I think the smallpox vaccine caused my heart failure. Patient is a 34 yo male who has new onset idiopathic dilated cardiomyopathy and heart failure.  He is currently on the heart transplant list.  He received his primary smallpox vaccination on 13 Aug 03.  He had been scheduled to receive his SPV before deployment but was granted an exemption based on his medical history of G6PD Deficiency.  He reports that he was ordered to take his smallpox vaccination.  He reports that he developed minor chills, non-productive cough, and flu-like symptoms for one week that he took Tylenol to relieve.  He reports that his SPV site followed the normal course.  After one week, symptoms subsided, and he reports that he did not experience any further symptoms until October 03 when he was returning from his deployment.  He denies any chest pain, shortness of breath (until October), or rash after receiving the SPV.  He denies any illnesses or infections.  When he returned from his deployment in October, he recalls that on the return trip he began having chills.  When he arrived back home, he developed a non-productive cough.  He noticed that the cough was worse in the morning and it usually lasted all morning.  He did not awaken any at night due to the cough or nocturnal dyspnea. He reports that he had no chest pain or pedal edema.  He did note shortness of breath, particularly after climbing stairs.  He had a weight gain of 15 pounds from August 2003 to October 2003, but he attributed the weight gain to a dramatic increase in weight lifting while deployed.  He noticed that he had become more fatigued and rates his average fatigue level at a 4.5 on a 0 (no fatigue) to 10 (worst fatigue) level.  He denies fever, night sweats, or dizziness.  He did develop bilateral knee arthralgia.  He reports occasional mild tension headaches.  Of note, he received his influenza vaccine on 28 October 2003 and reports no know adverse effects.  Near the end of October 2003, he purchased a humidifier that he kept by his bed, and he thought that helped improve his morning cough.  However, in December 2003, his symptoms worsened with a return of the non-productive cough.  In January 2003, the cough became productive  with "greenish bubbly secretions."  Around this time, his wife noted that he started wheezing at night.  Towards the end of January 2004, he noted a trace of blood in his sputum.  He was concerned that he had TB as his wife had previously had a positive PPD but completed her medication regimen.  Near the end of February 2004, he went to see his PCP regarding his persistent cough with bloody sputum.  He was diagnosed with an upper respiratory infection and allergic rhinitis.    On 27 Feb 04, he received Anthrax #4.    He reports no local reaction and reports no known reaction to previous doses of Anthrax.  He states that the morning after receiving this vaccination, he woke up and found it extremely difficult to breathe.  He continued with the productive cough and states that he now had "chunks of blood in his sputum."  He noticed an increase in his level of fatigue.  No chest pain, chest pressure, jaw or arm pain.  He also began to experience abdominal pain and bloating.  He tried to relieve this with Rolaids, but pain seemed to move up to the back of his neck.  He recalls that he tried to lie down, but he felt like he was drowning.  On 29 Feb 04, he went to the Emergency Dept and was diagnosed with a "gastrointestinal infection," given Maalox and discharged home.  At this time, he states that he did not have any x-ray or EKG done.  When he arrived home, he tried to sleep but the dyspnea became much worse  By 1500 on 01 March, he reports that he developed nausea and vomiting (no hematemesis).  His cough had worsened and the stomach pain remained.  No chest pain or fever.  He returned to medical center and a chest x-ray showed heart failure.   His echocardiogram showed an EF of 15%.   He was admitted, started on Lasix, and remained in the hospital for one week.  He was discharged on Lasix, ramapril, and Coreg.  He reports a decrease in cough and shortness of breath after discharge.  After one week, his abdominal pain and bloating returned.  He was no longer experiencing dyspnea.  He returned to medical center and a GI consult was obtained.  He was transferred to another hospital 3 days later.    Upon arrival, he states that he was ruled out for TB and HIV.  An infectious disease consult was obtained.  He states that his abdominal pain was attributed to hepatomegaly and gall bladder irritation.  He reports that he was diagnosed with idiopathic viral-related dilated cardiomyopathy and new onset heart failure.  He underwent a cardiac catheterization, which showed no blockage per his report.  He states that his echocardiogram showed slight improvement in his ejection fraction.  A defibrillator was placed on 02 April 2004.  He has been placed on the heart transplant list.  He was discharged on 03 April 2004 and has a follow-up appt. scheduled 20 April 2004.  Since his discharge, he reports decreased shortness of breath but continued fatigue.  No pedal edema, nocturnal dyspnea, or cough.  Of note, he is particularly concerned that the combination of his history of G6PD Deficiency, along with the SPV, may have contributed to his idiopathic dilated cardiomyopathy and heart failure.  He states that the only crisis he has had from the deficiency was in the mid-1990's when he received malaria prophylaxis for a trip.  He states that his blood pressure dropped and he became lethargic.  He was taken to the ER, received IV fluids, and later evaluated for appropriate malaria prophylaxis. He states that he is not sure which type of G6PD deficiency he has but has been told it was not the "bad kind."