Age: 19.0
Sex: M
Vaccine: ANTH, SMALL
Symptoms: Painful respiration, Palpitations, Prothrombin time normal, Red blood cell sedimentation rate increased, Renal function test normal
Clinical narrative: This case was received on 17 October 2014 via at third party query tool search on the VAERS database, under reference number 537947. An unidentified 19 year old male patient was vaccinated on 10 June 2014 at 09:00 percutaneously with Smallpox (Vaccinia) Live Vaccine batch number VV04003A into the left arm and Anthrax Vaccine, batch number FAV365A into the right arm, route not reported. The patient was in his normal state of good health at the time with no respiratory or GI illnesses within the last 30 days. He had a history of acne; pseudofolliculitis barbae; insomnia; scrotal varicocele; self-diagnosed seasonal allergies, heart murmur as a child, and chickenpox at an unknown age. He has no history of hypertension (HTN) or hyperlipidemia. His concomitant medications are Trazodone and Clindamycin topic gel. Two day post vaccination on 12 June 2014 the patient noted redness, swelling, induration and pain at the smallpox injection site and left axillary lymph node tenderness "consistent with a robust take". The patient did not note any redness, swelling or pain at the Anthrax Vaccine injection site. Additionally, he noted generalized muscle aches, joint pain and a headache when exercising. On 19 June 2014 at 1900 he noted substernal chest pressure (2/10) and shortness of breath (SOB) while exercising. His symptoms resolved quickly with rest. On 20 June 2014 while running he noted difficulty breathing and chest pressure (6/10). He completed the run finishing in first place. His symptoms lasted a total of 30 minutes and resolved when he rested. During the remainder of day he noted about four episodes of chest pressure which lasted at twenty minutes each-the pain worsened with deep breaths and he was also lightheaded. On 21 June 2014 after experiencing chest pressure (8/10), palpitations, SOB, nausea and lightheadedness for 3 hours he went to the emergency room. The patient stated that his symptoms worsened with lying flat, lying on his side and deep breathing. The symptoms improved with sitting up-leaning forward but made it 'harder to breathe'. The patient's Troponin I was 4.3, CRP was 21.2 and ESR was 19 and his EKG showed Sinus Bradycardia/Sinus Arrythmia with ST elevation. A bedside echo showed no wall motion abnormalities (WMA), and no pericardial effusion. The patient was given TORADOL 30mg IV with pain relief. He was evaluated by the Cardiologist and admitted with the diagnosis of myopericarditis. The patient was started on Ibuprofen 400 mg q6h. The patient reported that he had a few brief episodes of mild chest pressure (1-2/10) while in the hospital. His Troponin I peaked at 23.12 on 21 June 2014 at 1854. According to the discharge summary the Troponin I was 1.5 (this lab was not visible in the EMR. The last recorded Troponin I was 15.81 on 22 June 2014 at 02:54). An echocardiogram was done on 22 June 2014: EF 55-60%. The patient was discharged on 24 June 2014 with a recommendation for ten days of convalescent leave, a profile for limited duty and a cardiology follow-up appointment on 30 June 2014. At his appointment on 30 June 2014 he reported experiencing at least four episodes of mild (3/10) substernal chest pressure daily. These episodes lasted a "few minutes" each, resolved without treatment and were accompanied by nausea and lightheadedness. The patient denied palpitations, radiation of the pain, diaphoresis, shortness of breath or vomiting. The patient reported taking Ibuprofen 400mg q4-6 prn. PE was noted as "normal". The EKG showed Sinus Bradycardia. Troponin I was 0.2. As of 22 July 2014 the patient stated that he continues to experience intermittent mild (3/10) substernal chest pressure associated with nausea and lightheadedness lasting for a few minutes to several hours. He denied shortness of breath, palpitations, diaphoresis, radiation of the pain or vomiting. He stated that he continues to take the Ibuprofen prn. The patient was encouraged to take the Ibuprofen qid with food until his pain has resolved. He is scheduled to follow-up with the Cardiologist in mid-August for a possible stress test and it was suggested that he be placed on a Holter monitor to evaluate his lightheadedness. Lab data LABS: 6/21/14 0728: CRP 21.2H; CMP wnl except gluc 106H and bilirubin 2.0H; CBC, PT/PTT wnl; CKMB 32.9H; Troponin I 4.33H; ESR 19H; 6/21/14 1317: CK MB 56.9H; Troponin I 9.82H; 6/21/14 1854 CKMB 100.0H, Troponin I 23.12H; 6/22/14 0254 CKMB 69.5H, Troponin I 15.81H, CBC wnl; renal panel wnl except CA 8.7L, glucose 108 H; Mg wnl; hepatic function panel wnl except: Albumin 3.3L, Bilirubin 1.3 H, AST 92H; 6/23/14 0534 Renal panel wnl; Hepatic function panel wnl except Bilirubin 1.2H and AST 66H; 6/24/14 0435: CBC wnl; Renal Panel wnl; Hepatic function panel wnl except Bilirubin 1.5H, AST 46H; 6/30/14 1347: CRP 0.6; ESR 17H; BMP 18; Troponin I 0.2; Troponin I <0.011; CKMB 1.0; Studies: 6/21/14 CXR: wnl; 6/22/14 Echo: Sinus bradycardia, EF 55-60%. The events of effusion, hyperhidrosis and robust uptake were not included in the coding from the VAERS database, but were mentioned in the narrative. Documents held by sender: None.