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Citation: Mörz, M. A Case Report:
Multifocal Necrotizing Encephalitis
and Myocarditis after BNT162b2
mRNA Vaccination against
COVID-19. Vaccines 2022,10, 1651.
https://doi.org/10.3390/
vaccines10101651
Academic Editor: Sung Ryul Shim
Received: 31 August 2022
Accepted: 27 September 2022
Published: 1 October 2022
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4.0/).
Case Report
A Case Report: Multifocal Necrotizing Encephalitis and Myocarditis
after BNT162b2 mRNA Vaccination against COVID-19
Michael Mörz
Institute of Pathology ’Georg Schmorl’, The Municipal Hospital Dresden-Friedrichstadt, Friedrichstrasse 41,
01067 Dresden, Germany; michael.moerz@klinikum-dresden.de
Abstract:
The current report presents the case of a 76-year-old man with Parkinson’s disease (PD)
who died three weeks after receiving his third COVID-19 vaccination. The patient was first vaccinated
in May 2021 with the ChAdOx1 nCov-19 vector vaccine, followed by two doses of the BNT162b2
mRNA vaccine in July and December 2021. The family of the deceased requested an autopsy
due to ambiguous clinical signs before death. PD was confirmed by post-mortem examinations.
Furthermore, signs of aspiration pneumonia and systemic arteriosclerosis were evident. However,
histopathological analyses of the brain uncovered previously unsuspected findings, including acute
vasculitis (predominantly lymphocytic) as well as multifocal necrotizing encephalitis of unknown
etiology with pronounced inflammation including glial and lymphocytic reaction. In the heart, signs
of chronic cardiomyopathy as well as mild acute lympho-histiocytic myocarditis and vasculitis were
present. Although there was no history of COVID-19 for this patient, immunohistochemistry for
SARS-CoV-2 antigens (spike and nucleocapsid proteins) was performed. Surprisingly, only spike
protein but no nucleocapsid protein could be detected within the foci of inflammation in both the
brain and the heart, particularly in the endothelial cells of small blood vessels. Since no nucleocapsid
protein could be detected, the presence of spike protein must be ascribed to vaccination rather than
to viral infection. The findings corroborate previous reports of encephalitis and myocarditis caused
by gene-based COVID-19 vaccines.
Keywords:
COVID-19 vaccination; necrotizing encephalitis; myocarditis; detection of spike protein;
detection of nucleocapsid protein; autopsy
1. Introduction
The emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
in 2019 with the subsequent worldwide spread of COVID-19 gave rise to a perceived need
for halting the progress of the COVID-19 pandemic through the rapid development and
deployment of vaccines. Recent advances in genomics facilitated gene-based strategies
for creating these novel vaccines, including DNA-based nonreplicating viral vectors, and
mRNA-based vaccines, which were furthermore developed on an aggressively shortened
timeline [1–4].
The WHO Emergency Use Listing Procedure (EUL), which determines the acceptabil-
ity of medicinal products based on evidence of quality, safety, efficacy, and performance [
5
],
permitted these vaccines to be marketed as soon as 1–2 years after development had begun.
Published results of the phase 3 clinical trials described only a few severe side effects [
2
,
6
–
8
].
However, it has since become clear that severe and even fatal adverse events may occur;
these include in particular cardiovascular and neurological manifestations [
9
–
13
]. Clini-
cians should take note of such case reports for the sake of early detection and management
of such adverse events among their patients. In addition, a thorough post-mortem ex-
amination of deaths in connection with COVID-19 vaccination should be considered in
ambiguous circumstances, including histology. This report presents the case of a senior aged
76 years old, who had received three doses overall of two different COVID-19 vaccines,
Vaccines 2022,10, 1651. https://doi.org/10.3390/vaccines10101651 https://www.mdpi.com/journal/vaccines
Vaccines 2022,10, 1651 2 of 17
and who died three weeks after the second dose of the mRNA-BNT162b-vaccine. Autopsy
and histology revealed unexpected necrotizing encephalitis and mild myocarditis with
pathological changes in small blood vessels. A causal connection of these findings to
the preceding COVID-19 vaccination was established by immunohistochemical demon-
stration of SARS-CoV-2 spike protein. The methodology introduced in this study should
be useful for distinguishing between causation by COVID-19 vaccination or infection in
ambiguous cases.
2. Materials and Methods
2.1. Routine Histology
Formalin-fixed tissues were routinely processsed and paraffin-embedded tissues were
cut into 5
µ
m sections and stained with hematoxylin and eosin (H&E) for histopathologi-
cal examination.
2.2. Immunohistochemistry
Immunohistochemical staining was performed on the heart and brain, using a fully
automated immunostaining system (Ventana Benchmark, Roche). An antigen retrieval
(Ultra CC1, Roche Ventana) was used for every antibody. The target antigens and dilution
factors for the antibodies used are summarized in Table 1. Incubation with the primary
antibody was carried out for 30 min in each case. Tissues from SARS-CoV-2-positive
COVID-19 patients were used as a control for the antibodies against SARS-CoV-2-spike
and nucleocapsid (Figure 1). Cultured cells that had been transfected
in vitro
(see hereafter)
served as a positive control for the detection of vaccine-induced spike protein expression
and as a negative control for the detection of nucleocapsid protein. The slides were
examined with a light microscope (Nikon ECLIPSE 80i) and representative images were
captured by the camera system Motic®Europe Motic MP3.
Table 1.
Primary antibodies used for immunohistochemistry. Tissue sections were incubated 30 min
with the antibody in question, diluted as stated in the table.
Target Antigen Manufacturer Clone Dilution Incubation Time
CD3 (expressed by T-Lymphocytes) cytomed ZM-45 1:200 30 min
CD68 (expressed by monocytic cells) DAKO PG-M1 1:100 30 min
SARS-CoV-2-Spike subunit 1 ProSci 9083 1:500 30 min
SARS-CoV-2-Nucleocapsid ProSci 35–720 1:500 30 min
Vaccines 2022, 10, 1651 2 of 17
tion, a thorough post-mortem examination of deaths in connection with COVID-19 vac-
cination should be considered in ambiguous circumstances, including histology. This
report presents the case of a senior aged 76 years old, who had received three doses
overall of two different COVID-19 vaccines, and who died three weeks after the second
dose of the mRNA-BNT162b-vaccine. Autopsy and histology revealed unexpected ne-
crotizing encephalitis and mild myocarditis with pathological changes in small blood
vessels. A causal connection of these findings to the preceding COVID-19 vaccination
was established by immunohistochemical demonstration of SARS-CoV-2 spike protein.
