Age: 24.0
Sex: M
Vaccine: ANTH, SMALL, ANTH, SMALL, ANTH, SMALL, ANTH, SMALL
Symptoms: Asthenia, Blood creatine phosphokinase MB increased, Blood creatine phosphokinase increased, C-reactive protein normal, Chest X-ray normal
Clinical narrative: History of myocarditis, with presentation of dyspnea, mild chest pain, and fatigue 16-days following receipt of smallpox and anthrax vaccines on 14 FEB 2013. [The following information was obtained from notes, and face-to-face visits with patient (PT) on 8 MAR 2013.] On 14 FEB 2013, PT received AVA (2) vaccine in his right arm and did not experience unusual or prolonged local or systemic symptoms during the next week. He also received his primary smallpox vaccine in his left upper arm on that same day. He reports normal site progression and denies any significant redness, swelling, streaking, or tender or swollen axillary lymph nodes. Around post-vaccine day 7 (21 MAR), PT's smallpox vaccine site was assessed as a "take" and he does not recall any fever, chills, fatigue, body aches or headaches around that time. At that time, he was in his usual state of "very good" health. On 2 MAR 2013, during afternoon while exercising, PT felt short of breath and fatigued. He attributed the shortness of breath to the high altitude (5300 feet above sea level) and describes it as being winded like after exercise, but in this case, it occurred much earlier during his workout. He denies any weakness and describes fatigue like feeling really tired or having "no energy". These symptoms resolved after rest. That evening, around 2200, PT felt mild substernal chest pain which he thought was related to indigestion. He took a couple antacid tabs and went to bed. On 3 MAR 2013, around 0200 or 0300, PT awoke with significant chills. He denies any associated sweats or fever. He also noted his chest pain continued. He took a hot shower and while in the shower, he was "out of breath" and fatigued like before, but after he showered, he went back to sleep until around 0900. When he awoke, his chills were gone and he denies bed linens or night clothes being damp or wet with perspiration. He continued to have constant, mild, substernal chest pain which he describes as kind of a burning, pressure-type pain that did not radiate or change intensity or character with position changes or deep breaths. He rates the pain intensity level was 2 of 10 at onset  the night before and never increased beyond 2/10. (Using pain intensity scale of 0=no pain and 10=worst pain ever experienced.) Shortly after getting up, PT took some more antacids, without any change in his chest pain. He then went for evaluation by his unit medic, who evaluated him and then sent him for further evaluation. At facility, he had an ECG which showed ST elevations and he had positive quantitative troponins (x2). He was then hospitalized, where his troponin levels peaked at 12.5ng/mL. By the time PT was admitted on 3 MAR, all of his symptoms were gone and did not return. PT denies any palpitations, pedal edema, nausea and vomiting, or lightheadedness. He also denies any recent symptoms of infection prior to or shortly after vaccine receipt and had no recent exposures to sick contacts. (Reports last illness was "seasonal cold around New Year's".) On 5 MAR 2013, PT was transferred for further evaluation and management, with admission Dx of possible Myocarditis vs. AMI. He was later transferred again before being transferred to a final MC. PT remained stable and asymptomatic throughout his hospital course (See Diagnostics for LAB, ECG and IMAGING RESULTS). PT is currently asymptomatic. He will be staying where he is and has a Cardiology appointment scheduled later this month.