Sex: M
Vaccine: SMALL, SMALL
Symptoms: Angiogram, Angiogram normal, Atrioventricular block, Brain natriuretic peptide increased, Cardiomegaly
Clinical narrative: Initial unsolicited report received from the literature on 23-Nov-2017. Verbatim of the article: Vaccines are integral to primary care, particularly in military service. Conflicts have brought the need for vaccinations against endemic bacteria, viruses, and biochemical weapons. Yet, vaccinations do not come without risk. The smallpox vaccination has been linked to itching, lymphadenopathy, fever, fatigue, and rash. Additionally, new onset dyspnea, chest pain, and palpitations occur in 10.6% of smallpox vaccinations. More concerning is the occurrence of myocarditis. Rarely, myocarditis can be quite severe and debilitating, as presented below. DISCUSSION: Since 2002, approximately 2 million armed service members have been vaccinated against smallpox. Originally, cardiac complications were thought to be rare. However, we are finding these complications are more common. The incidence of confirmed myocarditis secondary to smallpox vaccination is estimated to be 16.1 per 100,000 service members, with a recent defense study estimating 12 per 100,000 in a review of 730,000 service members. Chest pain/heart failure symptoms after vaccination (i.e. Vaccina) should be taken seriously and addressed properly. CONCLUSIONS: Although important in health, we should recognize the rare, potentially life threatening, side effects of Vaccinations. We, as clinicians who are caring for patients who experience chest pain after vaccinations, specifically Vaccina Should be aware of the occurrence of myocarditis. This case involves a 36-year-old male patient, who was vaccinated with SMALLPOX VACCINE (batch number, expiry date, dose, route and site of administration were not reported) on an unknown date. Patient's medical history and concomitant medication was not reported. On an unknown date, five weeks following the vaccination, patient presented with intolerance to exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, and edema. On an unknown date after the vaccination, patient had mild distress, with severe orthopnea, tachypnea, tachycardia, bilateral crackles, and distant heart sounds. Electrocardiogram showed 2-to-1 AV block, with electrical cardioversion returning to sinus rhythm. A chest PA and lateral films revealed an enlarged cardiac silhouette. An echocardiogram revealed an ejection fraction of 21%, an apical thrombus, pericardial effusion, diastolic dysfunction, global hypokenesis, and moderate tricuspid and mitral regurgitation. A CT (computerized tomography) Angiogram showed no evidence of coronary artery disease. A contrast MRI (magnetic resonance imaging) showed eosinophilic myocarditis. On an unknown date, patient was hospitalized. Patient's other lab investigation revealed an elevated brain natriuretic peptide (572pg/mL) and troponin (10.3ng/ml). The patient was treated with Furosemide, Lisinopril, Carvedilol, and Rosuvastatin, Sans Carvedilol due to bradycardia. Lovenox was initiated for the LV thrombus and bridged to Warfarin for 6 months. On an unknown date, patient was recovered from "thrombus". Outcome of other events were not reported. It was also stated that as outpatient, cardiac function remains diminished with an EF of 20-25%. On an unknown date, patient got discharged from hospital. Documents held by sender: none. Sender's Comments: The patient experienced events Eosinophilic myocarditis with intolerance to exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, and edema, in mild distress, with severe orthopnea, tachypnea, tachycardia, bilateral crackles post vaccination with SMALLPOX VACCINE (Unknown manufacture). There is temporal relationship of events with the vaccine. Eosinophilic myocarditis which may suggest a possible underlying cardiac condition hence needed investigation results ruling out a concurrent infection, past medical history, any cardiac disorder and other etiologies would be helpful to further assess this case.