The methodology introduced in this study should be useful for distinguishing between
causation by COVID-19 vaccination or infection in ambiguous cases.
2. Materials and Methods
2.1. Routine Histology
Formalin-fixed tissues were routinely processsed and paraffin-embedded tissues
were cut into 5 μm sections and stained with hematoxylin and eosin (H&E) for histo-
pathological examination.
2.2. Immunohistochemistry
Immunohistochemical staining was performed on the heart and brain, using a fully
automated immunostaining system (Ventana Benchmark, Roche). An antigen retrieval
(Ultra CC1, Roche Ventana) was used for every antibody. The target antigens and dilu-
tion factors for the antibodies used are summarized in Table 1. Incubation with the pri-
mary antibody was carried out for 30 min in each case. Tissues from
SARS-CoV-2-positive COVID-19 patients were used as a control for the antibodies
against SARS-CoV-2-spike and nucleocapsid (Figure 1). Cultured cells that had been
transfected in vitro (see hereafter) served as a positive control for the detection of vac-
cine-induced spike protein expression and as a negative control for the detection of nu-
cleocapsid protein. The slides were examined with a light microscope (Nikon ECLIPSE
80i) and representative images were captured by the camera system Motic® Europe Motic
MP3.
Table 1. Primary antibodies used for immunohistochemistry. Tissue sections were incubated 30
min with the antibody in question, diluted as stated in the table.
Target Antigen
Manufacturer
Clone
Dilution
Incubation Time
CD3 (expressed by T-Lymphocytes)
cytomed
ZM-45
1:200
30 min
CD68 (expressed by monocytic cells)
DAKO
PG-M1
1:100
30 min
SARS-CoV-2-Spike subunit 1
ProSci
9083
1:500
30 min
SARS-CoV-2-Nucleocapsid
ProSci
35–720
1:500
30 min
Figure 1.
Nasal smear from a person with acute symptomatic SARS-CoV-2-infection (confirmed by
PCR). Note the presence of ciliated epithelium. Immunohistochemistry for two SARS-CoV-2 antigens
(spike and nucleocapsid protein) revealed a positive reaction for both as to be expected after infection.
(
a
) Detection of the spike protein. Positive control for spike subunit 1 SARS-CoV-2 protein detection. Several
Vaccines 2022,10, 1651 3 of 17
ciliated epithelia of the nasal mucosa show brownish granular deposits of DAB (red arrow). Com-
pared to nucleocapsid, the DAB-granules are fewer and less densely packed granular deposits of
DAB. (
b
) Detection of nucleocapsid protein. Positive control for nucleocapsid SARS-CoV-2 protein
detection. Several ciliated epithelia of the nasal mucosa show dense brownish granular deposits of
DAB in immunohistochemistry (examples red arrows). Compared to spike detection, the granules of
DAB are finer and more densely packed. Magnification: 400x.
2.3. Preparation of Positive Control Samples for the Immunohistochemical Detection of the
Vaccine-Induced Spike Protein
Cell culture and transfection: Ovarian cancer cell lines (OVCAR-3 and SK-OV3, CSL
cell Lines Service, Heidelberg, Germany) were grown to 70% confluence in flat bottom
75 cm
2
cell culture flasks (Cell star) in DMEM/HAMS-F12 medium supplemented with
Glutamax (Sigma-Aldrich, St. Louis, MO, USA), 10% FCS (Gibco, Shanghai, China) and
Gentamycin (final concentration 20
µ
g/mL, Gibco), at 37
◦
C, 5% CO
2
in a humidified cell
incubator. For transfection, the medium was completely removed, and cells were incubated
for 1 h with 2 mL of fresh medium containing the injection solutions directly from the
original bottles, diluted 1:500 in the case of BNT162b2 (Pfizer/Biotech), and 1:100 in cases of
mRNA-1273 (Moderna), Vaxzevria (AstraZeneca), and Jansen (COVID-19 vaccine Jansen).
Then, another 15 mL of fresh medium was added to the cell cultures and cells were grown
to confluence for another 3 days.
Preparation of tissue blocks from transfected cells: The cell culture medium was
removed from transfected cells, and the monolayer was washed twice with PBS, then
trypsinized by adding 1 mL of 0.25% Trypsin-EDTA (Gibco), harvested with 10 mL of
PBS/10% FCS, and washed 2
×
with PBS and centrifugation at 280
×
gfor 10 min each.
Cell pellets were fixed overnight in 2 mL in PBS/4% Formalin at 8
◦
C and then washed
in PBS once. The cell pellets remaining after centrifugation were suspended in 200
µ
L
PBS each, mixed with 400
µ
L 2% agarose in PBS solution (precooled to around 40
◦
C),
and immediately transferred to small (1 cm) dishes for fixation. The fixed and agarose-
embedded cell pellets were stored in 4% Formalin/PBS till subjection to routine paraffin
embedding in parallel to tissue samples.
2.4. Case Presentation and Description
2.4.1. Clinical History
This report presents the case of a 76-year-old male with a history of Parkinson’s
disease (PD) who passed away three weeks after his third COVID-19 vaccination. On the
day of his first vaccination in May 2021 (ChAdOx1 nCov-19 vector vaccine), he experienced
pronounced cardiovascular side effects, for which he repeatedly had to consult his doctor.
After the second vaccination in July 2021 (BNT162b2 mRNA vaccine/Comirnaty), the family
noted obvious behavioral and psychological changes (e.g., he did not want to be touched
anymore and experienced increased anxiety, lethargy, and social withdrawal even from
close family members). Furthermore, there was a striking worsening of his PD symptoms,
which led to severe motor impairment and a recurrent need for wheelchair support. He
never fully recovered from these side effects after the first two vaccinations but still got
another vaccination in December 2021. Two weeks after the third vaccination (second
vaccination with BNT162b2), he suddenly collapsed while taking his dinner. Remarkably,
he did not show coughing or any signs of food aspiration but just fell down silently. He
recovered from this more or less, but one week later, he again suddenly collapsed silently
while taking his meal. The emergency unit was called, and after successful, but prolonged
resuscitation attempts (over one hour), he was transferred to the hospital and directly put
into an artificial coma but died shortly thereafter. The clinical diagnosis was death due
to aspiration pneumonia. According to his family, there was no history of a clinical or
laboratory diagnosis of COVID-19 in the past.
