Difficult-to-treat recurrent pericarditis after SARS-CoV-2 vaccination

Introduction

Pericarditis is a recognized but rare complication of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) vaccination. While most cases are self-limited, some develop recurrent, difficult-to-treat pericarditis, requiring prolonged management. The exact pathophysiology remains unclear, but vaccine-related immune activation and inflammasome-mediated responses have been implicated.

Methods

We reported eight cases of difficult-to-treat pericarditis temporally associated with SARS-CoV-2 vaccination, seen at a single center between October 2021 and January 2025. Diagnosis followed ESC 2015 guidelines, and all patients tested negative for acute SARS-CoV-2 infection.

Results

The median age was 56 years, with six receiving Pfizer-BioNTech BNT162b2 and two Moderna mRNA-1273. For six individuals, this was their first episode of pericarditis, whereas two had a prior history of pericarditis. The median time to symptom onset was 14 days. Chest pain was reported by all patients, requiring emergency visits in six cases. Pericardial effusion was present in six patients, with one progressing to tamponade. Cardiac magnetic resonance revealed pericardial late gadolinium enhancement in three of seven patients. All patients received nonsteroidal anti-inflammatory drugs and seven were treated with colchicine. Due to inadequate response to first-line therapies, corticosteroids were administered in all eight cases. Due to persistent symptoms, six patients initiated rilonacept therapy, which led to complete symptom resolution.

Conclusions

Pericarditis following SARS-CoV-2 vaccination can evolve into a recurrent, difficult-to-manage inflammatory condition. Effective treatment may require IL-1 blockade to disrupt the autoinflammatory cycle. Prompt recognition and early escalation of therapy are essential to reduce morbidity and prevent complications.