Age: 34.0
Sex: M
Vaccine: SMALL, SMALL, SMALL
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Asthenia, Blood albumin normal, Blood alkaline phosphatase normal
Clinical narrative: 34 y/o patient with history of myocarditis, with presentation of V-tach and dyspnea 4-days following receipt of the smallpox vaccine in APR 2012. [The following information was obtained from available notes, EMR notes, emails with providers and face-to-face visits with patient on 19 and 20 APR 2012.] On 2 APR 2012 patient received AVA (2) vaccine and did not experience unusual or prolonged local or systemic symptoms during the next week. He reports right upper arm tender for a few days, but no increased redness and swelling or systemic symptoms. On 4 APR 2012, patient deployed. On 5 APR 2012, patient received his primary SPV in his right arm (15 jabs). At that time, he was in his usual state of good health. On 9 APR 2012, patient did not eat breakfast, but reported to work on flight line. Around 0730, he noted his heart beating fast, he felt a little weak and nauseated and he experienced mild shortness of breath which he describes as "couldn't get enough air". He continued working, and around 0945, he vomited. The nausea subsided after vomiting, but when he stood up, he reports feeling weak, clammy, shaky, and like he was going to pass out. He denies chest pain, but describes constant substernal chest pressure "like someone pushing on my chest"; rates as 6/10 with 0 =no pressure and 10 = perceived pressure with elephant on chest. Position changes, taking deep breaths, and rest made no difference with regard to his dyspnea and chest pressure. His coworkers said he was pale and his lips were turning blue; they transported him to the clinic and he was evaluated within 1 hour. At clinic/ER, report from attending that patient was hypotensive on initial VS, but with normal heart rate. Exam with pounding, racing heart rate with auscultation. ECG, rhythm strip, 3-lead revealed V-Tach. IV Amiodarone 150 mg was administered over 10 minutes. Patient converted to NSR with heart rate around 90 after about 30 mg amiodarone, and remained stable in NSR during his transfer to Hospital. While hospitalized at Hospital (x3 1/2 days), an amiodarone drip was initiated and patient was admitted to CCU under rule out protocol. Cardiac enzymes elevated with reported CK peak of >20,000, Troponin 6 and CK-BM >300. Patient's ECHO revealed EF of 45% with report of questionable RV enlargement and possible WMA (per notation, not actual reports; also reported down range ECG tracings reviewed - 1st: WCT at 214 bpm which appeared to be VT. Subsequent ECG showed NSR/SB with inferior T wave inversions. No ST segment elevations/depressions.). Patient reports he was asymptomatic during this time, except for noting increased tiredness shortly after admission. On 12 APR, patient was transferred to another hospital where he was hospitalized (x3 days), and had a left heart catheterization (no obstructive disease, EF 45% per note - not official report). On 15 APR, patient was medevac'd to hospital in another country where he remained an inpatient until 19 APR. Additional studies were completed (See Diagnostics) and patient was discharged wearing LifeVest. Cardiac enzymes trended down to CK 619, CK-MB 3.3 and Troponin 0.05 with normal CRP and ESR. Multiple viral studies obtained. Patient reports normal smallpox vaccine progression with a site check on post-vaccine day (PVD) 7 which was assessed as a "take". He denies significant redness, swelling, warmth, streaking, and swollen or tender axillary lymph nodes. During this time period, patient felt a little feverish and fatigued and recalls having a headache on day of presentation. (He attributed his headache to trying to withdraw from caffeine.) Currently asymptomatic except for reported fatigue. He estimates that his current exercise tolerance is about 30% of his baseline prior to deployment.