Vaccines 2022,10, 1651 4 of 17
2.4.2. Autopsy
The autopsy was requested and consented to by the family of the patient because of the
ambiguity of symptoms before his death. The autopsy was performed according to standard
procedures including macroscopic and microscopic investigation. Gross brain tissue was
prepared for histological examination including the brain (frontal cortex, Substantia nigra,
and Nucleus ruber) as well as the heart (left and right ventricular cardiac tissue).
3. Results
3.1. Autopsy Findings
Anatomical Specifications: Body weight, height, and specifications of body organs
were summarized in Table 2.
Table 2. Anatomical Specifications.
Item Measure
Body weight 60 kg
Hight 175 cm
Heart weight 410 g
Brain weight 1560 g
Liver weight 1500 g
Brain: A macroscopic examination of brain tissue revealed a circumscribed segmen-
tal cerebral parenchymal necrosis at the site of the right hippocampus. Substantia nigra
showed a loss of pigmented neurons. Microscopically, several areas with lacunar necrosis
were detected with inflammatory debris reaction on the left frontal side (Figure 2). Stain-
ing of Nucleus ruber with H&E showed neuronal cell death, microglia, and lymphocyte
infiltration (Figure 3). Furthermore, there were microglial and lymphocytic reactions as
well as predominantly lymphocytic vasculitis, sometimes with mixed infiltrates includ-
ing neutrophilic granulocytes (Figure 4) in the frontal cortex, paraventricular, Substantia
nigra, and Nucleus ruber on both sides. In some places with inflammatory changes in
brain capillaries, there were also signs of apoptotic cell death within the endothelium
(Figure 4). Meninges’ findings were unremarkable. The collective findings were sugges-
tive of multifocal necrotizing encephalitis. Furthermore, chronic arteriosclerotic lesions of
varying degrees were noted in large brain vessels, which are described in detail in section
“Vascular system”.
Parkinson’s disease (PD): Macroscopic and histological examination of brain tis-
sue revealed bilateral pallor of the substantia nigra with loss of pigmented neurons.
In addition, pigment-storing macrophages as well as scattered neuronal necrosis with
glial debris reaction were noted. These findings were suggestive of PD, confirming the
clinical diagnosis.
Thoracic cavity: An examination of the chest showed a funnel-shaped chest with
serial rib fractures (extending from the second to fifth ribs on the right, and from the
second to sixth ribs on the left); which is a common picture of a patient who underwent
cardiopulmonary resuscitation. An endotracheal tube was properly inserted. There was
evidence of regular placement of a central venous catheter in the left femoral vein. There
was evidence of regular placement of an arterial catheter in the left radial artery. The
urinary catheter was inserted as well. There was a 9 cm long skin scar on the front of the
right shoulder.
Vaccines 2022,10, 1651 5 of 17
Vaccines 2022, 10, 1651 6 of 17
Figure 2. Frontal brain. Already in the overview image (a), prominent vacuolations with increased
parenchymal cellularity are evident, indicative of degenerative and inflammatory processes. At
higher magnification (b), acute brain damage is visible with diffuse and zonal neuronal and glial
cell death, activation of microglia, and inflammatory infiltration by granulocytes and lymphocytes.
1: neuronal deaths (cells with red cytoplasm); 2: microglial proliferation; 3: lymphocytes. H&E
stain. Magnification 40× (a) and 200× (b).
Figure 3. Brain, Nucleus ruber. In the overview image (a), note pronounced focal necrosis with
increased cellularity, indicative of ongoing inflammation and glial reaction. At higher
magnification (b), death of neuronal cells is evident and associated with an increased number of
glial cells. Note activation of microglia and presence of inflammatory cell infiltrates, predominantly
lymphocytic. 1: neuronal death with hypereosinophilia and destruction of cell nucleus with signs
of karyolysis (nuclear content being distributed into the cytoplasm); 2: microglia (example); 3:
lymphocyte (example). H&E stain. Magnification 40× (a) and 400× (b).
Figure 2.
Frontal brain. Already in the overview image (
a
), prominent vacuolations with in-
creased parenchymal cellularity are evident, indicative of degenerative and inflammatory processes.
At higher magnification (
b
), acute brain damage is visible with diffuse and zonal neuronal and glial
cell death, activation of microglia, and inflammatory infiltration by granulocytes and lymphocytes.
1: neuronal deaths (cells with red cytoplasm); 2: microglial proliferation; 3: lymphocytes. H&E stain.
Magnification 40×(a) and 200×(b).
Vaccines 2022, 10, 1651 6 of 17
Figure 2. Frontal brain. Already in the overview image (a), prominent vacuolations with increased
parenchymal cellularity are evident, indicative of degenerative and inflammatory processes. At
higher magnification (b), acute brain damage is visible with diffuse and zonal neuronal and glial
cell death, activation of microglia, and inflammatory infiltration by granulocytes and lymphocytes.
1: neuronal deaths (cells with red cytoplasm); 2: microglial proliferation; 3: lymphocytes. H&E
stain. Magnification 40× (a) and 200× (b).
Figure 3. Brain, Nucleus ruber. In the overview image (a), note pronounced focal necrosis with
increased cellularity, indicative of ongoing inflammation and glial reaction. At higher
magnification (b), death of neuronal cells is evident and associated with an increased number of
glial cells. Note activation of microglia and presence of inflammatory cell infiltrates, predominantly
lymphocytic. 1: neuronal death with hypereosinophilia and destruction of cell nucleus with signs
of karyolysis (nuclear content being distributed into the cytoplasm); 2: microglia (example); 3:
lymphocyte (example). H&E stain. Magnification 40× (a) and 400× (b).
Figure 3.
Brain, Nucleus ruber. In the overview image (
a
), note pronounced focal necrosis with
increased cellularity, indicative of ongoing inflammation and glial reaction. At higher magnification
(
b
), death of neuronal cells is evident and associated with an increased number of glial cells. Note
activation of microglia and presence of inflammatory cell infiltrates, predominantly lymphocytic.
