Age: 14.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Tricuspid valve incompetence, Troponin, Troponin increased, Ventricular arrhythmia, Weight
Clinical narrative: myocarditis; Elevated troponin; first his L arm was sore; a Slight increase in heart rate; This is a spontaneous report from a contactable consumer.  A 14-year-old male patient  (consumer son) received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE lot# not provided), via an unspecified route of administration on 10Jun2021 (at the age of 14-year-old ) at single dose for COVID-19 immunization. Medical history included asthma, Raynaud disease and torn meniscus. The patient has not had COVID-19. Not on daily controller med cannot remember the last time he required albuterol.  Early on 12Jun2021, the patient was experiencing left sided chest pain so he came to ER for evaluation. The patient presenting with 2 days of chest pain. He first noticed the pain 2 days before, first his L arm was sore after receiving Pfizer COVID vaccines on 10Jun2021, he then noticed L sided chest pain. Describes pain as left sided, burning pain that is worse with inspiration and when laying down, pain does not radiate. No nausea, no diaphoresis, Denies reproducible pain with palpation. Due to mildly elevated troponin. Mildly abnormal ECG, he had echo which was normal; however, he was admitted to trend troponins and monitor for arrhythmia. ED course: Troponin mildly elevated at 0.088, normal echo. Admit to cardiology service for observation of rhythm, repeat troponins.  Admission on 12Jun2021 Troponin  on12Jun2021 Value: 0.088, on 13Jun2021Value: 2.000, on 14Jun2021 Value: 0.519. On 13Jun2021, has further elevation of troponin to 2 in setting of continuing, intermitted chest pain (improved with Motrin), though still no fever. Given timing of chest pain, abnormalities on ECG as well as rising troponin, he did appear to have possible post-covid-vaccine myocarditis, so obtained cardiac MRI on 14Jun2021. The patient was hospitalized from 12Jun2021 to 14Jun2021.  Patient physical findings: Pulse 82, Resp 16, BP RUE 110/74 (adult cuff) , BP LLE 114/0, BMI 19.32 kg/m2, 49%ile (Z= -0.02) based on CDC (Boys, 2-20 Years) BMI-for-age based on BMI available as of 28Jun2021, BSA 1.46 sq meters pulse Ox: 97 % (finger) Oxygen Supplementation: Room Air.  Review of Systems: Constitutional: no symptoms, Eyes: no symptoms, Ears: no symptoms, Nose: no symptoms, Throat: no symptoms, Cardiovascular: (myocarditis), Respiratory: (asthma). Gastrointestinal: no symptoms, Genitourinary: no symptoms, Musculoskeletal: no symptoms, Skin: no symptoms, Neurological: no symptoms, Psychiatric no symptoms, Hematologic/lymphatic: no symptoms, Endocrine: no symptoms, Hematologic/lymphatic: no symptoms, Endocrine: no symptoms. Constitutional: appropriate for age, non-distressed , Head: normocephalic, atraumatic , Eyes: normal sclera, conjunctiva and lids , ENT: inspection of nares, oral mucosa, and external ears appear normal, Neck: supple without masses , Chest and lungs: symmetric, clear to auscultation, normal air movement, no retractions o or deformity and no tenderness to palpation Cardiac: normally active precordium, regular rhythm, normal S1, physiologically split S2, no murmurs, clicks, rubs, or gallops, or normal distal perfusion with brisk capillary refill, no jugular venous distention, no clubbing, cyanosis, or edema and brachial and lower extremity (DP/DT) pulses are 2+ and symmetric without delay , Abdomen: soft and non-tender, active bowel sounds, no masses, no hepatomegaly and no splenomegaly , Musculoskeletal: grossly normal muscle mass. Strength and tone , Extremities: no joint swelling or tenderness, no obvious deformities , Skin: clear, no rashes, no lesions, Neurological: grossly intact, normal behavior for age. Laboratory tests: EKG: In order to assess the heart, a 12 lead electrocardiogram was performed.  This showed: Normal Sinus rhythm at 89 bpm. ORS axis +63 degree, normal intervals, normal voltages, and inverted T-waves in lead III, only. Echocardiogram: an echocardiogram was performed to heart function due to the post vaccine myocarditis. It demonstrated:  1. Normal intra-cardiac and aortic arch anatomy. 2. Physiologic tricuspid regurgitation and pulmonary insufficiency. 3. Normal cardiac dimensions and biventricular function, including normal tissue Doppler ,4. NO pericardial effusion.  Impression: Acute myocarditis following 2nd Pfizer vaccine for 2019 novel coronavirus disease. Elevated troponin. T-wave abnormalities on electrocardiograms.  Normal cardiac function by echocardiography (including today's) and heart MRI , Normal heart MRI-does not meet imaging criteria for myocarditis. Meets case definition of post-Covid vaccine myocarditis.  