Age: 24.0
Sex: M
Vaccine: SMALL
Symptoms: Electrocardiogram ST segment elevation, Electrocardiogram T wave inversion, Electrocardiogram ambulatory abnormal, Extrasystoles, Fibrin D dimer normal
Clinical narrative: The pt received his primary Smallpox Vaccination in his left upper arm on 1/24/12. At the time he was in his normal state of good health. The pt denies any viral symptoms (cough, sore throat, rhinorrhea, PND, abdominal pain or diarrhea) 30 days prior to vaccination. Per the pt's description he had a "normal take" (no excessive redness, swelling, or site pain and minimal axillary lymph node "irritation"). On 2/3/12 at 0800 the pt woke with a headache and feeling feverish, dizzy and nauseated. The pt reported to medical where per the pt he had a temp of 102.0; was treated with MOTRIN and IV fluids. The pt was feeling better and he was released and placed on SIQ for 24 hours. At 0200 on 2/4/12 the pt woke with "sharp stabbing" (5/10) substernal chest pain, palpitations, SOB, nausea and chills (no diaphoresis). When he sat up the pain improved but was not relieved. By 0400 the substernal chest pain was more severe (9/10); his right arm felt numb and he was diaphoretic and SOB. The chest pain was worsened with deep inspiration. The pt returned to medical; VSS (afebrile). On PE: regulate rate; no murmurs, gallops or rubs were noted; CTA bilaterally. He had an EKG which showed NSR with diffuse ST elevation. CBC w/diff, BMP were wnl; Qualitative enzymes (CKMB, Myoglobin, Troponin I) were all positive. At 1000 he was medivaced. In the ER the pt had a bedside echocardiogram (EF wnl with mild pericardial fluid, no wma); EKG: NSR with inverted T wave lead III (no ST elevation); CXR wnl; Cardiac enzymes were positive (see labs below). He was admitted to the ICU. PE revealed: "left shoulder with 7-8 mm crusted eschar at vaccination site with 6cm x 5cm surrounding erythema, no adenopathy; no rubs, murmurs or gallops (in supine, sitting and leaning forward)". EKG: NSR with nonspecific T wave abnormality. Repeat echo: EF 55-60%, no effusion, no wma. The pt was discharged on 2/6/12 in a light duty and non-deployable status for 6 months. He was given MOTRIN 800mg tid x10d and Colchicine .6mg bid. At that time the pt continued with constant mild (1-2/10) substernal chest pain and palpitations which increased to a 4/10 when lying flat or walking for >100ft. On 2/8/12 PRILOSEC 20mg qd was started for abdominal pain which provided the pt relief from his symptoms. The pt had a CTA (normal) and cardiac MRI w/wo gadolinium (unremarkable for age) on 2/20/12. ON 2/22/12 the pt reported continued mild chest pain which was worse when lying down and relieved with sitting up (after at 20 minutes). The pt also reported "feeling of SOB" and "chest compression" when on the flight line esp. when the rotors were spinning/popping. The pt reported that his Rx for MOTRIN ran out on 2/16/12. Dr advised that the sensation of SOB and chest compression when on the flight line might be due to pressure blasts and the resulting vibratory effect of the air-filled space. The pt was restarted on MOTRIN 800mg tid per cardiology. At his follow-up appt with cardiology on 3/12/12 the pt reported continuation of the above symptoms in spite of resuming MOTRIN. He was seen again on 3/30/12 and started on a prednisone taper (25mg qd x4 weeks, then taper by 5mg weekly). Echo revealed EF >55%, no effusion and no wma. On 5/11/12 the pt described the chest pain as constant pressure (2-3/10) which increases to a "crampy tightness" (7-8/10) with "skipped beats" when he increases his activity. The pt was seen in by the cardiologist on 5/18/12 and he was restarted on INDOCIN 25mg tid for 30 days. When the pt was seen by Dr on 5/18/12 he complained of continued chest pain (described above). A Holter monitor was ordered for 24 hours. According to the pt he did not experience "skipped beats" but he did have two brief episodes of chest pressure which correlated with NSR - see results below. On 6/27/12 the pt reported that he has resumed physical activity - he was able to perform weight lifting without symptoms and he was able to exercise on the treadmill to 1 mile before he experienced "chest pressure". The pt has been near the flight line without experiencing previous sx of SOB  or chest compression. In late July the pt noted that he was able to exercise without chest pain/pressure or palpitations. the pt had a normal stress test on 11/5/12 (see results below). The pt's blood pressure at rest was 155/95 and rose to a maximum of 213/99; he was instructed to follow-up with his PCM. The pt was found fit for full duty.