Chest pain/ anterior ischemic charges. The pt is a 65 year old male who was admitted to cardiology service for evaluation of exertional angina and cardiac enzyme elevations. The history was obtained from the pt and the medical record. The pt has a past medical history significant for single vessel coronary artery disease, hypertension, diabetes mellitus, and recent smallpox vaccination on 3/3/03 who presented to the ER with chest, shoulder, and arm pain. The pt describes a several month history of recurrent left sided chest, shoulder and arm "ache" and dyspnea on exertion which has become more noticeable since receiving the smallpox vaccination three weeks ago. On the day of admission, the pt had a 25 minute episode of left sided chest, shoulder, and arm discomfort 4-5/10 and dyspnea. He was treated with SL nitroglycerine and admitted to the coronary care stepdown unit for chest pain syndrome and rule out myocardial infarction. An EKG revealed no acute changes and serial cardiac enzymes were drawn. The troponin level remained negative and there was a noted increased in creatinine kinases in the 200s, but the MB fraction was less than 5%. He states that the achy pain is brought on with climbing two flights of stairs or walking two blocks uphill and is relieved with five minutes of rest. The left sided chest and shoulder discomfort is associated with left forearm and hand numbness and dyspnea. The pt's routine exercise regimen consists of swimming 20 laps three times a week. If he attempts to increase the intensity of his workout with more vigorous swimming, the chest, shoulder and arm symptoms arise and resolve after a minute or so with rest. Over the past three weeks, the pt's exercise capacity has worsened and he complains of marked fatigue. He states that he "ran out of gas" by 14:00 daily and was going to sleep by 21:00 nightly, which is unusual for him. Day0:3/3/03 smallpox vaccination-15 punctures. Day 1: no symptoms. Day 2: no symptoms. Day 3: no symptoms. Day 4: reddish blister at vaccination site. Day 5: reddish blister at vaccination site, mild swelling, 3+ pruritis at site, fatigue, malaise. Day 6: reddish blister at vaccination site, mild swelling at site, 4+ puriritus at site, cervical spine stiffness, decreased range of motion, 3+ muscle pain, fatigue, malaise, Motrin 400mg po TID, Benadryl 50mg po with good relief. Day 7: 4+ pruritis at site, cervical spine stiffness, decreased range of motion, 4+ muscle pain, fatigue, malaise, Motrin 400mg po TID. Day 8: 6+ cervical spine stiffness, decreased range of motion, 4+ muscle pain, fatigue, Motrin 400mg po TID. Day 9: 6+ cervical spine stiffness, decreased range of motion, 4+ muscle pain, fatigue. Day 10: 6+ cervical spine stiffness, decreased range of motion, 6+ muscle pain, 2+ dyspnea on exertion, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, fatigue. Day 11: scab formation, 6+ cervical spine stiffness, decreased range of motion, 6+ muscle pain, 2+ dyspnea on exertion, decreased intellectual performance, erythematous, papular, nonpriritic lesions on chest, no vesicles, fatigue. Day 12: 6+ cervical spine stiffness, decreased range of motion, 3+ muscle pain, 2+ dyspnea on exertion, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, fatigue. Day 13: 6+ cervical spine stiffness, decreased range of motion, 3+ muscle pain, 3+ dyspnea on exertion, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, fatigue. Day 14: 2+ cervical spine stiffness, decreased range of motion, 3+ muscle pain, 3+ dyspnea on exertion, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, small papular lesion on left cheek, fatigue. Day 15: 2+ cervical spine stiffness, decreased range of motion, 3+ muscle pain, 3+ dyspnea on exertion, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, small papular lesion on left cheek, fatigue. Day 16: scab fell off, 2+ dyspnea on exertion, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, small papular lesion on left cheek, fatigue. Day 17: 2+ dyspnea on exertion, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, small papular lesion on left cheek, fatigue. Day 18: 2+ dyspnea on exertion, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, small papular lesion on left cheek, fatigue. Day 19: + dyspnea on exertion, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, erythematous, papular, nonpruritic lesions on chest, no vesicles, small papular lesion on left cheek, fatigue. Day 20: 2+ dyspnea on exertion, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, rash with decreased erythema, fatigue. Day 21: 2+ dyspnea on exertion, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, rash with decreased erythema, fatigue. Day 22: 2+ dyspnea on exertion, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, rash with decreased erythema. Day 23: 3+ dyspnea on exertion lasting 25 minutes, 3+ muscle pain, 2+ cervical spine stiffness, mole on scapular area pruritic, decreased intellectual performance, rash with decreased erythema. Assessment: the pt is a 65 year old male with a history of single vessel coronary artery disease, recurrent stable angina with noticeable increase in chest, arm, and shoulder discomfort and dyspnea on exertion after smallpox vaccination. In addition, the pt had a maculopapular rash on his chest erupting day 10 post-vaccination without progression to generalized vaccinia. There is no evidence of acute myocardial infarction with negative serial cardiac enzymes. Stress test and further cardiac workup pending. Concern for possible circulating immune complexes in this pt with generalized rash after smallpox vaccination as seen in two other recent cases Follow-up: States cardiac condition worsened after SPV and mentioned in primary report. Patient states the exacerbated condition has continued to the present. Still experiences frequent episodes of angina with any exercise, eg (walking up 2 flights of steps, swimming over 10 laps) He is on beta blocker and ACE inhibitor. States HgaA1C, BP and lipids are all borderline.