1: neuronal death with hypereosinophilia and destruction of cell nucleus with signs of karyolysis
(nuclear content being distributed into the cytoplasm); 2: microglia (example); 3: lymphocyte
(example). H&E stain. Magnification 40×(a) and 400×(b).
Vaccines 2022,10, 1651 6 of 17
Vaccines 2022, 10, 1651 7 of 17
Figure 4. Brain, periventricular vasculitis. Cross section through a capillary vessel showing
prominent signs of vasculitis. The endothelial cells (5) show swelling and vacuolation and are
increased in number with enlargement of nuclei, indicative for activation. Furthermore, presence of
mixed inflammatory cell infiltrates within the endothelial layer, consisting of lymphocytes (1),
granulocytes (2), and histiocytes (4). The adjacent brain tissue also shows signs of inflammation
(encephalitis) with presence of lymphocytes as well and activated microglia (3). H&E.
Magnification: 200× (a) and 400× (b).
Figure 4.
Brain, periventricular vasculitis. Cross section through a capillary vessel showing prominent
signs of vasculitis. The endothelial cells (5) show swelling and vacuolation and are increased in
number with enlargement of nuclei, indicative for activation. Furthermore, presence of mixed
inflammatory cell infiltrates within the endothelial layer, consisting of lymphocytes (1), granulocytes
(2), and histiocytes (4). The adjacent brain tissue also shows signs of inflammation (encephalitis)
with presence of lymphocytes as well and activated microglia (3). H&E. Magnification: 200
×
(
a
) and
400×(b).
Lungs: Macroscopical lung examination revealed cloudy secretion and purulent spots
with notably brittle parenchyma. The pleura showed bilateral serous effusion, amounting
to 450 mL of fluid on the right side and 400 mL on the left side. Bilateral mucopurulent
tracheobronchitis was evident with copious purulent secretion in the trachea and bronchi.
Bilateral chronic destructive pulmonary emphysema was detected. Bilateral bronchopneu-
monia was noted in the lower lung lobes at multiple stages of development and lobe-filling
with secretions and fragile parenchyma. Furthermore, chronic arteriosclerotic lesions of
varying degrees were noted, which are described in detail in the section “Vascular system”.
Heart: Macroscopic cardiac examination revealed manifestations of acute and chronic
cardiovascular insufficiency, including ectasia of the atria and ventricles. Furthermore,
left ventricular hypertrophy was noted (wall thickness: 18 mm, heart weight: 410 g, body
weight: 60 kg, height: 1.75 m). There was evidence of tissue congestion (presumably
due to cardiac insufficiency) in the form of pulmonary edema, cerebral edema, brain
congestion, chronic hepatic congestion, renal tissue edema, and pituitary tissue edema.
Moreover, there was evidence of shock kidney disorder. Histological examination of
the heart revealed mild myocarditis with fine-spotted fibrosis and lympho-histiocytic
infiltration (Figure 5). Furthermore, there were chronic arteriosclerotic lesions of varying
degrees, which are described in detail under “Vascular system”. In addition to these, there
were more acute myocardial and vascular changes in the heart. They consisted of mild
signs of myocarditis, characterized by infiltrations with foamy histiocytes and lymphocytes
as well as hypereosinophilia and some hypercontraction of cardiomyocytes. Furthermore,
mild acute vascular changes were observed in the capillaries and other small blood vessels
of the heart. They consisted of mild lympho-histiocytic infiltrates, prominent endothelial
swelling and vacuolation, multifocal myocytic degeneration and coagulation necrosis as
well as karyopyknosis of single endothelial cells and vascular muscle cells (Figure 5).
Occasionally, adhering plasma coagulates/fibrin clots were present on the endothelial
surface, indicative of endothelial damage (Figure 5).
Vaccines 2022,10, 1651 7 of 17
Vaccines 2022, 10, 1651 7 of 17
Figure 4. Brain, periventricular vasculitis. Cross section through a capillary vessel showing
prominent signs of vasculitis. The endothelial cells (5) show swelling and vacuolation and are
increased in number with enlargement of nuclei, indicative for activation. Furthermore, presence of
mixed inflammatory cell infiltrates within the endothelial layer, consisting of lymphocytes (1),
granulocytes (2), and histiocytes (4). The adjacent brain tissue also shows signs of inflammation
(encephalitis) with presence of lymphocytes as well and activated microglia (3). H&E.
Magnification: 200× (a) and 400× (b).
Figure 5.
Heart left ventricle. (
a
): Mild lympho-histiocytic myocarditis.Pronounced interstitial
edema (7) and mild lympho-histiocytic infiltrates (2 + 4). Signs of cardiomyocytic degeneration
(5) with cytoplasmic hypereosinophilia and single contraction bands. (
d
): Arteriole with signs of
acute degeneration and associated inflammation, associated by lymphocytic infiltrates (2) within
the vascular wall, endothelial swelling and vacuolation (3), and vacuolation of vascular myocytes
with signs of karyopyknosis (1). Within the vascular lumen (
d
), note plasma coagulation/fibrin
clots adhering to the endothelial surface, indicative of endothelial damage. 1: pyknotic vascular
myocytes, 2: lymphocytes, 3: swollen endothelial cells, 4: macrophages, 5: necrotic cardiomyocytes,
6: eosinophilic granulocytes, 7 (blue line): interstitial edema. H&E stain. Magnification: 200
×
(
a
) and
(c), 40×(b), and detailed enlargement (d).
Vascular system (large blood vessels): The pulmonary arteries showed ectasia and
lipidosis. The kidney showed slight diffuse glomerulosclerosis and arteriosclerosis with
renal cortical scars (up to 10 mm in diameter). The findings are suggestive of generalized
atherosclerosis and systemic hypertension. Major arteries including the aorta and its
branches as well as the coronary arteries showed variable degrees of arteriosclerosis and
mild to moderate stenosis. Furthermore, examination revealed mild nodular arteriosclerosis
of cervical arteries. Ascending aorta, aortic arch, and thoracic aorta showed moderate,
nodular, and partially calcified arteriosclerosis. The cerebral basilar artery showed mild
arteriosclerosis. Nodular and calcified arteriosclerosis were of high grade in the abdominal
aorta and iliac arteries and moderate grade with moderate stenosis in the right coronary
arteries. Coronary artery examination showed variable degrees of arteriosclerosis and
stenosis more on the left coronary arteries. The left anterior descending coronary artery (the
anterior interventricular branch of the left coronary artery; LAD) showed high-grade and
moderately stenosed arteriosclerosis. The arteriosclerosis and stenosis of the left circumflex
artery (the circumflex branch of the left coronary artery) were mild. Mild cerebral basal
artery sclerosis. High-grade nodular and calcified arteriosclerosis of the abdominal aorta
and the iliac arteries. Moderate stenosed arteriosclerosis of the right coronary artery.
