Age: 39.0
Sex: F
Vaccine: ANTH, FLUX, HEP, HEPA, MEN, SMALL, YF, ANTH, FLUX, HEPA, MEN, SMALL, YF, ANTH, FLUX, HEP, HEPA, MEN, SMALL, YF
Symptoms: Anorexia nervosa, Chest pain, Laboratory test abnormal, Myocardial infarction, Pleural effusion
Clinical narrative: Patient was diagnosed with a non Q-wave myocardial infarction on 21 May 03 (4 months after receipt of Anthrax #1, Hep B #1, Hep A #2, Influenza, Meningococcal, Smallpox, and Yellow Fever Vaccinations and 2.5 months after receipt of Anthrax #2 and Hep B #2).  She reports that she started experiencing chest pain one week after receiving the January 2003 set of vaccinations.  She experienced similar chest pain the second week in February, and at the end of March.  She did not seek medical evaluation until the chest pain episodes returned on 5/20/03 while she was deployed.  After an elevated CPK (peak of 317) and elevated troponin (result not listed in available medical records), the patient was medically evacuated to a Medical Center.    While at the medica center, cardiac enzymes were abnormal with a peak CK of 98 (Nml), CK-MB of 12 H, and initial troponin of 21 H.  A cardiac catheterization revealed a right dominant coronary system with branch vessel disease.  She had a very small first obtuse marginal branch that had a 90% ostial lesion in it.  She also had a 60% ostial moderate size diagonal branch lesion.  Given her cardiac cath findings, as well as continued chest discomfort, she remained in the ICU.  During this time, she continued to have chest pain, and she was placed on a full Bruce treadmill test.  She did not develop any ischemic ECG changes on the treadmill.  Given these findings but with continued chest pain, her physicians did not feel that her chest pain was cardiac related.    A PA/Lateral chest x-ray revealed a blunt right hemidiaphragm consistent with a small effusion.  A repeat chest x-ray five days later showed that the effusion had resolved.  An abdominal ultrasound was performed, which was unremarkable other than a nondistended gallbladder.  A gastroenterology consult was obtained, and a esophagogastroduodenoscopy was performed which revealed a small erosion on the antral portion of the stomach.  However, this was not felt to be causal of the chest pain.  She was placed empirically on Aciphex.  While at the medical center, a psychiatry consult was obtain to evaluate her eating habits, and she was diagnosed with anorexia nervosa of a restricted type.  No medications were started for this.  She stayed at the medical center for 2-3 weeks before being transferred to another medical center for further evaluation. Her discharge medications include Lopressor 25 mg po BID, Plavix 75 mg po QD, and Aciphex 20 mg po BID.  Her evaluation showed:  On 06 Jun 03, during cardiology eval, her EKG showed NSR, NL EKG.  GXT-Thall obtained on 6/9/02 showed moderate to severe diminished activity in the anterolateral wall after 12:56 minutes, which improves with rest.  EF=55%.  TTE (6/10/03):  Normal echo with EF=60-65%.  Dr indicated that although her MPS showed ischemia in the anterolateral wall, her ability to exercise for 12:55 minutes without cardiac symptoms translates in "a good prognosis."  He also reported that she was having non-cardiac chest pain:  most likely musculoskeletal in nature and referred her to internal medicine.  Her medications included metoprolol, Plavix, Aciphex, and Zocor. She received evaluation by Internal Medicine for work-up of Non-cardiac chest pain.  Thought to be likely costochondritis-referred for PA Chest x-ray (Records indicate nml Chest x-ray.) 60 day follow 4/5/2004: She continues to experience daily chest pain with exertion and at rest. She is under the care of physicians including cardiology, gastroenterology, and internal medicine. Per annual report- As of 13 Jan 04, patient still experiences chest pain routinely.  Follow-up care with primary physician and cardiologist was pending.