Age: 13.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Chest pain, Electrocardiogram abnormal, Pain, Pain in extremity, Painful respiration
Clinical narrative: Brief history and medical decision making: a 13 year old male with a history of Myocarditis in 2015 who presented with severe right sided chest pain and elevated troponin 3 days after his second dose Pfizer COVID vaccination. Baseline echocardiogram on admission demonstrated normal intracardiac anatomy with normal biventricular size and systolic function.  A CTA at outside hospital demonstrated no PE.  He was transferred for further evlauation.  ID was consulted and infectious work up was sent and is pending.  The Troponin peaked at 1,097, but it has nicely trended down.  Most recent Troponin level this morning is low at 51.  A cardiac MRI was preformed 6/14/2021 and shows a small area of LGE in the left ventricle confirming myocarditis.   He was hemodynamically stable overnight.  Chest pain resolved on Motrin around the clock.  Troponin this morning significantly lower at 51.  Repeat EKG today show shows sinus bradycardia with incomplete RBBB.  There is no evidence of significant ST/T wave changes.  Telemetry reviewed and no concern for arrhythmia.  ID consulted and appreciate recommendations.  Will continue to await further infectious work up for etiology of myopericarditis.  At this time, working diagnosis is post COVID vaccine.  ID reported the concern to VAERS.  Respiratory effort stable on room air.  Good oral intake.  Evidence of AKI on admission with elevated creatinine.  IVF given and creatinine improved.  H/H on admission within normal limits.  Will plan to discharge home on Motrin 600 mg q8 and plan repeat laboratory work, EKG and echocardiogram next week at hospital.  Will then arrange for a virtual visit on Wednesday 6/23/2021.  His mother, and I had a detailed discussion that in the setting of myocarditis, the recommendation is activity restrictions for 3 months with a metabolic stress test at that time before returning to play.  I asked him to limit his activity and maintain a HR < 120 bpm as he requested a HR limit.  They expressed understanding DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Myocarditis (HCC) [I51.4]   HOSPITAL COURSE: a 13 year old male with pmhx of presumed viral myocarditis in 2015, otherwise healthy, who presented from an outside hospital with complaints of right sided chest pain. Work up significant for elevated troponin and D-dimer. CTA obtained and negative for PE. An ECHO was then obtained and demonstrated normal biventricular function. He was later transferred to for further workup of suspected myocarditis. Of note, he received his second dose of Pfizer COVID vaccine on 6/8. Below is a summary of hospital course by system.    CV/ID:  ECHO obtained and viewed by cardiologist and reported as normal and EKG on admission was normal sinus rhythm without ischemic changes or evidence of pericarditis. Serial troponins were monitored throughout hospitalization and peaked at 1,097 on 6/13. At time of discharge troponin level was down trending to 51.  Cardiac MRI was obtained on 6/14/21 and demonstrated acute myocarditis, normal biventricular function, small inferior pericardial effusion, normal RCA and LMCA origins, and no evidence of myocardial infarction from epicardial coronary artery disease, myocardial infiltration, or intracardiac thrombus. He will have follow up labs and ECHO with virtual telemedicine appointment with Dr. in 1 week following discharge.   ID consulted on admission and performed comprehensive infectious workup, most of which remain pending at time of discharge.  Scheduled Ibuprofen was started on admission for anti-inflammatory. No further treatment was recommended by ID given his normal cardiac function. Will continue ATC Motrin until labs, including inflammatory markers, are repeated in one week.     Resp:  Remained in room air throughout hospitalization.    Renal/FEN/GI:  He had mildly elevated creatinine on admission, likely secondary to mild dehydration while being NPO majority of the day during transfer. Patient was allowed to eat on admission and was placed on IV fluids x 12 hours with normalization of his creatinine the following day. Tolerating general diet.    Heme:  No concerns   Neuro:  No concerns.  Discharge instructions and activity restrictions reviewed by Dr. at bedside with patient and his mom who both verbalized understanding.