Lymphocytic periarteritis was detected as well.
Vaccines 2022,10, 1651 8 of 17
3.2. Other Findings
-
Oral cavity: tongue bite was detected with bleeding under the tongue muscle (tongue
bite is common with epileptic seizures).
- Adrenal glands: bilateral mild cortical hyperplasia.
- Colon: the elongated sigmoid colon was elongated with fecal impaction.
-
Kidneys: slight diffuse glomerulosclerosis and arterio-sclerosis, renal cortical scars
(up to 10 mm in diameter), bilateral mild active nephritis and urocystitis as well as
evidence of shock kidney disorder.
- Liver: slight lipofuscinosis.
- Spleen: mild acute splenitis.
- Stomach: mild diffuse gastric mucosal bleeding.
-
Thyroid gland: bilateral nodular goiter with chocolate cysts (up to 0.5 cm in diameter).
-
Prostate gland: benign nodular prostatic hyperplasia and chronic persistent prostatitis.
3.3. Immunohistochemical Analyses
Immunohistochemical staining for the presence of SARS-CoV-2 antigens (spike protein
and nucleocapsid) was studied in the brain and heart. In the brain, SARS-CoV-2 spike
protein subunit 1 was detected in the endothelia, microglia, and astrocytes in the necrotic
areas (Figures 6and 7). Furthermore, spike protein could be demonstrated in the areas of
lymphocytic periarteritis, present in the thoracic and abdominal aorta and iliac branches,
as well as a cerebral basal artery (Figure 8). The SARS-CoV-2 subunit 1 was found in
macrophages and in the cells of the vessel wall, in particular the endothelium (Figure 9),
as well as in the Nucleus ruber (Figure 10). In contrast, the nucleocapsid protein of SARS-
CoV-2 could not be detected in any of the corresponding tissue sections (Figures 11 and 12).
In addition, SARS-CoV-2 spike protein subunit 1 was detected in the cardiac endothelial
cells that showed lymphocytic myocarditis (Figure 13). Immunohistochemical staining did
not detect the SARS-CoV-2 nucleocapsid protein (Figure 14).
Vaccines 2022, 10, 1651 9 of 17
Figure 6. Frontal brain. Immunohistochemistry for CD68 (expressed by monocytic cells). Note
map-like tissue destruction with the presence of CD68-positive microglial cells. Furthermore zonal
activation of microglia (brown granules). Activation of the microglia means that tissue destruction
has taken place in the brain, which is cleared/removed by macrophages (called microglia in the
brain). Brown granules: macrophages/microglia. Magnification: 40×.
Figure 7. Brain. Nucleus ruber. Immunohistochemistry for CD68 (expressed by monocytic cells)
shows abundant positive cells, indicative of zonal activation of microglia (brown granules). Mag-
nification: 40×.
Figure 6.
Frontal brain. Immunohistochemistry for CD68 (expressed by monocytic cells). Note
map-like tissue destruction with the presence of CD68-positive microglial cells. Furthermore zonal
activation of microglia (brown granules). Activation of the microglia means that tissue destruction
has taken place in the brain, which is cleared/removed by macrophages (called microglia in the
brain). Brown granules: macrophages/microglia. Magnification: 40×.
Vaccines 2022,10, 1651 9 of 17
Vaccines 2022, 10, 1651 9 of 17
Figure 6. Frontal brain. Immunohistochemistry for CD68 (expressed by monocytic cells). Note
map-like tissue destruction with the presence of CD68-positive microglial cells. Furthermore zonal
activation of microglia (brown granules). Activation of the microglia means that tissue destruction
has taken place in the brain, which is cleared/removed by macrophages (called microglia in the
brain). Brown granules: macrophages/microglia. Magnification: 40×.
Figure 7. Brain. Nucleus ruber. Immunohistochemistry for CD68 (expressed by monocytic cells)
shows abundant positive cells, indicative of zonal activation of microglia (brown granules). Mag-
nification: 40×.
Figure 7.
Brain. Nucleus ruber. Immunohistochemistry for CD68 (expressed by monocytic cells)
shows abundant positive cells, indicative of zonal activation of microglia (brown granules). Magnifi-
cation: 40×.
Vaccines 2022, 10, 1651 10 of 17
Figure 8. Frontal brain. Immunohistochemistry for CD3 (expressed by T-Lymphocytes) shows
numerous CD3-positive lymphocytes (brown granules, red arrow highlights an example), partic-
ularly within the endothelium, but also in the brain tissue, indicative of lymphocytic vasculitis and
encephalitis. Blue dotted lines: blood vessels. Magnification: 200×.
Figure 9. Frontal brain. Positive reaction for SARS-CoV-2 spike protein. Cross section through a
capillary vessel (same vessel as shown in Figure 11, serial sections of 5 to 20 µ m). Immunohisto-
chemical reaction for SARS-CoV-2 spike subunit 1 detectable as brown granules in capillary en-
dothelial cells (red arrow) and individual glial cells (blue arrow). Magnification: 200×.
Figure 8.
Frontal brain. Immunohistochemistry for CD3 (expressed by T-Lymphocytes) shows
numerous CD3-positive lymphocytes (brown granules, red arrow highlights an example), particu-
larly within the endothelium, but also in the brain tissue, indicative of lymphocytic vasculitis and
encephalitis. Blue dotted lines: blood vessels. Magnification: 200×.
Vaccines 2022,10, 1651 10 of 17
Vaccines 2022, 10, 1651 10 of 17
Figure 8. Frontal brain. Immunohistochemistry for CD3 (expressed by T-Lymphocytes) shows
numerous CD3-positive lymphocytes (brown granules, red arrow highlights an example), partic-
ularly within the endothelium, but also in the brain tissue, indicative of lymphocytic vasculitis and
encephalitis. Blue dotted lines: blood vessels. Magnification: 200×.
