Age: 20.0
Sex: U
Vaccine: ANTH, SMALL, TYP
Symptoms: Arrhythmia, Arteriogram coronary abnormal, Bundle branch block left, Cardiac ablation, Cardiac electrophysiologic study abnormal
Clinical narrative: Possible myocarditis; Cough, fever three days after immunizations - persisted and turned into pneumonia, treated for pneumonia. On 7/19/15 had a VT which cardioverted. Placed on TOPROL XL 50mg. Had RVOT VT in Aug 2015 - received ablation, March 2016, another VT had repeat ablation, July 2016 - wide complex tach. converted. Still with cardiac problems most recent ablation 9/13/16. The following information was received in a literature search from on 04Feb2019. Additional information added to case: event of myocarditis, vomiting, cough, headache, fever, fatigue, malaise; laboratory testing and diagnostics and updates to clinical course including outcome. The publication discussed the administration of smallpox vaccine and a potential case of smallpox mediated dysrhythmia. Four weeks (vaccination on 15JUN2015) after receipt of smallpox vaccine, the patient presented to the Emergency Department with a chief complaint of vomiting and 3 weeks of productive cough, headache, subjective fever, fatigue, and general malaise. Initial electrocardiogram (ECG) revealed a wide complex tachycardia at a rate of approximately 220 beats per minute and stable systolic blood pressure. He was treated with adenosine, but failed to convert to a normal sinus rhythm (NSR). Subsequently he underwent a successful synchronized cardioversion (CV); his baseline ECG showed NSR with no repolarization abnormality evident. He was discharged with a diagnosis of idiopathic right ventricular outflow tract (RVOT) ventricular tachycardia (VT) and given a prescription for metoprolol succinate. Approximately two weeks later, the patient presented again with VT and underwent another CV. An electrophysiology study (EP) with ablation then done to the area of the posterior RVOT. Following the procedure, ambulatory rhythm monitoring failed to reveal any recurrence of the tachycardia. Cardiac magnetic resonance imaging (MRI) demonstrated no abnormality. Approximately five months later, the patient presented again with symptomatic palpitations due to a recurrent VT (four episodes) that required a second EP study with ablation and further evaluation. A third EP study with ablation identified a left bundle branch block (LBB). Based upon the finding of multiple VT morphologies and several failed attempts at endocardial ablation, an epicardial site was suspected to be the source of the patient's recurrent tachycardia. Subsequently, a fourth EP study using 3-dimensional electroanatomic mapping was performed. Endocardial voltage mapping demonstrated a small region of scar in the posterior free wall RVOT, which was thought to be the site of previous ablations. Isoproterenol induced VT with LBB; the rhythm however led to hemodynamic deterioration and necessitated pace termination. After a coronary angiography was performed, it was decided that further epicardial ablation outweighed the benefits and was cancelled. Because the patient's tachycardia could not be eliminated and the patient was treated with Sotalol and a single chamber implantable cardioverter-defibrillator was placed. The authors suggested that the administration of smallpox vaccine may have directly resulted in the development of acute myocarditis with ventricular arrhythmia. The patient may have developed cardiac scarring which directly led to the development of recurrent scar-mediated VT. Other possible causes were ruled out.