Age: 17.0
Sex: M
Vaccine: COVID19
Symptoms: Electrocardiogram repolarisation abnormality, Enterovirus test, Eosinophil count decreased, Eosinophil percentage decreased, Epstein-Barr virus antibody
Clinical narrative: **Please note - we do not have access to the immunization registry and cannot provide lot numbers or exact dates**  Admission Date/Time: 07/18/2021 18:23:00 Discharge Date/Time: 07/21/2021 12:53:15  Chief Complaint  COVID vaccine myocarditis  Patient Narrative          ILLNESS SEVERITY:   The patient is returning to baseline, requires assessment.   PATIENT SUMMARY:  Reason for Hospitalization: Chest pain    Admission HPI: a 17 year old young man with a remote history of asthma (last used inhaler 5-6 years ago) who is presenting with 1 day chest pain in the setting of recent Pfizer Covid vaccination. He received his second Pfizer vaccine dose 3 days ago. The following day, he experienced low grade fever to 100.4 and mild headache. He felt fine yesterday, but this morning he woke up with dyspnea and feeling like he "couldn't get air in all the way". He denied feeling chest pressure but endorsed mid sternal chest pain without radiation. The pain was not exacerbated by exercise and was not positional. He presented to an urgent care facility this morning, where they did an EKG that showed ST segment elevations diffusely. He was then transferred to Hospital.  he was overall well appearing with slight tachypnea but otherwise normal vital signs. He initially was not endorsing chest pain. They drew a troponin that was elevated to 1515 ng/L with an upper limit of normal 54 (likely 1.5 on our scale). BNP, electrolytes, CBC were all within normal limits. Initial EKG did not have any ST segment elevation. They did a chest XR which did not show any signs of pulmonary edema or cardiomegaly. He later developed chest pain so an EKG was repeated which showed recurrence of the ST elevations diffusely; most prominently in V1-2. Repeat troponin was 2000. He was given a single dose of aspirin 81mg and transferred for further care.   In the ED, he was well appearing and no longer endorsing chest pain. He was monitored on continuous telemetry with no abnormalities. His troponin here was 0.27 ng/mL, CRP was elevated to 2.6, he had a mild transaminitis of 41/37 and mildly elevated LDH to 236. Covid antibodies were positive. CBC, ferritin, d-dimer, ESR were all within normal limits, rapid Covid/flu/RSV negative. Repeat EKG was similar to the second EKG with very minimal ST-segment elevations.   He denies any URI symptoms, rashes, N/V/D, and joint pain. He's had good PO intake until today. He is an athlete (currently playing baseball) and has never experienced chest pain with exercise.   Surgical hx: T&A  Family history: Negative for any cardiac pathology or autoimmune disease  Allergies: rash with penicillin  Social: here with grandma who is legal guardian  Hospital Course: admitted to the cardiology floor for continued monitoring of his troponin levels and EKG. The morning after his admission, his troponin was uptrending slightly to 0.37 and echocardiogram showed mildly depressed systolic function and longitudinal strain, so the decision was made to treat. Cardiac MRI performed prior to treatment showed good systolic function but mild LV late gadolinium enhancement and corresponding hypokinesis. He received one time IVIG 2g/kg and IV methylprednisolone 30mg BID for 2 doses. His chest pain came and went throughout his admission and was treated with ibuprofen and Tylenol as needed. He was transitioned over to PO steroids on 7/20 which he tolerated well. On day of discharge, his troponin levels were trending down. Pt was scheduled for outpatient follow up including ECHO at that time.   By time of discharge, patient was well-appearing, vitals stable, demonstrating good PO intake. Chest pain was fully resolved. Prescriptions sent to preferred pharmacy. Follow up with cardiology in place. Discharge instructions and return precautions reviewed with patient and parent, who expressed good understanding and agreement with plan.  