Age: 15.0
Sex: M
Vaccine: COVID19
Symptoms: Electrocardiogram ambulatory, Enterovirus test, Enterovirus test negative, Epstein-Barr virus test negative, Fatigue
Clinical narrative: 15 yo M with no PMH p/w 1 day of chest pain and elevated troponin and lateral ST segment elevations.  On Wednesday 6/30 he had his second dose of Pfizer COVID vaccine. There after he had headache, tactile fever, fatigue and myalgias which resolved by Friday 7/2. On Friday at midnight, he awoke with 7/10 sharp substernal chest pain, non radiating. No recent trauma to the chest. He took Tylenol at home which did not relieve the pain.  No recent URI sx over the last month. The last time he remembers having URI sx was 1.5 years ago. He does endorse "one or two sneezes" over the past month, which he attributes to allergies.  Today 7/3, he presented to urgent care center where he got an EKG, which was concerning for ST elevations. He was given ASA which did not relieve the pain. He was sent to hospital for further work up where he had a Troponin to 1.59, CRP to 36, AST to 79, ALT to 64, Alkphos to 74, BNP to 119, ESR to 10, and WBC to 13.4.  EKG showed ST elevation in I, II, precordial leads V4 V5 V6. CXR wnl. He was given IV toradol at hospital, which alleviated his CP. He was transferred to ED for further evaluation.  On arrival to the ED on 7/3, he was HDS afebrile, with BP 111/69, HR of 80, and satting 100% on RA. His CP had resolved to a level of 0/10. Additional labs were obtained including repeat CBC (with WBC 10K, Hgb of 14), normal ESR of 20, normal D-dimer of less than 0.27, BMP wnl, elevated LFTs with AST 103, ALT of 61, elevated LDH to 293, normal GGT and alk phos, normal BNP to 28, elevated CRP to 3, and an extremely elevated troponin of 3.15. NP swab for COID, Influenza A/B, and RSV were negative. CXR wnl but did note findings consistent with degenerative disc disease at one level in the mid-distal thoracic spine.  Hospital Course: Patient was admitted to the cardiology floor for continued monitoring of his troponin levels and EKG. He was then treated with IVIG 2g/kg and started on methylprednisolone IV x 8 doses. His chest discomfort improved by day 2 of admission. An echocardiogram was performed which did not show any cardiac dysfunction. His troponin downtrended while on IV steroids, therefore he was transitioned over to PO steroids which he tolerated well. On day of discharge, his troponin levels were continuing to trend down, and EKG was WNL. Cardiac MRI was performed and showed late gadolinium enhancement in the left ventricle. He had occasional NSVTs/PVCs; he was started on Bisoprolol 2.5mg daily to prevent arrhythmias after discharge. He was discharged home with a Holter monitor to be worn for 4 days. Viral myocarditis studies were sent and all negative.   By time of discharge, patient was well-appearing, vitals stable, demonstrating good PO intake. Prescriptions sent to preferred pharmacy. Follow up with cardiology in place. Discharge instructions and return precautions reviewed with patient and parent, who expressed good understanding and agreement with plan.  Patient will follow up in cardiology clinic next week with a repeat MRI 3-6 months.   Of note, CXR from 7/3 with incidental findings suspicious for degenerative disc disease at one level in the mid-distal thoracic spine. This should be followed  by his primary care physician as an out patient.   Reasons for new, changed, and discontinued medications:  - Bisoprolol 2.5mg daily (for prevention of NSVT)  - Prednisone 30mg BID (myocarditis)  - Famotidine 20mg daily (while on steroids)  Reasons for new, changed, and discontinued equipment: NA   Relevant Diagnostic Images/Studies:  Cardiac MRI (7/7): ? Normal biventricular size and systolic function. ? No regional wall motion abnormalities. ? Suggestion of increased T2 signal intensity/edema. ? Positive myocardial late gadolinium enhancement without functional correlate. ? No significant valvular dysfunction. ? No coronary artery aneurysms. ? Small pericardial effusion.  Echocardiogram (7/3): ? Normal valvular function. ? Normal left ventricular size and systolic function. ? Normal diastolic function indices. ? Reduced longitudinal strain with normal circumferential strain. ? Normal appearing proximal coronary arteries. ? Qualitatively normal right ventricular systolic function. ? No pericardial effusion present. ? A comprehensive anatomic survey was not performed at this time.    Tests Pending  Enterovirus PCR QuaL, Stool Miscellaneous Test Arup    These tests will be followed after Discharge  Vitals and Discharge Physical  T: 36.5  °C   HR: 64 (Monitored)  RR: 20  BP: 131/59  SpO2: 98%  HT: 168 cm  WT: 76.4 kg  BMI: 27.1   Discharge Physical Exam  General: NAD, lying in bed, sleepy, but conversational HEENT: atraumatic, normocephalic, no icterus, no conjunctivitis; extraocular muscles intact; moist mucous membranes CV: RRR, S1/S2, no murmurs, gallops or rubs noted; dp pulses 2+; capillary refill <2 seconds. Resp: unlabored respirations; symmetric chest expansion; clear breath sounds bilaterally Abd: soft, nontender, nondistended; bowel sounds normal Ext: no clubbing, cyanosis, or edema; normal upper and lower extremities Neuro: no atrophy, normal tone; moves all extremities equally; no focal deficits Skin: no rash or erythema  Diagnosis List  1. Myocarditis, 07/04/2021 2. COVID-19 mRNA vaccine adverse reaction, 07/04/2021