Letter to the Director
Pleuropericardial Effusion and Systemic Inflammatory Syndrome Secondary to the Administration of the mRNA-1273 Vaccine for SARS-CoV-2
Derrame pleuropericárdico y síndrome inflamatorio sistémico secundario a la administración de vacuna ARNm-1273 para coronavirus del síndrome respiratorio agudo grave de tipo 2 (SARS-CoV-2)
Ignacio Boira, Anastasiya Torba, Carmen Castelló, Violeta Esteban, Sandra Vañes, Eusebi Chiner
Corresponding author
Servicio de Neumología, Hospital Universitario San Juan de Alicante, Alicante, Spain
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(B) Chest computed axial tomography showing bilateral pleural effusion and pericardial effusion (upper arrow indicates pericardial effusion and the right arrow indicates pleural effusion).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">SARS-CoV-2 infection has caused more than 5 million deaths worldwide and has had a major impact on the economy and healthcare. Vaccination has changed the management of these patients by preventing transmission and reducing mortality.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Side effects associated with SARS-CoV-2 mRNA vaccines, some serious, have been reported. One of the major adverse events associated with the Moderna vaccine (mRNA-1273), myocarditis, seen primarily in young adults, occasionally occurs concomitantly with heart disease, while another rarely reported event is multisystem inflammatory syndrome (MIS).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report a clinical case of MIS following administration of the Moderna vaccine. To our knowledge, this is the only published case of pleural exudate in this context.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our patient was a 33-year-old woman, with no drug allergies, smoker of 5 pack-years, with no medical or surgical history of interest. She was not receiving any regular treatment, and worked at home as a mother of 2 children with a dog and a cat as pets.</p><p id="par0025" class="elsevierStylePara elsevierViewall">She attended the emergency room with a 3-week history of sternal pain that worsened with postural changes. The symptoms had developed 5 days after administration of the second dose of the Moderna vaccine. She also reported moderate dyspnea on exertion, low-grade fever, and arthralgias, with no cough or other symptoms.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On physical examination, she was in good general condition, with normal coloring, normal hydration, and normal breathing at rest. She had no supraclavicular lymphadenopathies or nail clubbing. Blood pressure was 101/70<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 74<span class="elsevierStyleHsp" style=""></span>bpm, respiration rate 12 breaths/m, and SpO<span class="elsevierStyleInf">2</span> (room air) 98%</p><p id="par0035" class="elsevierStylePara elsevierViewall">Cardiac auscultation was normal and pulmonary auscultation showed decreased breath sounds in the lower third of both lungs, with decreased transmission of vocal fremitus, dullness on percussion, and signs of pleural effusion. The rest of the examination was normal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Antigen and polymerase chain reaction (PCR) for COVID-19 were negative.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Chest X-ray in the emergency room showed blunting of both costophrenic angles consistent with bilateral pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The blood count showed 10.1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l leukocytes with 5.9% eosinophils (600<span class="elsevierStyleHsp" style=""></span>eosinophils) and hemoglobin 14.2<span class="elsevierStyleHsp" style=""></span>g/dl. Biochemistry showed total proteins 6.69<span class="elsevierStyleHsp" style=""></span>g/dl, LDH 257<span class="elsevierStyleHsp" style=""></span>U/l, CRP 4.03<span class="elsevierStyleHsp" style=""></span>mg/dl. Coagulation tests showed D-dimer 2656<span class="elsevierStyleHsp" style=""></span>ng/ml.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Pneumococcus and <span class="elsevierStyleItalic">Legionella</span> antigens in urine and parallel respiratory serology for <span class="elsevierStyleItalic">Legionella</span>, <span class="elsevierStyleItalic">Mycoplasma</span> and respiratory viruses were negative.</p><p id="par0060" class="elsevierStylePara elsevierViewall">A chest computed tomography angiogram conducted to rule out pulmonary thromboembolism confirmed moderate bilateral pleural effusion with bibasilar and middle lobe atelectasis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). This was confirmed on chest ultrasound that also ruled out vascular involvement.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Echocardiography showed mild pericardial effusion not affecting cavity filling. Abdominal ultrasound was normal.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Thoracentesis showed exudate (proteins 4.25<span class="elsevierStyleHsp" style=""></span>g/dl and LDH 191<span class="elsevierStyleHsp" style=""></span>U/l) with predominantly polymorphonuclear cells (73.2%), normal ADA (6.7<span class="elsevierStyleHsp" style=""></span>U/l), cholesterol 75<span class="elsevierStyleHsp" style=""></span>mg/dl, CEA<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1.7<span class="elsevierStyleHsp" style=""></span>ng/ml, and negative antinuclear antibodies. Cytology was negative for malignancy, culture showed no microorganisms, and Ziehl-Neelsen and culture in Löwenstein-Jensen media were negative.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Azithromycin 500<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h and methylprednisolone 40<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h were administered for 6 days with favorable clinical and radiological evolution, and the patient was discharged with prednisone 30<span class="elsevierStyleHsp" style=""></span>mg in a tapering regimen and azithromycin 500<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h for a further 4 days, and was referred for monitoring in the outpatient clinic.