Age: 24.0
Sex: M
Vaccine: SMALL
Symptoms: International normalised ratio increased, Left ventricular end-diastolic pressure increased, Liver function test abnormal, Localised infection, Malaise
Clinical narrative: Patient treated for life threatening complications following initial symptoms observed by parents following military discharge in Sept. 2004 including dry cough/abnormal fatigue with patient sleeping 12 hours or more progressing to a self report of chest pain in 2005 with continuation of early symptoms and then on Feb 6, 2006 admitted for serious complications that were life threatening which included all earlier symptoms plus coughing up blood and severe chest pain and admitted to intensive care unit for 1 week.  In 2006 re-admitted on two seperate occasions for intensive care treatment and at this report on Nov. 22, 2006 is again in Intensive Care Unit being treated by a Cardiologist. MR received from treating cardiologist for pt. who initially presented to this MD in February of 2006 with new onset severe congestive heart failure.  Pt. presented to ER on 2/5/2006 with c/o nausea, vomiting of blood, and shortness of breath.  He has felt ill for 4-6 weeks, maybe longer, with weight loss of 30 lbs. Recent toe infection txd with antibiotics-resolved.  PE: Pale and ill-appearing. (+) for basilar rales and orthopnea. Seen by Cardiology and GI consults. Treated medically and an ICD was placed on 2/9/2006. Discharge DX: 1) Probable viral cardiomyopathy 2) CHF 3) Ventricular tachycardia. Conclusions: 1) Severe non-ischemic cardiomyopathy which may be viral in origin. 2) Markedly elevated left ventricular filling pressures and fairly well preserved cardiac output, likely related to his low SVR. 3) Severe pulmonary hypertension, which equates to 75-80% of his left ventricular systemic pressures. Records also sent for 2 admissions on 11/21/2006 and 12/01/2006 for exacerbations of CHF. Assessment:  CHF with biventricular failure, s/p ICD. PAF: remains in sinus rhythm with Amioderone and prior DC cardioversion.   Record received from facility dated from initial visit of 05/11/2005 to 11/30/2006. PMH: PE on 5/11/2005 shows 24 yr. old with no significant PMH except UTI/cystitis in 2002.  Feeling fine, no c/o.   Subsequent visits beginning 05/2006 after hospitalization and Dx. of  Viral cardiomyopathy/CHF/ventricular tachycardia in 02/2006. Developed atrial fibrillation after discharge from hospital. Implanted defibrillator placed. Now treated with Lanoxin, Lisinopril, Darvon, Correg, Coumadin, KCl, Spironolactone, Amioderone, Lasix, Mg, Fe, and MVIs. Routine F/Us until 11/30/2006 when pt. c/o intermittent epigastric pain, nausea, and vomiting of bilious fluid.  Admission to hospital ICU for pulmonary edema the  week prior to appt. Impression: 1) CHF/Viral cardiomyopathy/history of vent. fibrillation s/p AICD implant in 02/2006.  2) Mildly elevated LFTs with mid-epigastric pain during past week. 3) H/o liver problems with intermittant flare-up since diagnosed with viral CHF in 02/2006. Hospital MR also received for admission of 11/21/2006 with c/o nausea, vomiting, SOB and severe weakness with Discharge DX of 1) Acute CHF. 2) Severe dilated cardiomyopathy 3) Hepatic congestion with elevated liver enzymes, 4) Paroxysmal atrial fibrillation 5) Chronic Coumadin anti-coagulation. 6) Hx: ventricular tachycardia with ICD. Additional records from cardiologist received, including a letter to VAERS re: the case, requesting consideration that "smallpox vaccination may be linked to the development of a cardiomyopathy in otherwise healthy young patients". 10/23/08 Tag-2 received from CDC which reports pt had heart transplant 8/15/2007 which was infected with CMV. 3/31/10 Follow up: 3/17/07 At this time, patient is so sick, he cannot go anywhere or do anything. Thursday of this week, we are taking him to meet with the transplant team.