Age: 33.0
Sex: M
Vaccine: SMALL
Symptoms: Nausea, Protein urine present, Red blood cell sedimentation rate increased, Troponin I increased, Vomiting
Clinical narrative: MEDICAL AIR EVACUATION SUMMARY  DATE ADMITTED:  15 Jan 08 DATE OF AIR EVACUATION:  Pending  ADMISSION DIAGNOSIS:  Chest pain with EKG changes and positive cardiac enzymes consistent with myocardial infarction.  HISTORY OF PRESENT ILLNESS:  This is a 33-year-old active duty male who developed burning chest pain with radiation down the left arm beginning the day prior to admission.  Initially the pain was mild and he was able to sleep through the pain.  During his night shift, he developed progression of symptoms with development of nausea and vomiting.  He initially went to the Medical Clinic in the early morning and was evaluated by the medics.  The medics thought he had food poisoning and sent him back to quarters.  The patient took two aspirin and felt better.  The medics then came and got the patient at 0800 and took him to the doctor and he was subsequently admitted to the hospital.  His cardiac enzymes were positive with Troponin ranging from 2-7.  He had one brief recurrence of chest pain yesterday afternoon while hospitalized.  His initial EKG showed ST segment elevation of 2 mm in the inferior leads with what appeared to be reciprocal ST depression and AVL and also some mild ST elevation anterolaterally.  Thrombolytics were not given.  ALLERGIES:  No known drug allergies. PAST MEDICAL HISTORY:  None PRIOR MEDICATIONS:  Doxycycline 100 mg a day SOCIAL HISTORY:  Positive tobacco FAMILY HISTORY:  Mother with Type II diabetes. MEDICATIONS ON AEROMEDICAL EVACUATION:  Aspirin 325 mg a daily, Captopril 6.25 mg t.i.d., Lovenox 80 mg b.i.d., Zocor 40 mg daily, Plavix 75 mg daily.  The patient received the small pox vaccine on 02 Jan 08. REVIEW OF SYSTEMS:  As per the history of the present illness. PHYSICAL EXAMINATION:  Blood pressure 120/70, pulse 70, temperature 98.6°.  In general, he was in no acute distress without chest pain.  His neck exam was normal.  His lungs are clear.  His heart was a regular rate without murmur, rubs or gallops.  His abdomen was soft.  His extremities showed no edema with good pulses.  His neurological exam was normal.  His EKG here at Medical Center showed mild persistent ST segment elevations in the inferior leads with associated T-wave inversions and no Q-waves.  His laboratory data here at Medical Center was remarkable for initial cardiac enzymes on admission, a CK of 2761 with a CKMB of 15.5 and a Troponin of 7.47.  He had normal coags.  His WBC was 7.2 with a hematocrit of 40.7 and platelets of 260,000.  His urinalysis was remarkable for a mild elevated protein of 5 mg per deciliter.  His chemistry showed glucose of 102, sodium of 137, potassium 4.2, CO2 of 29, a chloride of 101, BUN of 6 and creatinine of 1.1.  His liver function tests were significant only for a mildly AST of 77.  He had an elevated myoglobin of 2166.  His C reactive protein was mildly elevated at 2.41.  His repeat cardiac enzymes showed a CK of 5575 with a CKMB of 4.3 and a Troponin of 2.52.  His ESR was 34. HOSPITAL COURSE:  He was admitted to the Intensive Care Unit (ICU) and he underwent a cardiac catheterization.  Cardiac catheterization was significant for a long concentric 30% stenosis in the mid LAD.  He had normal LV systolic function and wall motion.  The cardiac catheterization did not show any evidence for an acute coronary syndrome.  The patient tolerated the cardiac catheterization without complications.  At this point, we redirected therapy for treatment of a likely myopericarditis related to small pox vaccine.  He was started on Motrin 800 mg t.i.d.  He was transferred to the ward.  He had no recurrence of chest pain.  He is currently hemodynamically stable and doing well.   DISCHARGE MEDICATIONS:  Motrin 800 mg t.i.d., Aspirin 81 mg daily, Zocor 40 mg daily and Prilosec 20 mg daily. SUMMARY:  Likely myopericarditis related to the small pox vaccine. PLAN:  I initially thought this patient had an acute coronary syndrome, but found no evidence of this on cardiac catheterization.  The time of onset of this illness after the small pox vaccination is very supportive of the diagnosis of a myopericarditis.  He just had an echocardiogram which was normal.  I will report this as an adverse vaccine event by filing a report via the internet.  The patient is stable for aeromedically evacuation.  He may fly commercial.  He should have two weeks of convalescent leave and should only perform light daily activities for the next six weeks.  He should followup with a physician within two to four weeks of his arrival.  I recommend risk factor modification for his mild non-obstructive coronary artery disease.