Figure 9. Frontal brain. Positive reaction for SARS-CoV-2 spike protein. Cross section through a
capillary vessel (same vessel as shown in Figure 11, serial sections of 5 to 20 µm). Immunohisto-
chemical reaction for SARS-CoV-2 spike subunit 1 detectable as brown granules in capillary en-
dothelial cells (red arrow) and individual glial cells (blue arrow). Magnification: 200×.
Figure 9.
Frontal brain. Positive reaction for SARS-CoV-2 spike protein. Cross section through a cap-
illary vessel (same vessel as shown in Figure 11, serial sections of 5 to 20
µ
m). Immunohistochemical
reaction for SARS-CoV-2 spike subunit 1 detectable as brown granules in capillary endothelial cells
(red arrow) and individual glial cells (blue arrow). Magnification: 200×.
Vaccines 2022, 10, 1651 11 of 17
Figure 10. Brain, Nucleus ruber. The abundant presence of SARS-CoV-2 spike protein in swollen
endothelium of a capillary vessel shows acute signs of inflammation with sparse mononuclear in-
flammatory cell infiltrates (same vessel as shown in Figure 12, serial sections of 5 to 20 µm). Im-
munohistochemical demonstration for SARS-CoV-2 spike protein subunit 1 visible as brown
granules in capillary endothelial cells (red arrow) and individual glial cells (blue arrow). Magnifi-
cation: 200×.
Figure 11. Frontal brain. Negative immunohistochemical reaction for SARS-CoV-2 nucleocapsid
protein. Cross section through a capillary vessel (same vessel as shown in Figure 9, serial sections
of 5 to 20 µm). Magnification: 200×.
Figure 10.
Brain, Nucleus ruber. The abundant presence of SARS-CoV-2 spike protein in swollen
endothelium of a capillary vessel shows acute signs of inflammation with sparse mononuclear
inflammatory cell infiltrates (same vessel as shown in Figure 12, serial sections of 5 to 20
µ
m). Im-
munohistochemical demonstration for SARS-CoV-2 spike protein subunit 1 visible as brown granules
in capillary endothelial cells (red arrow) and individual glial cells (blue arrow). Magnification: 200
×
.
Vaccines 2022,10, 1651 11 of 17
Vaccines 2022, 10, 1651 11 of 17
Figure 10. Brain, Nucleus ruber. The abundant presence of SARS-CoV-2 spike protein in swollen
endothelium of a capillary vessel shows acute signs of inflammation with sparse mononuclear in-
flammatory cell infiltrates (same vessel as shown in Figure 12, serial sections of 5 to 20 µm). Im-
munohistochemical demonstration for SARS-CoV-2 spike protein subunit 1 visible as brown
granules in capillary endothelial cells (red arrow) and individual glial cells (blue arrow). Magnifi-
cation: 200×.
Figure 11. Frontal brain. Negative immunohistochemical reaction for SARS-CoV-2 nucleocapsid
protein. Cross section through a capillary vessel (same vessel as shown in Figure 9, serial sections
of 5 to 20 µm). Magnification: 200×.
Figure 11.
Frontal brain. Negative immunohistochemical reaction for SARS-CoV-2 nucleocapsid
protein. Cross section through a capillary vessel (same vessel as shown in Figure 9, serial sections of
5 to 20 µm). Magnification: 200×.
Vaccines 2022, 10, 1651 12 of 17
Figure 12. Brain, Nucleus ruber. Negative immunohistochemical reaction for SARS-CoV-2 nucle-
ocapsid protein. Cross section through a capillary vessel (same vessel as shown in Figure 11, serial
sections of 5 to 20 µm). Magnification: 200×.
Figure 13. Heart left ventricle. Positive reaction for SARS-CoV-2 spike protein. Cross section
through a capillary vessel (same vessel as shown in Figure 14, serial sections of 5 to 20 µm). Im-
munohistochemical demonstration of SARS-CoV-2 spike subunit 1 as brown granules. Note the
abundant presence of spike protein in capillary endothelial cells (red arrow) associated with
prominent endothelial swelling and the presence of a few mononuclear inflammatory cells. Mag-
nification: 400×.
Figure 12.
Brain, Nucleus ruber. Negative immunohistochemical reaction for SARS-CoV-2 nucleo-
capsid protein. Cross section through a capillary vessel (same vessel as shown in Figure 11, serial
sections of 5 to 20 µm). Magnification: 200×.
Vaccines 2022,10, 1651 12 of 17
Vaccines 2022, 10, 1651 12 of 17
Figure 12. Brain, Nucleus ruber. Negative immunohistochemical reaction for SARS-CoV-2 nucle-
ocapsid protein. Cross section through a capillary vessel (same vessel as shown in Figure 11, serial
sections of 5 to 20 µm). Magnification: 200×.
Figure 13. Heart left ventricle. Positive reaction for SARS-CoV-2 spike protein. Cross section
through a capillary vessel (same vessel as shown in Figure 14, serial sections of 5 to 20 µ m). Im-
munohistochemical demonstration of SARS-CoV-2 spike subunit 1 as brown granules. Note the
abundant presence of spike protein in capillary endothelial cells (red arrow) associated with
prominent endothelial swelling and the presence of a few mononuclear inflammatory cells. Mag-
nification: 400×.
Figure 13.
Heart left ventricle. Positive reaction for SARS-CoV-2 spike protein. Cross section through
a capillary vessel (same vessel as shown in Figure 14, serial sections of 5 to 20
µ
m). Immunohistochem-
ical demonstration of SARS-CoV-2 spike subunit 1 as brown granules. Note the abundant presence of
spike protein in capillary endothelial cells (red arrow) associated with prominent endothelial swelling
and the presence of a few mononuclear inflammatory cells. Magnification: 400×.
Vaccines 2022, 10, 1651 13 of 17
Figure 14. Heart left ventricle. Negative immunohistochemical reaction for SARS-CoV-2 nucle-
ocapsid protein. Cross section through a capillary vessel (same vessel as shown in Figure 13, serial
sections of 5 to 20 µm). Magnification: 400×.
