Age: 34.0
Sex: M
Vaccine: SMALL
Symptoms: Pericarditis, Syncope
Clinical narrative: This healthy 35 year-old received his Smallpox vaccination on September 15, 2004 and was deployed. Approximately two to four weeks later, he woke up suddenly from sleep with a sharp stabbing substernal chest pain.  He described the pain as a 20/10 scale as if "some one was repeatedly stabbing him in the chest".  This pain was relieved with sitting upright and forward, worsening if he laid down.  The pain persisted for 3-4 hours easing to a 6-7/10 scale later that day.  He states he just tolerated the pain unsure as what was causing it.  He denies any past history chest pain, breathing difficulty, nausea, vomiting, radiating pain, and diaphoresis.  His job was working on small boats as a gunner, driver or look out. He denies any change in his physical activity or heavy lifting.   He reports this pain persisted over the next few months with brief period of radiating pain to first the 4th and 5th fingers of his left hand and then to his neck.  These episodes would last for a ten seconds to forty-five minutes and resolve spontaneously to a dull ache. His medical records indicated he was "first seen 01 October 2004 for pericarditis, treated with Indomethacin and Omeprazole with some improvement; 03 November 2004 for persistent pain and continuation of meds; 17 November 2004 pain persisted, prednisone taper added with minimal improvement; 25 November 2004 meds continued; 07 December 2004 Colchicine added, prednisone completed; 15 December 2004 continue meds, some improvement and 22 December 2004 Naprosyn added" (these medical records are unavailable for review). This caused him to be reassigned off small boats to the galley and then to the motor pool handing out keys.  On 25 December 2004, his began to feel a fluttering sensation with lightheadedness, near syncope with chest pain "gathering in the center of his chest" that radiated into his left arm and neck on a 20/10 scale.  He reports the pain felt as if it would "knock him to the ground" and he "felt like he was going to die". He stated the pain became manageable by leaning forward; however, this strategy quickly stopped working. Tylenol did not help the pain.  The pain lasted for 45 minutes. He was admitted to hospital with doctor documenting an admission diagnosis as "presumptive diagnosis of chronic pericarditis (vaccina related)", rule of myocardial infarction. He was given two nitroglycerin, IV Toradol and tapers of morphine with pain relief.  He states Dr. advised him there were EKG changes indicative of pericarditis in October 2004 yet the December 2004 EKG, cardiac enzymes and echocardiogram were all normal.  He was released three days later with a diagnosis of "recurrent chest pain (possible chronic pericarditis)".  He was medevac'd to another hospital where he was evaluated prior to being medevac'd to another hospital on 28 December 2004 for admission (see consultations).  He was evaluated by a infectious disease doctor who diagnosed him with "post Smallpox vaccination pericarditis and Tinea Cruris".  He was placed on Colchicine 0.6mg bid, Motrin 800mg bid and Aciphex 20 mg daily and limited duty MEB for 4-8 months.   As of this interview, he is being evaluated by cardiology. He has been profile for limited duty.  He reports prior to the onset of chest pain, he would run up to 10 miles per 1-2 days but has been restricted for the last six months due to pain and orders.  He was instructed not to lift greater than ten pounds.  He does walk 2-3 miles in 20-30 minutes three times a week with no difficulty.  He reports his pain has remained constant without change in quality or place but varies in intensity.  He scores his pain as a 1-7/10 that is centered substernally to the left chest wall that periodically radiates along the left anterior neck region once or twice every two weeks lasting for a few seconds up to 15 minutes.  He was restarted on a five day prednisone taper on 20 January 2005 with a diagnosis of costochondritis.  The taper did improve his discomfort however his anterior chest discomfort and numbness of the left arm persisted. He was scheduled for a stress MRI, 2D echo in March 2005; however, he is due for deactivation. He states the MRI was cancelled.  His stress test was completed 10 February 2005 was normal.  His functional capacity was documented above average (>20%) with chest tightness at 1/10 and a normal ECG with isolated ventricular premature beats.  Of note, his records show Liver function test performed on 20 January 2005 were elevated.  These were redrawn and scheduled for re-evaluation in two weeks by infectious disease physicians.  He states his deactivation depends on recommendations made by the HC and further evaluation of his persistent chest pain.