Age: 17.0
Sex: M
Vaccine: HEPA, MEN, TDAP
Symptoms: C-reactive protein increased, C-reactive protein normal, Cardiac enzymes normal, Chest pain, Cytomegalovirus test
Clinical narrative: Information was received from a literature article, titled as stated above, concerning a 17-year-old boy who was vaccinated with a dose of hepatitis A virus vaccine inactivated (manufacturer unknown). The patient was admitted to the PICU with intermittent, retrosternal chest pain for 1 day. He had no history of angina pectoris, cocaine abuse, hyper lipidemia, or congenital heart disease, He also had no history of autoimmune disorder, no previous travel, and no previous flu-like illness with diarrhea and/or respiratory symptoms suggestive of an infectious syndrome. Two days before admission, he received Dtap, meningococcal conjugate (MCV4), and hepatitis A vaccines. This was the first time he had ever received meningococcal or hepatitis A vaccine. The following day he complained of diffuse arthralgia and chest pain, and he had a low-grade fever. In the emergency department his physical examination was normal, but he was found to have diffuse ST-segment elevation on ECG and elevated serum cardiac enzyme levels: troponin I, 15.9 ng/mL (reference: <0.4 ng/mL); creatine kinase, 1106 U/L 9reference radiograph was normal, and a two-dimensional echocardiogram showed no segmental wall-motion abnormalities, normal biventricular systolic function, and no pericardial effusion. Other laboratory findings included a white blood cell count of 8.3 x 109/L (with 62% neutrophils, 22% lymphocytes, and 3.7% eosinophils), hemoglobin level of 14.6 g/dL, C-reactive protein level of 59 mg/L (reference: <8 mg/L), erythrocyte sedimentation rate of 17 mm/hour (reference: <15 mm/hour), C4 level of 38 mg/dL (reference: 16-47 mg/dL), and C3 level of 142 mg/dL (reference: 88-201 mg/dL). Rectal and nasopharyngeal swabs were sent for adenovirus and enterovirus cultures, and the results were negative. Lyme immunoglobulin G (IgG)/IgM antibody, cytomegalovirus IgG, Epstein-Barr virus capsid IgM antibody, antinuclear antibody, and anti-DS DNA screens were also negative. Convalescent samples for the above-named infectious etiologies were not obtained. Over the following 24 hours, the patient's cardiac enzyme levels continued to rise to a maximum of 22.8 ng/mL for the troponin I. Gadolinium-enhanced cardiac MRI was positive for acute myocarditis, as evidenced by delayed subepicardial enhancement of the basal to midanterolateral and inferolateral regions of the left ventricular wall. Chest pain was relieved with ketorolac, and his serum enzyme levels gradually decreased. The patient was discharged 4 days later on indomethacin 50 mg orally 3 times per day with the recommendation of restricting physical activity for a total of 4 to 6 weeks. Serum cardiac enzyme and C-reactive normalization of the ST segment, and at the 3-week follow-up, there was diffuse T-wave inversion. AT 10 weeks, ECG finding had resolved, and the follow-up cardiac MRI showed decrease in the area of contrast enhancement. The patient remained asymptomatic with normal ventricular function as assessed by echocardiogram and MRI. The acute myopericarditis was noted to be temporally related to booster Tdap administered simultaneously with hepatitis A virus vaccine inactivated and meningococcal conjugate (MCV4) vaccines before college entry. A copy of the published literature article is attached as further documentation of the patient's experience.