Age: 23.0
Sex: M
Vaccine: ANTH
Symptoms: Blood magnesium normal, Blood osmolarity increased, Blood phosphorus normal, Blood thyroid stimulating hormone normal, Cardiac enzymes increased
Clinical narrative: On evening of 9/27/2012 this 24 year old male presented to ER via ambulance with acute syncope after training. His record reported episodes of substernal chest pain and tightness and nausea with exertion for last 30 days. (FLUMIST was documented being given on 9/19/2012 with note opened 9/26/12, vaccine given 9/27/2012 and note signed 9/28/2012). Medical history review from patient and with medical records: 1. 8/17/2012 Initial chest pain (32 days before FLUMIST given and 41 days after AVA #2 and 74 days after SPV): described as sudden onset of chest tightness or heavy pressure 6/10 after basketball practice that eased with 30 minutes rest. He stated chest pain returned during early morning training with numbness in chest and down right arm. He was taken to barracks and then medical when his chest pain worsened with nausea, sweats while lying down or trying to sit up. His exam documented chest pain 2/10 with RUQ abdominal pain (pain with palpation). EKG: Sinus bradycardia (58 bpm) with rrr, no m/g/r/c, heaves or lifts. RUQ pain likely MS in nature... diagnosed with atypical chest pain and treated with naproxen x 2 wk. Patient advised this pain took 2 weeks to resolve using NSAIDs. (He denied any URI like symptoms or exposure to anyone with viral illness). 2. 9/19/2012 Electronic immunization records documented FLUMIST given 9/19/2012 (patient and his local provider concurs receipt here) however a note suggests administration of FLUMIST vaccine on 9/26/2012 (was chest pain free from August event when vaccine administered). 3. 9/27/2012 day 8 after Influenza vaccine: After completing basketball practice, he received FLUMIST vaccine and then reported for routine training. Approximately 4-5 hours into training, he complained he "felt weird". He stated he was able to complete 2 laps of a run but stopped due to 9/10 chest pain, urge to vomit, dizziness and shortness of breath. He stated his heart beat was rapid and it was difficult to catch his breath. Lying down seemed to help but said the cold grass with arms extended up over head helped. He was escorted back with chest pain a 7/10 where he vomited, passed out for few seconds, regained consciousness, sat up and passed out again (unsure length of time). (He again denied any URI like symptoms or exposure to anyone with viral illness). He was taken to nearby hospital via ambulance 9/27/2012 where he "was rehydrated with IV fluids with return of consciousness". ER providers documented patient reporting other training events did trigger this chest pain/dyspnea on exertion over the past month (described chest pain as gripping to left sided with 2-9/10 chest pain; pain lasts 7-10 minutes and eases with rest or lying flat for 10 minutes; pain worsened with exercise), however patient advised this episode was different in severity of pain (sharper) and this time he lost consciousness when compared to August 2012 chest pain. Patient does admit to poor eating habits and drinks 5-6 liters of water a day due to severe sweating with exercise/basketball programs. He was admitted to ICU on 9/18/2012 for syncope and chest pain. Internal Medicine Providers discharge diagnosis on 9/30/2012 was "acute myopericarditis based upon EKG findings, elevated cardiac markers and syncope. His symptoms have been long standing. Timeframe with onset of symptoms starting in August 2012 (day 41 after AVA2 and 73 after SPV) would be consistent with vaccine reaction. His acute worsening 9/28/2012 (day 9 after FLUMIST) my be due to exertion which exacerbated this event". He was treated with ASA 650 mg 4x/day and colchicine 0.6 mg twice a day. 11/8/2012: Hepatitis A and Hepatitis B #3 vaccine given. Healthcare spoke with patient who advised he continued to experience episodes of chest discomfort. He described a sensation of a rapid heart rate at rest or with exertion lasting for 6-7 minutes resolving with 10 minutes of rest. He had one episode about 11/1/2012 and again on 11/8/2012-about 4 hours after receipt of Hepatitis A/B vaccination. This discomfort was similar but less intense to prior episodes. He was taking MOTRIN and then Colchicine which did resolve his discomfort on 11/1/2012, but he has not been using the medication routinely (none on 11/8/2012). Patient instructed to seek medical care now for recurrent chest pain. Patient was seen 11/9/2012 with instructions to continue NSAID/colchicine and referred to cardiology and/or follow up with internal medicine. Further follow up exams November 2012 documented 3 visits to cardiology with no chest pain, lightheadedness, dizziness or shortness of breath (at exams). However, he did admit experiencing intermittent chest pain described as pressure or someone squeezing his heart at level T4 extending under the nipple line about 4 times per week since his September admission. There was no radiating pain and lying flat made his pain better. Walking or running exacerbated the pain. Discomfort would last 7-10 minutes with some shortness of breath. TYLENOL has helped. His EKG 11/14/2012 showed sinus bradycardia (rate 50) with normal axis, TWI in leads II, III and aVF, ST elevation V2-V5, TWI in V6. These were similar findings compared to 9/28/2012 EKG when diagnosed with myopericarditis. ESR and CRP were normal (no cardiac labs drawn). Lab 11/18-19/2012: CRP <0.5, ANA negative, EKG on 11/27/2012: Sinus brady (49 bpm) - MD wrote SB nl axis/PR internal with lateral ST elevation inferior TWI - old). Follow up exams with Internal medicine (IM) and PCP in December 2012 reported continued complaints of chest pain, dizziness and nausea. He admits to taking indomethacin but is not taking the colchicine as instructed (he forgets). His symptoms eased with NSAID use but the sensations of dizziness and nausea have persisted since September. He was re-instructed on use of his medications and restarted on colchicine twice a day; indomethacin three times a day (with food) and given NEXIUM and ZOFRAN. He reported resolution of symptoms with use of medications. IM/cardiology completed his TST/repeat echo on 12/27/2012. He admits to a "chronic chest ache-pangs" but otherwise no problems on meds. His TST and repeat echo were normal. His echo showed a trivial pericardial effusion - unchanged since 9/28/12. He was instructed to follow up with PCM and resume light exercise with gradual increase to prior baseline as tolerated.