Age: 23.0
Sex: M
Vaccine: ANTH, HEPA, IPV, MEN, TD
Symptoms: Liver function test abnormal, Myocardial infarction, Vasospasm, Ventricular extrasystoles
Clinical narrative: Developed chest pain approximately 3 weeks  after receipt of smallpox vaccine, with multiple vaccines within 60 days of symptom onset. Chest pain, substernal start 4/5/03. Dyspnea (SOB) start 4/15/03. Premature ventricular contractions 9/5/03. Follow up 01/07/2005: A 24 year old was seen for consultation on 01/06/05. All relevant documentation was reviewed. On 03/13/03, he received hepatitis A, anthrax, typhoid, tetanus and meningococcal vaccines. On 03/02/03, he received the small pox vaccination and was classified as a "take." He received anthrax vaccination again on 03/26/03, and the final dose of anthrax on 04/10/03. Finally, he received hepatitis B vaccine on 04/19/04. He reportedly was feeling well throughout that time. On or about 04/20/03, the patient recalls (not reported until after August, 2003) the beginning of "indigestion" that was sharp, located on the left side of the sternum, non radiating, non exertional, and non positional. This would occur intermittently, last seconds to minutes and was not pleuritic. He had no limitations from this, contiued to train up with his unit in anticipation of deployment, and at no time did he seek medical attention for this symptom during his active duty period. In June, 2003, his unit's deployment was cancelled. He returned to heavy construction work and bartending. He had occasional chest pain episodes as above, but these were never concerning to him and he did not seek attention. On 08/04/03, he had much diffrent chest pain that was a "constricting" feeling that radiated into his neck. He waited several hours prior to seeking medical attention, and his chest pain resolved (after approximately 4 hours of pain) in the waiting room prior to him being seen in the emergency room ( it is significant that he did not have an ECG with pain given findings on re-presentation). His cardiac enzymes were elevated on admission (troponin I 12.88), and peaked at 14.48, and started to fall within 24 hours of presentation. He was transferred to another facility. He under went echocardiography, which was significant for a normal LVEF and no wal motion abnormality. He had a brief episode of recurrent chest discomfort and underwent cardiac catheterization, demonstrating no significant ASCAD. He was placed on Asprin, and long acting diltiazem, counseled on tobacco cessation and discharged. He did well with out recurrent index ischemic pain, but with occasional "indigestion" pains. He noted occasional palpitations ("skipping") that were brief ( he does not recall tachypalpitations). He did not have syncope or pre-syncope with these episodes. He felt well. He went back to work without limitations. He ran ot of medications im md-April, 2004. He continued smoking. On 04/23/04, he had multiple episodes of recurrent chest pain radiating to the jaw beginning in the morning and he had had 1 hour of continuous 10/10 chest pain unresponsive to nitroglycerin when he returned to the medical center. He had ST elevation in leads I, II, aVL, V4, V5 and V6 with reciprocal depression in aVR tht presisted on ECGs for 2 days, then developed T-wave inversion in leads V4, V5 and V6. He ruled in for myocardial infraction, with a peak troponin I of 29.4 (peak CK 892). His rise and fall of enzyme occured within 24 hours of his symptom onset. He was noted to have non sustained ventricular tachycardia in the emergency department. He underwent elective catheterization the next day, demonstrating no obstructive ASCAD, a small area in the mid LAD consistent with an intramyocardial segment (without angiographic bridging), and left venticulography demonstrated an anterior wall motion abnormality. Immediately following his catheterzation he had 45 beats of non sustained ventricular tachycardia (still <24 hours post MI). He underwent a laboratory evaluation for vasculitic, hypercoaguable as well as illicit substance use, all was norma. His liver function tests were abnormal, with an AST of 126, Alt 98, and alk phos of 332. He had a + hepatitis A anitibody, but negative IgM. His ESR was 78 and His CRP was 5.48 (nl at that lab <0.3). His cholesterol was 124 total and HDL was 31. His ECG demonstrated return to baseline of ST segments over days with evolutionaly T-wave bisphasic changes, and the absence of Q waves. In clinic with his cardiolgist on 05/26/04, he had T wave inversions in V4-46 subsuquently has resolved. dut to his non sustained ventricular tachycardia he underwnt placement of an implantable defibrillator and was discharged on 05/05/04. On 06/20/04, he was swimming and was shocked by his ICD. He was able to get out of the pool and was shocked 5 more times in rapid succesion. Interrogation of the defibrillator indicated that he was shocked for sinus tachycardia. The ICD was reprogrammed and he was discharged. Since this time he has not had any limiting symptoms, but no longer works and lives at home ( he states that his employers did not want him on the job with his health problems). He occasionally gets sharp indigestion pain he has had now for 2 years, but has no symptoms similar to his angina. He accasionally feels palpitations "skipped beats," but no tachypalpitations or syncope/pre-sycnope episodes. He has been compliant with his medications. Discussion: 24 year old specialist with 2 episodes of discrete infarction with ECG and enzymens consistent with epicardial obstruction due to clot or spasm. Second myocardial infarction complicated by non sustained ventrcular tychycardia during the early post infarction period. Normal LV function and no obstructive ASCAD portneds a good prognosis. Etiologies of his condition include spasm within his intra-myocardial segment or undiagnosed/unknown hypercoaguable state (with overlying tobacco abuse causing or contributing to either). Spasm is supported by the re-occurrence of events less that 10 days following of diliazme. The patient did report almost a year following vaccination that he developed vague chest discomfort 31 days following vaccination. However, there is no documentation of this, and this would still be outside the case definition even if his symptoms were classic. His symptoms that he did report were no pericarditis and were not of sufficient severity to cause seeking of medical attention. This pain appears completely unrelated to his events of Aug 03 and April 04. Currently, a detailed analysis of the entire military's experience is being performed to evaluate any contribution of vaccination to the reisk of ischemic coronary events. especially when these events occur more than a year following vaccination. In this soldiers case tobacco abuse and (possibly) an intra myocardial segment predisposed this patient to the rare occurrence of ischemic events. Assessment: 1. Myocardial infarction x2, likely due to variant angina (coronary vasospasm) 2. Tobacco abuse, now ceased (contributing to 1). 3. Intra-myocardial segment of LAD (possibley contrbuting to 1) 4. Elevated liver function test, now resolved 5. Anxiety disorder; Recomentations: Continuation of current aspirin and Diltiazem for life. Continuation of tobacco cessatio. Routine medical follow up with cardiologist for ICD management and clinical symptoms. Follow up 02/22/05: Patient has not recovered from these events.