Reasons for new, changed, and discontinued medications:  Prednisone for myocarditis to complete 5 day steroid course (last dose morning of 7/24)  Famotidine (GI protection while taking prednisone)  Reasons for new, changed, and discontinued equipment: NA   Relevant Diagnostic Images/Studies:   Echocardiogram 7/19: ? Technically difficult examination due to suboptimal echocardiographic windows. Unable to evaluate the atrial septum, systemic and pulmonary veins, pulmonary arteries, and aortic arch. Coronary artery dilation is not excluded. ? Normal valvular function. ? Normal left ventricular size and low-normal systolic function. Reduced longitudinal strain. ? Qualitatively normal right ventricular systolic function. ? No pericardial effusion.  Cardiac MRI 7/19: ? Normal left ventricular size and global systolic function. ? Basal inferoseptal, inferior, and inferolateral left ventricular late gadolinium enhancement with corresponding mild hypokinesis. ? Normal right ventricular size and global systolic function. No right ventricular late gadolinium enhancement or regional wall motion abnormalities. ? No significant valvular dysfunction. ? No coronary artery aneurysms. ? No pericardial effusion.  Admission EKG 7/18:  ST segment changes, non-specific.  Discharge EKG:  minimal ST segment changes, improved from admission.    Tests Pending   Adenovirus PCR QuaNT, Stool  Adenovirus PCR QuaNT, Urine  CMV Antibody IgG  CMV Antibody IgM  EBV Antibody IgG  EBV Antibody IgM  EBV Antibody to EA-D, IgG  EBV Antibody to NA, IgG  Enterovirus PCR QuaL, Stool  HSV I/II Combined Antibody IgG  Lyme Antibody, Total  Mayo Misc Test  Miscellaneous Lab Test  Miscellaneous Test Arup  Miscellaneous Test Arup  Miscellaneous Test Arup  Parvovirus B-19 IgG  Parvovirus B-19 IgM  Parvovirus DNA PCR QuaNT, Blood  Respiratory Virus PCR Panel - sendout  Viral Culture, Non Respiratory    These tests will be followed by the Primary Service at Discharge after Discharge  Vitals and Discharge Physical  T: 37.1  °C   HR: 64 (Monitored)  RR: 20  BP: 120/58  SpO2: 96%  HT: 167 cm  WT: 94.9 kg  BMI: 34   Discharge Physical Exam     Gen: Well-appearing, well-developed teenager sitting up in bed. Appropriately interactive./ HEENT: Normocephalic, atraumatic. Moist mucous membranes. EOMI, no conjunctivitis. Resp: Clear to auscultation bilaterally, no increased work of breathing. No wheezes CV: Normal rate, RR with no murmurs, rubs, or gallops. Capillary refill <2 sec. Distal pulses 2+. Abd: Soft, non-distended, non-tender. Normal bowel sounds Ext: Normal range of motion of all extremities, no peripheral edema Skin: Pink, warm, no bruising Neuro: Alert, responsive, developmentally appropriate, normal tone  Diagnosis List  1. Chest pain, 07/18/2021 2. Shortness of breath, 07/18/2021 3. Myocarditis, 07/18/2021  Procedure History  No Procedure History  Social History  Smoking Status      No Smoking Status Documented  Allergies  penicillin  Laboratory Results Returned 48 Hours Prior to Discharge   Labs Last 48 Hours      Event Name  Event Result  Date/Time   WBC 7.88 K cells/uL 07/20/21  Hemoglobin 12.6 g/dL 07/20/21  Hematocrit 36.6 % Low 07/20/21  Platelet 298 K cells/uL 07/20/21  MPV 9.1 fL Low 07/20/21  RBC 4.17 M cells/uL Low 07/20/21  MCV 87.8 fL 07/20/21  MCH 30.2 pg 07/20/21  MCHC 34.4 g/dL 07/20/21  Red Cell Distribution Width CV 11.9 % 07/20/21  Nucleated Red Blood Cell % 0 /100 WBC 07/20/21  Nucleated Red Blood Cell Count 0 K cells/uL 07/20/21  Absolute Neutrophil Count 6.38 K cells/uL High 07/20/21  Absolute Lymphocyte Count 0.97 K cells/uL Low 07/20/21  Absolute Eosinophil Count 0.02 K cells/uL Low 07/20/21  Absolute Basophil Count 0.01 K cells/uL Low 07/20/21  Absolute Monocyte Count 0.45 K cells/uL 07/20/21  Absolute Immature Granulocyte Count 0.05 K cells/uL High 07/20/21  Neutrophil/Band 81 % High 07/20/21  Immature Granulocytes 0.6 % High 07/20/21  Lymphocyte 12.3 % Low 07/20/21  Monocyte 5.7 % Low 07/20/21  Eosinophil 0.3 % Low 07/20/21  Basophil 0.1 % Low 07/20/21  Sodium 137 mmol/L 07/19/21  Potassium 5.14 mmol/L High 07/19/21  Chloride 102 mmol/L 07/19/21  CO2 21 mmol/L Low 07/19/21  Anion Gap 14 mmol/L 07/19/21  Glucose Level 133 mg/dL 07/19/21  BUN 11 mg/dL 07/19/21  Creatinine 0.61 mg/dL 07/19/21  Calcium 9.3 mg/dL 07/19/21  Phosphorus 4.5 mg/dL 07/19/21  Magnesium 1.9 mg/dL 07/19/21  Troponin T 0.21 ng/mL Critical 07/21/21  Troponin T 0.22 ng/mL Critical 07/20/21  Troponin T 0.22 ng/mL Critical 07/20/21  C-Reactive Protein 0.77 mg/dL High 07/20/21  Mycoplasma pneumoniae, IgG 1.87 High 07/19/21  Mycoplasma pneumoniae, IgM 0.47 07/19/21  Microbiology Results (Last 30 Days)  Micro Results: Updates since 06/21/2021 00:00.  