Age: 27.0
Sex: M
Vaccine: SMALL
Symptoms: Pharyngolaryngeal pain, Photophobia, Proteinuria, Red blood cell sedimentation rate increased, Sensation of pressure
Clinical narrative: Admission Diagnosis Chest pain, On Sept 16 2005 this 27 year old active duty medic received the small pox vaccine to the left arm. three to 4 days later he felt fatigued. The fatigue resolved within several days. He did have subsequent injection site soreness as expected. Three days ago, the patient had the onset of a persistent squeezing headache associated with a constant diffuse pressure to the head, he did physical training. but he was excessively fatigued in that he did not have the stamina to continue with the sit ups and pushups as he normally does. Two days ago, the patient had 24 hours duty. Late into the night he felt bad. he was nauseated, and he was achy and felt like I drank a cheap bottle of wine. He went home and slept for 8 hours, and then he awoke and again felt bad, with mild chest pain. the chest pain persisted, and he had general malaise yesterday. He took ibuprofen with no significant relief, However, he did feel a little better last night. This morning after awakening, he did not feel well. he went to work this morning and after eating lunch he had the onset of chest pain, he had the sensation of a strong pressure to his chest. He brought to hospital Emergency Room where he was found to have elevated troponin and CK-MB. The patient has had neck pain and diffuse headache over the last several days, along with a cough and mild sore throat. There has been no shortness of breath. There has been no fever, chills, nausea, dysuria, or diarrhea, He has had mild neck stiffness and mild photophobia. When the pain has been worse, it was painful to take a deep breath, There was no change in the chest pain with position. There has been no rash, pruritus, or hives. The patient did take 2 acetaminophen this afternoon. The patient has not had any immunizations besides the smallpox vaccine. He has not been out of the country for the last several years. He has not spent any time in a third world country. Right anterior cruciate ligament (ACL) repair 1 year ago by DR at hospital. No hospitalizations. He did have outpatient sleep testing for sleep apnea 1 year ago and apparently had no significant apnea or oxygen desaturations. No known drug allergies. Current medications none. Social history Tobacco none, Alcohol occasional beer on the weekends. the patient is married, and he has no children. Family history: the patients mother is 47 and his father is in his late 40s, both are in good health, A half brother and a half sister are in good health. A half brother and a half sister are in a good health. There is no history of cardiac disease. Review of systems, vision no change in his vision. HEENT. ears no hearing impairment. Mouth and throat, the teeth are okay. Pulmonary there has been no cough and no wheezing, vascular, no swelling of the legs. Breast no lumps, pain, or discharge. Gastrointestinal, no difficulty swallowing. No heartburn, constipation, diarrhea. No change in stool or rectal bleeding. Genitourinary, there is no difficulty starting the stream. There is no testicular pain or swelling. Musculoskeletal. there has been no joint pain. Neurologic, there is no tingling or burning of the hands or feet. He has no tremors. His memory is okay. Sleep has always been a problems. Temperature is 98, heart rate 67-68, respirations 18-20, blood pressure 128/156 over 64-93. His pain scale on admission was 10/10, at the time of my examination it is 0/10. Weight 195 pounds. He is a well appearing young man in no distress. He has clear tympanic membranes. Clear oropharynx. There is no cervical or supraclavicular adenopathy. He has clear symmetrical breath sounds. A regular rate and rhythm, without murmurs or gallops either sitting or supine. Abdomen soft , without hepatosplenomegaly. GU/Rectal Deferred. Extremities he has no edema. Neurologic he has normal gait. Skin the left arm shows a scabbed, circular smallpox vaccine site of approximately 1.5 cm. There is no significant surrounding erythema. This 27 year old male was 13 days out from a smallpox vaccine when he had the onset of chest pain starting approximately 2 days ago, His cardiac enzymes are consistent with myocarditis. He does not have any clinical findings to suggest pericarditis at this time. He most certainly has nothing to suggest congestive heart failure. It is felt that this patients condition is related to smallpox vaccination. Nonetheless, other causes will be addressed as below. 1.Cardiac telemetry, 2. Ibuprofen 800 mg QIS, 3. Echocardiogram in the am to assess for wall motion abnormalities/cardiomyopathy. 4.Follow cardiac enzymes. 5. serologic studies depending on availability will include coxsackie and Echovirus titers, influenza titer, Epstein Bar virus, viral capsid antigen (VCA-IgM and VCA-IgG), Hiv, Lyme IgM and IgG, toxoplasma gondii IgG and IgM, ANA rheumatoid factor, serum iron, serum ferritin, TSH, and free T4. 6. Will discuss with Hospital cardiology and, as well, will contact the vaccine administrator here for further workup and appropriate followup.