3.4. Autopsy-Based Diagnosis
The 76-year-old deceased male patient had PD, which corresponded to typical
post-mortem findings. The main cause of death was recurrent aspiration pneumonia. In
addition, necrotizing encephalitis and vasculitis were considered to be major contribu-
tors to death. Furthermore, there was mild lympho-histiocytic myocarditis with fi-
ne-spotted myocardial fibrosis as well as systemic arteriosclerosis, which will have also
contributed to the deterioration of the physical condition of the senior.
The final diagnosis was abscedating bilateral bronchopneumonia (J18.9), Parkin-
son’s disease (G20.9), necrotic encephalitis (G04.9), and myocarditis (I40.9).
Immunohistochemistry for SARS-CoV-2 antigens (spike protein and nucleocapsid)
revealed that the lesions with necrotizing encephalitis as well as the acute inflammatory
changes in the small blood vessels (brain and heart) were associated with abundant de-
posits of the spike protein SARS-CoV-2 subunit 1. Since the nucleocapsid protein of
SARS-CoV-2 was consistently absent, it must be assumed that the presence of spike pro-
tein in affected tissues was not due to an infection with SARS-CoV-2 but rather to the
transfection of the tissues by the gene-based COVID-19-vaccines. Importantly, spike
protein could be only demonstrated in the areas with acute inflammatory reactions
(brain, heart, and small blood vessels), in particular in endothelial cells, microglia, and
astrocytes. This is strongly suggestive that the spike protein may have played at least a
contributing role to the development of the lesions and the course of the disease in this
patient.
4. Discussion
This is a case report of a 76-year-old patient with Parkinson’s disease (PD) who died
three weeks after his third COVID-19 vaccination. The stated cause of death appeared to
be a recurrent attack of aspiration pneumonia, which is indeed common in PD [14,15].
However, the detailed autopsy study revealed additional pathology, in particular ne-
crotizing encephalitis and myocarditis. While the histopathological signs of myocarditis
were comparatively mild, the encephalitis had resulted in significant multifocal necrosis
and may well have contributed to the fatal outcome. Encephalitis often causes epileptic
seizures, and the tongue bite found at the autopsy suggests that it had done so in this
Figure 14.
Heart left ventricle. Negative immunohistochemical reaction for SARS-CoV-2 nucleocapsid
protein. Cross section through a capillary vessel (same vessel as shown in Figure 13, serial sections of
5 to 20 µm). Magnification: 400×.
3.4. Autopsy-Based Diagnosis
The 76-year-old deceased male patient had PD, which corresponded to typical post-
mortem findings. The main cause of death was recurrent aspiration pneumonia. In
addition, necrotizing encephalitis and vasculitis were considered to be major contributors
to death. Furthermore, there was mild lympho-histiocytic myocarditis with fine-spotted
myocardial fibrosis as well as systemic arteriosclerosis, which will have also contributed to
the deterioration of the physical condition of the senior.
Vaccines 2022,10, 1651 13 of 17
The final diagnosis was abscedating bilateral bronchopneumonia (J18.9), Parkinson’s
disease (G20.9), necrotic encephalitis (G04.9), and myocarditis (I40.9).
Immunohistochemistry for SARS-CoV-2 antigens (spike protein and nucleocapsid)
revealed that the lesions with necrotizing encephalitis as well as the acute inflammatory
changes in the small blood vessels (brain and heart) were associated with abundant deposits
of the spike protein SARS-CoV-2 subunit 1. Since the nucleocapsid protein of SARS-CoV-2
was consistently absent, it must be assumed that the presence of spike protein in affected
tissues was not due to an infection with SARS-CoV-2 but rather to the transfection of
the tissues by the gene-based COVID-19-vaccines. Importantly, spike protein could be
only demonstrated in the areas with acute inflammatory reactions (brain, heart, and small
blood vessels), in particular in endothelial cells, microglia, and astrocytes. This is strongly
suggestive that the spike protein may have played at least a contributing role to the
development of the lesions and the course of the disease in this patient.
4. Discussion
This is a case report of a 76-year-old patient with Parkinson’s disease (PD) who died
three weeks after his third COVID-19 vaccination. The stated cause of death appeared
to be a recurrent attack of aspiration pneumonia, which is indeed common in PD [
14
,
15
].
However, the detailed autopsy study revealed additional pathology, in particular necrotiz-
ing encephalitis and myocarditis. While the histopathological signs of myocarditis were
comparatively mild, the encephalitis had resulted in significant multifocal necrosis and may
well have contributed to the fatal outcome. Encephalitis often causes epileptic seizures, and
the tongue bite found at the autopsy suggests that it had done so in this case. Several other
cases of COVID-19 vaccine-associated encephalitis with status epilepticus have appeared
previously [16–18].
The clinical history of the current case showed some remarkable events in correlation
to his COVID-19 vaccinations. Already on the day of his first vaccination in May 2021
(ChAdOx1 nCov-19 vector vaccine), he experienced cardiovascular symptoms, which
needed medical care and from which he recovered only slowly. After the second vaccination
in July 2021 (BNT162b2 mRNA vaccine), the family recognized remarkable behavioral and
psychological changes and a sudden onset of marked progression of his PD symptoms,
which led to severe motor impairment and recurrent need for wheelchair support. He
never fully recovered from this but still was again vaccinated in December 2021. Two weeks
after this third vaccination (second vaccination with BNT162b2), he suddenly collapsed
while taking his dinner. Remarkably, he did not show any coughing or other signs of food
aspiration but just fell from his chair. This raises the question of whether this sudden
collapse was really due to aspiration pneumonia. After intense resuscitation, he recovered
from this more or less, but one week later, he again suddenly collapsed silently while taking
his meal. After successful but prolonged resuscitation attempts, he was transferred to the
hospital and directly set into an artificial coma but died shortly thereafter. The clinical
diagnosis was death due to aspiration pneumonia. Due to his ambiguous symptoms after
the COVID-vaccinations the family asked for an autopsy.