Collection date displayed. Cytomegalovirus PCR, blood, QuaNT:  (Blood) 07/19/2021.  Final Report: No CMV detected by PCR. This test does not detect latent CMV infections. A reference range for this test has not been established. Results should be interpreted in the context of other clinical and laboratory information. This test should not be used to diagnose latent or previous CMV infection. People with latent or previous CMV may not have detectable CMV DNA by this test. The variability of this test should be considered when interpreting results. Changes of approximately three fold in the quantity of CMV DNA detected may be due to variation in the test rather than actual changes in the level of CMV DNA in the sample. Note: This test was developed and its performance characteristics determined by the Hospital. It has not been cleared or approved by the Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. Epstein-Barr Virus PCR, QuaNT:  (Blood) 07/19/2021.  Final Report: No EBV detected by PCR. This test does not detect latent EBV infections. A reference range for this test has not been established. Results should be interpreted in the context of other clinical and laboratory information. This test should not be used to diagnose latent or previous EBV infection. People with latent or previous EBV infection may not have detectable EBV DNA by this test. The variability of this test should be considered when interpreting results. Changes of approximately three fold in the quantity of EBV DNA detected may be due to variation in the test rather than actual changes in the level of EBV DNA in the sample. Note: This test was developed and its performance characteristics determined by the Hospital. It has not been cleared or approved by the Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. Health Care Proxy: Under 18 years old MOLST: Under 18 years old  Follow-Up and Patient Instructions  Patient Instructions  He was admitted for management of myocarditis thought to be due to his SARS-CoV2 vaccination. Myocarditis is inflammation of the heart muscle that can happen with many different types of infections and virusesHe received IVIG and steroids. He had multiple EKGs, echocardiograms, and a cardiac MRI which showed mild changes but overall good heart function. His chest pain and heart studies improved throughout his stay and he was safe for discharge home.   He should refrain from strenuous exercise for the next couple of months and you should discuss when it is safe to return to exercise with your outpatient cardiologist.    Medications:  --- Prednisone 30mg twice per day for _ days (last day _)  --- Famotidine 20mg twice per day for _ days (last day _)   It is important to minimize activity that raises his heart rate for the next 3 months. This will be discussed in more detail at cardiology appointment. Until then, no strenuous exercise.   Attending Attestation  CARDIOLOGY INPATIENT ATTENDING DISCHARGE NOTE:  I reviewed the history and hospital course, examined the patient on rounds, reviewed the testing, discussed the findings with the Cardiology Team, and participated directly in formulation of the assessment and plan for discharge.  I have reviewed and agree with the documentation above with the following additions/revisions:17yo admitted with COVID vaccine associated myocarditis, with repolarization abnormalities on ECG, elevated troponin, and chest pain within days after receiving his 2nd dose. He remained hemodynamically stable with preserved ventricular systolic function. Echo did show abnormal strain, and MRI showed LGE with focal hypokinesis. Due to increasing troponin level, he was treated with IVIG and steroids with improvement in troponins. No significant arrhythmia. Plan for follow-up next week with MISC/vaccine myocarditis group, and to complete a 5-day course of steroids. Restricted from sports and intense activity for likely at least 3 months.