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Follow-up chest CT at 15 days showed a marked decrease in pleural and pericardial effusion.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Follow-up clinical laboratory tests at 23 days after discharge showed normal antinuclear antibodies and anti-neutrophil cytoplasm antibodies (P-ANCA and <span class="elsevierStyleSmallCaps">C</span>-ANCA). Serology was positive for SARS-CoV-2 IgG.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The Moderna mRNA-1273 vaccine is given in 2 doses and has demonstrated 94.7% efficacy and very good safety. Most of the adverse effects are mild, and while serious events, such as myalgias, arthralgias and asthenia, have been reported, particularly after the second dose, pleural and pericardial effusion are not listed in the Summary of Product Characteristics or reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Our patient, who had recently received the Moderna vaccine, developed bilateral and pericardial pleural effusion. After ruling out other causes, her clinical picture was consistent with MIS caused by the Moderna vaccine, resulting in bilateral pleural and pericardial exudate.</p><p id="par0100" class="elsevierStylePara elsevierViewall">MIS after vaccination (usually the second dose) is exceptional, and very few cases have been published, particularly in children and adolescents. It consists of a systemic clinical syndrome (diarrhea, dyspnea, abdominal pain, skin rash, and hypotension) involving at least 2 organs. Progress is favorable after administration of corticosteroids and, in some cases, intravenous immunoglobulins.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">This entity may have clinical similarities with active SARS-CoV-2 infection, so assessment of the vaccination history is essential when taking the medical history. Most cases are reported at 2–4 weeks after administration and involve gastrointestinal symptoms. The only cases of pleural effusion reported have been associated with heart failure, and none of these patients were studied for pleural fluid. Long-term functional consequences are unknown.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The SARS-CoV-2 vaccine – generally the Janssen vaccine – has been associated with some rare reports of MIS in the literature, and in no case has pleural fluid been studied to complete the diagnosis. Exudative pleural-pericardial effusion without accompanying myocarditis should be considered among the complications caused by the mRNA-1273 vaccine.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1130 "Ancho" => 2508 "Tamanyo" => 240016 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Anterior-posterior chest X-ray at admission showing right pleural effusion and left costophrenic angle blunting. (B) Chest computed axial tomography showing bilateral pleural effusion and pericardial effusion (upper arrow indicates pericardial effusion and the right arrow indicates pleural effusion).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Maintaining safety with SARS-CoV-2 vaccines" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.C. Castells" 1 => "E.J. 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Johnson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/ciab926" "Revista" => array:3 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2021" "paginaInicial" => "ciab926" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.R. Baden" 1 => "H.M. El Sahly" 2 => "B. Essink" 3 => "K. Kotloff" 4 => "S. Frey" 5 => "R. Novak" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa2035389" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2021" "volumen" => "384" "paginaInicial" => "403" "paginaFinal" => "416" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33378609" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adult multisystem inflammatory syndrome in a patient who recovered from COVID-19 postvaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.K. Uwaydah" 1 => "N.M.M. Hassan" 2 => "M.S. Abu Ghoush" 3 => "K.M.M. 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Morris" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.chest.2020.09.097" "Revista" => array:7 [ "tituloSerie" => "Chest" "fecha" => "2021" "volumen" => "159" "paginaInicial" => "471" "paginaFinal" => "472" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33285106" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1552526011000999" "estado" => "S300" "issn" => "15525260" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005800000004/v5_202301090807/S0300289622001685/v5_202301090807/en/main.assets" "Apartado" => array:4 [ "identificador" => "93644" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director/Carta al Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005800000004/v5_202301090807/S0300289622001685/v5_202301090807/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289622001685?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 4 | 17 |
| 2024 October | 96 | 25 | 121 |
| 2024 September | 190 | 15 | 205 |
| 2024 August | 129 | 36 | 165 |
| 2024 July | 72 | 16 | 88 |
| 2024 June | 100 | 23 | 123 |
| 2024 May | 103 | 27 | 130 |
| 2024 April | 67 | 17 | 84 |
| 2024 March | 80 | 26 | 106 |
| 2024 February | 70 | 32 | 102 |
| 2024 January | 73 | 25 | 98 |
| 2023 December | 138 | 21 | 159 |
| 2023 November | 122 | 21 | 143 |
| 2023 October | 193 | 25 | 218 |
| 2023 September | 113 | 24 | 137 |
| 2023 August | 76 | 36 | 112 |
| 2023 July | 87 | 23 | 110 |
| 2023 June | 103 | 10 | 113 |
| 2023 May | 96 | 24 | 120 |
| 2023 April | 114 | 27 | 141 |
| 2023 March | 140 | 22 | 162 |
| 2023 February | 110 | 26 | 136 |
| 2023 January | 134 | 35 | 169 |
| 2022 December | 158 | 36 | 194 |
| 2022 November | 193 | 31 | 224 |
| 2022 October | 191 | 45 | 236 |
| 2022 September | 190 | 68 | 258 |
| 2022 August | 189 | 60 | 249 |
| 2022 July | 230 | 53 | 283 |
| 2022 June | 209 | 40 | 249 |
| 2022 May | 306 | 52 | 358 |
| 2022 April | 133 | 14 | 147 |
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