Based on the alteration pattern in the brain and heart, it appeared that the small blood
vessels were especially affected, in particular, the endothelium. Endothelial dysfunction is
known to be highly involved in organ dysfunction during viral infections, as it induces a
pro-coagulant state, microvascular leak, and organ ischemia [
19
,
20
]. This is also the case for
severe SARS-CoV-2 infections, where a systemic exposure to the virus and its spike protein
elicits a strong immunological reaction in which the endothelial cells play a crucial role,
leading to vascular dysfunction, immune-thrombosis, and inflammation [21].
Although there was no history of COVID-19 for this patient, immunohistochemistry
for SARS-CoV-2 antigens (spike and nucleocapsid proteins) was performed. Spike protein
could be indeed demonstrated in the areas of acute inflammation in the brain (particularly
within the capillary endothelium) and the small blood vessels of the heart. Remarkably,
however, the nucleocapsid was uniformly absent. During an infection with the virus, both
Vaccines 2022,10, 1651 14 of 17
proteins should be expressed and detected together. On the other hand, the gene-based
COVID-19 vaccines encode only the spike protein and therefore, the presence of spike
protein only (but no nucleocapsid protein) in the heart and brain of the current case can
be attributed to vaccination rather than to infection. This agrees with the patient’s history,
which includes three vaccine injections, the third one just 3 weeks before his death, but no
positive laboratory or clinical diagnosis of the infection.
Discrimination of vaccination response from natural infection is an important question
and had been addressed already in clinical immunology, where the combined application
of anti-spike and anti-nucleocapsid protein-based serology was proven as a useful tool [
22
].
In histology, however, this immunohistochemical approach has not yet been described, but
it is straightforward and appears to be very useful for identifying the potential origin of
SARS-CoV-2 spike protein in autopsy or biopsy samples. Where additional confirmation is
required, for instance in a forensic context, rt-PCR methods might be used to ascertain the
presence of the vaccine mRNA in the affected tissues [23,24].
Assuming that, in the current case, the presence of spike protein was indeed driven
by the gene-based vaccine, then the question arises whether this was also the cause the
accompanying acute tissue alterations and inflammation. The stated purpose of the gene-
based vaccines is to induce an immune response against the spike protein. Such an immune
response will, however, not only results in antibody formation against the spike protein but
also lead to direct cell- and antibody-mediated cytotoxicity against the cells expressing this
foreign antigen. In addition, there are indications that the spike protein on its own can elicit
distinct toxicity, in particular, on pericytes and endothelial cells of blood vessels [25,26].
While it is widely held that spike protein expression, and the ensuing cell and tissue
damage will be limited to the injection site, several studies have found the vaccine mRNA
and/or the spike protein encoded by it at a considerable distance from the injection site
for up to three months after the injection [
23
,
24
,
27
–
29
]. Biodistribution studies in rats with
the mRNA-COVID-19 vaccine BNT162b2 also showed that the vaccine does not stay at the
injection site but is distributed to all tissues and organs, including the brain [
30
]. After the
worldwide roll-out of COVID-19 vaccinations in humans, spike protein has been detected
in humans as well in several tissues distant from the injection site (deltoid muscle): for
instance in heart muscle biopsies from myocarditis patients [
28
], within the skeletal muscle
of a patient with myositis [
23
] and within the skin, where it was associated with a sudden
onset of Herpes zoster lesions after mRNA-COVID-19 vaccination [29].
The underlying diagnosis in this patient was Parkinson’s disease, and one may ask
what role, if any, this condition had played in the causation of the encephalitis, and the
myocarditis detected at post-mortem examination. PD had been long-standing in the cur-
rent case, whereas the encephalitis was acute. Conversely, there is no plausible mechanism
and no case report of PD causing secondary necrotizing encephalitis. On the other hand,
numerous cases have been reported of autoimmune encephalitis and encephalomyelitis
after COVID-19 vaccination [
12
,
31
]. Autoimmune diseases in organs other than the CNS
have been reported as well, for example, a striking case of a patient who after mRNA
vaccination suffered multiple autoimmune disorders all at once—acute disseminated en-
cephalomyelitis, myasthenia gravis, and thyroiditis [
32
]. In the case reported here, it may
be noted that the spike protein was primarily detected in the vascular endothelium and
sparsely in the glial cells but not in the neurons. Nevertheless, neuronal cell death was
widespread in the encephalitic foci, which suggests some contribution of immunological
bystander activation, i.e., autoimmunity, to the observed cell and tissue damage.
A contributory role of PD in the development of cardiomyopathy is indeed docu-
mented and cannot be ruled out with absolute certainty. However, inflammatory myocar-
dial changes with pathological alterations in small blood vessels as seen in the current case
are uncommon. Instead, the most prominent cause of cardiac failure in PD patients is rather
due to cardiac autonomic dysfunction [
33
,
34
]. PD seems well to be significantly associated
with increased left ventricular hypertrophy and diastolic dysfunction [
34
]. In the current
case, ventricular dilatation and hypertrophy were present but seem rather related to mani-
Vaccines 2022,10, 1651 15 of 17
fest signs of chronic hypertension. In contrast, myocardial inflammatory reactions had been
well-linked to gene-based COVID-19 vaccinations in numerous cases [
9
,
35
–
37
]. In one case,
the spike protein of SARS-CoV-2 could also be demonstrated by immunohistochemistry in
the heart of vaccinated individuals [28].
5. Conclusions
Numerous cases of encephalitis and encephalomyelitis have been reported in connec-
tion with the gene-based COVID-19 vaccines, with many being considered causally related
to vaccination [
31
,
38
,
39
]. However, this is the first report to demonstrate the presence of
the spike protein within the encephalitic lesions and to attribute it to vaccination rather
than infection. These findings corroborate a causative role of the gene-based COVID-19
vaccines, and this diagnostic approach is relevant to potentially vaccine-induced damage
to other organs as well.
Funding: This research received no specific funding.
Institutional Review Board Statement:
According to the Saxonian State Chamber of Medicine
(Ethikkommission Landesärztekammer Sachsen), no explicit ethical approval is required for autopsy
case reports as long as informed consent was obtained from the entitled person and all data has
been anonymized.
Informed Consent Statement:
The informed consent was obtained from the entitled person for the
subject involved in this case report.
Data Availability Statement: Data are available upon request.
Acknowledgments:
The author wishes to thank Hany A. Salem and David O. Fischer for supporting
the preparation of this paper with valuable comments and suggestions.
Conflicts of Interest: The author declares he has no conflict of interest.
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