Age: 38.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood gases abnormal
Clinical narrative: As per cardiologist's note on 10/3/21:  "Cardiology was asked to urgently evaluate this 38-year-old male not previously known to my service who was brought into the emergency room at hospital after presumed cardiac arrest.  Patient's recent history is quite complex and much of this information was obtained after cardiology's initial evaluation of patient.  In short patient had received a second Pfizer COVID-19 vaccination yesterday which was Saturday, October 2, 2021.  Patient had not had any reaction to first vaccination dose.  Patient also denies Covid 19 infection previous to vaccination.  Patient at approximately 3 AM woke with chills and rigors which was concerning to his wife however patient reassured her that he was okay and that this was just simply reaction to the vaccination.  At approximately 5 AM patient had extreme chills rigors and apparent loss of consciousness but regained consciousness after approximately 45 seconds to a minute.  Patient was slow to respond initially however did not exhibit any evidence of a postictal state.  Patient had no loss of bladder or bowel function, no tongue biting.  And although only was confused for a few moments after the event.   Patient also did not complain any shortness of breath or chest pain although he felt weak.  Patient had another similar episode for which wife called EMS however patient responded and patient deferred transfer to emergency room.  Patient was shortly thereafter found unresponsive by wife once again.  Patient this time was having tonic-clonic activity with questionable urinary incontinence.  Patient was intubated in the field and in route received 4 shocks from an AED device.  There are no strips available at this time for perusal however that may be a moot point as later patient had witnessed ventricular tachycardia and fibrillation.  Please see critical care consultation which accompanies this dictation.  Cardiology evaluated patient shortly after presentation to the ER as a good Samaritan gesture as I was not formally involved with the case.  At this time I did a courtesy bedside echocardiogram using the emergency room's basic Sonos equipment.  Obviously the initial concern was possible myocarditis post mRNA vaccination.  Echocardiogram at that time showed robust, normal left ventricular function with ejection fraction of proximally 60%.  As the patient story was extremely suggestive of arrhythmic nature, not neurologic I suggested to the emergency room physician that amiodarone 150 mg bolus to be given as it had not been given in the field.  Ultimately cardiology was asked to formally evaluate and continue to treat.  Anecdotally patients mother is known to our practice.   Of note patient does have a  past medical history of migraines, but is not on any medications .  Patient has not to anyone's knowledge taken any possible offending agents which could precipitate ventricular tachycardia and or torsades .  As per the family, the patient is active physically without history of tobacco EtOH or illicit drug use.  Patient exercises quite regularly and leads what would be considered a very healthy lifestyle.  His brother describes having a very violent reaction to the Covid 19 Johnson & Johnson vaccination however he attributed that to the fact that he had had Covid several months prior.  Patient did have symptoms of  what could be considered a generalized flulike illness beginning several days prior to presentation but was not was not characterized by the wife or family as a major illness of any sort   Patient had 2 additional cardiac events which will be described in more detail in separate progress note, however in summary patient was witnessed to go into torsades and required defibrillation x2.  Patient was rebolused with amiodarone and additional IV magnesium given.  Patient proxy an hour later became fairly hypotensive and initially after discussion with  cardiac electrophysiology it was initially felt that we would want to avoid pressors as they may precipitate further arrhythmias and plans were made for intra-aortic balloon pump to be placed.  Patient's blood pressure dropped precipitously and small doses of Neo-Synephrine given by cardiology without any further ventricular arrhythmias.  Patient did well on just very low-dose Neo-Synephrine was monitored by cardiology on transfer to ICU within the ICU.  Decision to place intra-aortic balloon pump defer at this time after discussion with intensivist and cardiac electrophysiology.  Of note when patient became hypotensive propofol was discontinued and during that time patient was seen to wake fully, before given IV Ativan"  On 10/4/21, the patient was discharged to Medical Center for more advanced cardiac care. On 10/4/21 (day of transfer), a consulting cardiologist documented the following:  ASSESSMENT AND PLAN:   Migrane headaches VT/VF arrest Syncope Seizure Acute hypoxic respiratory failure ? Severe Myocarditis s/p COVID vaccine ? Brugada Syndrome Hypotension Bradycardia CHF, acute systolic   VT/VF storm in setting of ? severe myocarditis vs brugada syndrome with reduced EF EKG reviewed Initial Echo 10/3 EF 55, mild TR Repeat Echo 10/4 EF 20, global hypokinesis of LV LHC 10/4 showed normal coronaries IABP placed, 1:1; TVP settings: A-paced rate 70, output 0.8, sensing 3.0 On IV Amiodarone and Lidocaine drips Plan to transfer today for possible Impella placement. The history is also suggestive of Brugada VT storm as he came with a fever after vaccine. The baseline EKG has incomplete RBBB and episodes of spontaneous VF HE does have BBR VT, fascicular VT or CPVT on any of these episodes Likely diagnosis is either Brugada or severe myocarditis. Would recommend Isuprel along with PO quinidine which are not available at facility Possibly will also need ventricular biopsy to rule out myocarditis."