Age: 14.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Chest pain, Electrocardiogram normal, Heart rate irregular, Immunoglobulin therapy, Liver function test increased
Clinical narrative: PATIENT SUMMARY:  Reason for Hospitalization: Myocarditis  Admission HPI: The patient is a 14 yo with no significant PMH who presented with chest pain x 2 days and diffuse ST segment elevation x 1 day, 4 days after receiving his booster COVID-19 vaccine.     Family reports that the patient had previously received 2 doses of the Pfizer vaccine without complication. Following his booster, he initially had headaches and chills, and then on Wednesday he started to develop chest pain localized to the center of the chest with numbness and worsening with exertion.  He went to his primary care doctor on Wednesday 1/19/2022 and given that the pain was mostly exertional in nature, was sent home with return precautions. Then in the middle of the night on Wednesday night into Thursday 1/20/2022, patient had an episode of chest pain that woke him from sleep with 5/10 pain.  He took a dose of ibuprofen, and was eventually able to go back to sleep.  He continued to have chest pain this morning, particularly walking at school, and his parents called PCP office back regarding persistent pain.  He then presented to the PCPs office , where he received a EKG, chest x-ray, and blood work including a troponin.  Parent subsequently received a call from the PCP regarding abnormal EKG findings, and he was referred to the emergency department.   Hospital Course:   In the ED, patient was reporting 1-2/10 chest pain worse with mild exertion such as walking. He also endorses lightheadedness particularly with standing up. He denies any shortness of breath. VSS, no tachycardia, well appearing. Cardiac exam normal. No lower extremity edema. EKG reviewed there. Troponin from PCP resulted at 2.09, repeat labs in process and thus far include: normal chem, no leukocytosis, Hgb 14.2, Plt 174 (borderline low), d-dimer wnl, CRP 3.8. Troponin rising to 2.63. AST/ALT with transaminitis. Repeat CXR unremarkable. COVID PCR today is negative. A point of care ultrasound was obtained with two cardiac views which visualized the pericardial space   He was admitted to cardiac service: During his stay we trended his Troponin that was downtrending. He had no chest pain. On 1/22/2022 had a run of Ventricular tachycardia, and was started on Nodalol. Received a IVIG and started the 5 day course of Steroids. On the day of discharge, Troponin down to 0.1, no arrhythmias over the past 48 hours. patient was in no apparent distress, afebrile. Patient was tolerating PO intake well with no vomiting or diarrhea. Family was given written and verbal discharge instructions including follow up and when to seek urgent care. Parents agreed with plan for discharge.  Reasons for new, changed, and discontinued medications:  -Nodalol 40 mg OD  -Prednisone 40 mg twice daily for 6 more doses. ( received 4 doses of 30 mg Methylprednisolone IV during his admission will continue on 1:1 steroid conversion at home)  Reasons for new, changed, and discontinued equipment: NA   Relevant Diagnostic Images/Studies:  Echo done during his stay: ? Pulmonary venous connections, normal, left lower pulmonary vein, right lower pulmonary vein ? Systemic venous connections, normal ? Left atrium, no abnormalities detected ? Right atrium, no abnormalities detected ? Atrial septal defect, ruled out. No significant atrial septal defect; unable to exclude a small defect.    Tests Pending   Adenovirus PCR, QuaNT  Cytomegalovirus PCR, blood, QuaNT  Epstein-Barr Virus PCR, QuaNT  LCFREEZE  Lyme Antibody, Total  Parvovirus DNA PCR QuaNT, Blood  SARS CoV-2 (COVID-19) PCR, Resp, QuaL  Treponema Pallidum Abs (FTA-ABS)    These tests will be followed by the Primary Service at Discharge after Discharge  Vitals and Discharge Physical  T: 36.9  °C  (Temporal Artery)  HR: 74 (Monitored)  RR: 20  BP: 130/68  SpO2: 98%  WT: 75.7 kg   Discharge Physical Exam     General: alert, no acute distress, playful, normal hydration, not ill appearing Skin: warm, well-perfused Cardiovascular: regular rate and rhythm, no murmur, normal peripheral perfusion Respiratory: lungs CTA, non-labored respirations  Gastrointestinal: soft , nontender, nondistended Neurological: no focal neuro deficits  Diagnosis List   1. Myocarditis, 01/20/2022  Procedure History  No Procedure History  Social History  Smoking Status      No Smoking Status Documented  Allergies   No known allergies  Laboratory Results Returned 48 Hours Prior to Discharge       Labs Last 48 Hours      Event Name  Event Result  Date/Time   Sodium 135 mmol/L 01/23/22  Potassium 3.98 mmol/L 01/23/22  Chloride 103 mmol/L 01/23/22  CO2 23 mmol/L 01/23/22  Anion Gap 9 mmol/L 01/23/22  Glucose Level 95 mg/dL 01/23/22  BUN 14 mg/dL 01/23/22  Creatinine 0.56 mg/dL 01/23/22  Calcium 8.8 mg/dL 01/23/22  Phosphorus 4.4 mg/dL 01/23/22  Magnesium 1.9 mg/dL 01/23/22  AST (Aspartate Aminotransferase) 20 unit/L 01/23/22  ALT 22 unit/L 01/23/22  Alkaline Phosphatase 114 unit/L 01/23/22  Albumin 3.5 g/dL 01/23/22  Total Protein 9.1 g/dL High 01/23/22  Troponin T 0.1 ng/mL Critical 01/24/22  Troponin T 0.42 ng/mL Critical 01/23/22  Bilirubin, Total 1 mg/dL 01/23/22  Bilirubin, Direct <0.2 01/23/22  C-Reactive Protein 0.71 mg/dL High 01/23/22       Microbiology Results (Last 30 Days)  Micro Results: Updates since 12/25/2021 00:00.  Collection date displayed. HerpesSimplex Virus 1/2 PCR, QuaL:  (Blood) 01/22/2022.  Final Report: No HSV type 1 detected by PCR. No HSV type 2 detected by PCR.  Discharge Information  Discharge Activity Level: No physical activity  Discharge Diet: Resume home diet  Discharge Disposition: Discharged home   Medications on Discharge  nadolol (nadolol 40 mg oral tablet) 1 tab(s)  by mouth Once a day predniSONE (predniSONE 20 mg oral tablet) 2 tab(s)  by mouth Twice a day  Duration: 3 Days  14 year old who developed myocarditis 4 days after receiving Pfizer booster of SARS CoV2, with STT wave changes and pericardial changes, significantly elevated troponin. Was noted to have NSVT 3 episodes, fastest rate of ~ 170. Started on nadolol and treated with IVIG and steroids, without further episodes of chest pain (which stopped prior to admission) or VT. Follow-up for testing this week (cMRI tomorrow), and Bardy being sent to the house. Follow up in several weeks. Limited from moderate and vigorous activity. short course of prednisone.