Chest pain; presumably secondary to Acute myocarditis. Physical Exam at discharge on 14Jun2021: Vital signs at discharge: BP 108/67 | Pulse 83 | Temp 36.3 degree Celsius (Tympanic) | Resp. 18 |Ht 161cm | Wt 48.3kg | Sp02 99% | BMI 18.63kg/m2 Room Air  Result Date: 14Jun2021  Impression:  Normal right ventricular size, RVEDV 64 cc/m2, Normal right  ventricular systolic function, RV EF = 55%. Normal left ventricular size, LVEDV = 58 cc/m2. Normal left ventricular systolic function. LV EF = 59%. With no regional wall motion abnormalities  No evidence of high signal intensity on T2 weighted imaging to suggest edema, T1 early post-contrast imaging to suggest hyperemia, or late gadolinium enhancement imaging to suggest myocardial fibrosis. The patient does not meet CMR criteria for myocarditis.  Normal origins of the left and right coronary arteries, without evidence of dilation or aneurysm.  Rhythm data: ECG on: 13Jun2021, Heart rate 90 , RR 668 , P-R Interval 165 , P Axis 31 , QRS Duration 74 , QT Interval 367 , Q 449 , QRS Axis 71 , T wave Axis 33 Impression  Normal ECG  Pediatric ECG interpretation  Sinus rhythm  normal p axis, V-rate 60-119 , Normal axes and intervals  Flattened T waves In lll, V5, V6  Compared to ECG from 12Jun2021 , now see normal T wave axis, Still see flattened T waves in VS, V6 and now in Ill. Somewhat slower rate on current recording; otherwise, no significant change  Discharge Medications.  Amoxicillin 875mg 1 Tablet (875mg) by mouth 2 times a day for 1 dose Last dose is tonight  Ibuprofen (MOTRIN) 400mg 1 Tablet (400mg) by mouth every 6 hours as needed for mild chest pain or moderate pain   and ALBUTEROL IN, Inhale into lungs as needed. Oxygen-l supplementation: RA , Feeding regimen for home: Regular diet  Recommended no strenuosu exercise for the next 2 weeks until his follow up cardiology visit on 28Jun2021.  Discharge date: 14Jun2021 4:05 PM  Since his Discharge from on 14Jun2021, the Patient has continued to have episodic chest pain. He describes a sharp pain that is worse with breathing occurring over a moderate-sized region of the mid-upper left anterior chest without radiation. The last episode occurred on 17Jun2021 when he was walking and running outside playing a "water gun" game with friends. He ran about 10 minutes and developed chest pain for several minutes that then lasted for a total of an hour. He felt a Slight increase in heart rate with the chest pain. He has no history of chest pain prior to the second dose of the Pfizer COVID-19 vaccine. His asthma episodes are triggered by upper respiratory tract infections. He has had no lightheadedness, syncope, dyspnea or exercise intolerance.  The recent records were reviewed, Including the discharge summary, electrocardiograms, labs, heart MRI report, and echocardiogram reports. The electrocardiograms used T wave abnormalities and elevated troponin, but a structurally and functionally normal heart by echocardiogram and heart MRI. Diaqnosis of, post, Covid Vaccine myocarditis was made.  An echocardiogram was performedto assess heart function due to the post vaccine myocarditis. It demonstrated:  Normal intra-cardiac and aortic arch anatomy.  Physiologic tricuspid regurgitation and pulmonary insufficiency.  Normal cardiac dimensions and biventricular function, including normal tissue Doppler  NO pericardial effusion.  The patient who was previously healthy, developed chest pain with electrocardiographic abnormalities and elevated troponin after his second Pfizer COVID-19 vaccine, consistent with post-Covid vaccine myocarditis. He has had 1 other episode of chest pain since discharge from the hospital. I recommended restricting from significant physical activity or competitive sports, pending a repeat troponin level. At the time of this writing (30Jun2021 at 11 PM), I have not received a copy of the troponin level. If the troponin level is normal or significantly trending down, I would refer him for a cardiopulmonary exercise test in the near future prior to allowing return to normal physical activities. Cardiac: normally active precordium, regular rhythm, normal S1, physiologically split S2, no murmurs, clicks, rubs, or gallops, or normal distal perfusion with brisk capillary refill, no jugular venous distention, no clubbing, cyanosis, or edema and brachial and lower extremity (DP/DT) pulses are 2+ and symmetric without delay . Laboratory tests:  EKG: In order to assess the heart, a 12 lead electrocardiogram was performed.  This showed: Normal Sinus rhythm at 89 bpm. ORS axis +63 degree, normal intervals, normal voltages, and inverted T-waves in lead III, only. Follow-up will be determined on results of these tests. Pending Tests: Blood tests (Troponin level). Disposition: Ibuprofen (Motrin) 400mg tablet, Take 1 Tablet (400mg) by mouth every 6 hours as needed for mild pain moderate pain , ALBUTEROL IN, Inhale into lungs as needed. The outcome of the events was unknown.  The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.