a critical role in cardiac damage.
The immunopathology of this extremely rare disorder remains to be defined but is likely to be mediated by cytotoxic T cells producing IL5...
It seems probable the Pfizer-BioNTech vaccine was responsible for the fatal fulminant necrotizing myocarditis in this case. The temporal association is compatible with such a hypersensitivity reaction, other causes have been excluded, and the histomorphology is consistent with the diagnosis."
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