Age: 39.0
Sex: F
Vaccine: ANTH, FLUX, HEP, HEPA, MEN, SMALL, YF, ANTH, FLUX, HEPA, MEN, SMALL, YF, ANTH, FLUX, HEP, HEPA, MEN, SMALL, YF
Symptoms: Chest pain, Gastrooesophageal reflux disease, Laboratory test abnormal, Myocardial infarction, Skin ulcer
Clinical narrative: Information has been received from a health professional and from the Center for Disease Control concerning a 39 year old female with a history of hiatus hernia, gastritis, migraines, osteoarthritis of hte left knee, and hyperlipidaemia. The pt denied any history of valvular heart diseasee, hyypertention, cerebrovascular accident, carotid artery disease, anemia, asthma, cancer, diabetes, eczema, chronic skin disorders, gallbladder disease, hepatitis, or thyroid disease. There were no concurrent diseases. On 1/29/03, the pt was vaccinated IM with a second dose of hep A virus vaccine inactivated. Suspect therapy that day included a first dose of hep B virus vaccine administered IM, a first dose of yellow fever administered SC, a second dose of Menomune, a first dose of anthrax vaccine SC, a first dose of smallpox vaccine administered ID, a fifth dose of influenza virus vaccine administered IM. Concomitant therapy included vitamin E. One week after receiving the vaccinations, on approximately 2/5/03, the pt started to experience chest receiving the vaccinations, on approximately 2/5/03, the pt started to experience chest pain. The pt also reported experiencing similar chest pain the second week of February. On 3/4/03, the pt also received a second dose of hep B virus vaccine administered IM and a dose of anthrax vaccine administered SC. At the end of March 2003, the pt again experienced chest pain. She did not seek medical care until the chest pain episodes returned on 5/20/03 while she was deployed. The pt was reportedly diagnosed with a non-Q wave myocardial infarction. Diagnostic tests revealed an elevated CPK (peak of 317) and an elevated troponin. Other lab data on 5/21/03 included: glucose 94; BUN 8; creatinine 0.9; Na 137; K 4.1; Cl 107; CO2 21; CPK 138; and second CPK 317. The pt was medically evacuated to a medical center. While at the center, her cardiac enzymes showed to be abnormal with a peak CK of 98 (normal), elevated CK-MB of 12, and an elevated troponin of 21. A cardiac catheterization on 5/23/03 revealed a right dominant coronary system with branch vessel disease (significant disease involving a very small branch of the circumflex system). The pt had a very small first obtuse marginal branch that had a 90% ostial lesion in it. She also had a 60% ostial moderate size diagonal branch lesion. Normal overall LV systolic function without segmental wall motion abnormalities or mitral regurgitation. Given the relatively small size of the affected vessel, the pt was not considered a good candidate for revascularization. Given the findings and continuous chest discomfort, the pt remained in the ICU and was placed on a full Bruce treadmill test. She did not develop any ischemic ECG changes on the treadmill. The pt's physicians did not feel that her chest pain was cardiac related. A PA/ lateral chest x-ray revealed a blunt right hemidiaphragm consistent with a small effusion. The pt was hospitalized for three days. A repeat chest x-ray, obtained 5 days later, showed that the effusion had resolved. An abdominal ultrasound was performed, which was unremarkable other than a non distended gallbladder. A gastroenterology consult was obtained, and an esophagogastroduodenoscopy was performed, which revealed a small erosion on the antral portion of the stomach, but was not felt to be causal of the chest pain. She was placed empirically on Aciphex. While at the center, a psychiatry consult was obtained to evaluate the pt's eating habits, and she was diagnosed with anorexia nervosa of a restrictive type. No medications were started for this. She stayed at the center for 2-3 weeks before being transferred to another center for further evaluation. Her discharge medications included Lopressor 25mg twice daily, Plavix 75mg daily, Aciphex 20mg twice daily, and simvastatin. On 6/6/03, during a cardilogy evaluation, her EKG showed NSR, NL EKG GXT-Thall obtained on 6/9/03 showed moderate to severe diminished activity in the anterolateral wall after 12:56 minutes, which improves with rest. EF 55%. TTE 6/10/03: normal echography with EF 60-65%. The physician indicated that although her MPS showed ischemia in the anterolateral wall, her ability to exercise for 12:55 minutes without cardiac symptoms translates in a "good prognosis." He also reported that the pt's chest pain was non-cardiac, but most likely musculoskeletal in nature and referred her to internal medicine. It was thought to likely be costochondritis and she was referred for a PA chest x-ray, which the records indicated were normal. At the time of vaccination, the pt also took vitamin E. After her myocardial infarction, she started Librax capsules daily for a hiatal hernia, rabeprazole 20mg twice daily, atenolol daily, Davocet-N 100mg every eight hours as needed for pain, nitroglycerin spray as needed for chest pain, and an Epi-pen for emergency use. Reportedly, the pt did not recover from these events. The following diagnostic lab data were obtained. On 6/4/03, a lung ventilation-perfusion scan exam showed an area of relative photopenia corresponding in location to the oblique fissure of the left lung; relative widening of this area of photopenia in the mid-lung; additionally, there was mild, relatively decreased perfusion to the right lung apex; the mediastinal and cardiac silhouettes were normal in appearance; the ventilation images showed matching, though less prominent, areas of relative photopenia in the oblique fissure of the left lung an in the right apex; a moderate amount of gastrointestinal activity was observed in the ventilation images; exam revealed matching, non-segmental perfusion and ventilation defects with a pattern suggestive of fluid in the left oblique fissure consistent with a low probability for pulmonary embolism. On 6/6/03 at 9:58, a "Coll+HIB-1 AB: negative, Coll-G6PD: normal." On 6/9/03 at 7:08, a myocardial perfusion (spect) multi-ST exam showed LVEF of 55% with normal wall motion; under myocardial stress conditions, there was a moderate to severe diminished activity about the interolateral wall, which improved in the resting conditions; this was in the distribution of the first diagonal vessel; the exam revealed an abnormal myocardial perfusion study with findings consistent with ischemia in the anterolateral distribution consistent with first diagonal obstructive vessel. On 6/11/03, a chest x-ray showed normal lung volumes and her lungs were clear; cardiomediastinal silhouette and pulmonary vasculature were normal; osseous structures were unremarkable; no acute disease found. On 6/11/03 at 13:28, cholesterol was elevated at 311 (50-200) mg/dl, LDL (direct) was elevated at 211 (1-129) mg/dl, VLDL was at 34 and total cholesterol/HDL at 4.71. On 7/5/03 at 8:40, albumin was low at 3.5L (3.9-5.0) g/dL. On 8/12/03, an echocardiogram showed a normal echo doppler; overall left ventricular function was normal with an estimated EF of 60-65%; no pericardial effusion was seen no valvular or structural abnormalities were noted; there were no intracardiac shunts; doppler flows were normal. On 8/14/03, myocardial imaging showed a negative stress test: no evidence of ischemia, normal wall motion, and normal EF of 67%. On 10/1/03, an upper GI series showed mild to moderate gastroesophageal reflux and a mild to moderate hiatal hernia; findings were suggestive of at least gastritis; recommended treatment included treadmill exercise with rest and stress/ cardiolyte. A gastroenterology consult was obtained, and a esophagogastroduodenoscopy was performed, which revealed a small erosion on the antral portion of the stomach. Info received on 2/5/03 was received which pertained to events that occurred 48 days after vaccination with hep A virus vaccine. This info contained the following adverse experiences: small effusion and anorexia nervosa. Chest pain and myocardial infarction were considered to be lifethreatening and to be other important medical events (OMIC). Additional info is expected.