The vaccinee has a history of Breast cancer including post lump excisions and Lymph node dissection 1999. The vaccines concurrent conditions include chronic obstructive pulmonary disease and chronic anemia. The vaccines family history includes congestive heart failure (brother at age 59) and myocardial infraction (brother at age 67). The vaccinee dose not consume alcohol, was on no medications and has no known history of coronary artery disease prior to October 2000. In Oct 2000, the vaccinee presented to the hospital with a chief complaint of shortness of breath, choking in the throat and a funny feeling in her abdomen. On admission the electrocardiogram revealed ST elevation in II, III, a VP, Q waves in II, III a VF and ST depressions in V1-V. Laboratory date demonstrated elevated cardiac enzymes (CPK peak of 1575 IU/L) consistent with an inferior wall myocardial infarction. On physical examination, the vaccinee was in respiratory distress. She had a harsh III/VI systolic murmur suggestive of mitral regurgitation MR. She was incubated and mechanically ventilated for respiratory distress. A bedside Transthoracic echocardiogram was performed and revealed a myxomatous mitral valve and partial rupture of the posteromedial papillary muscle, as well as severe eccentric mitral regurgitation. Severe hypokinesis of the mid and basal inferior walls were also noted. Emergency cardiac catherization was performed revealing total occlusion of the mid segment of the right coronary artery, normal left anterior descending artery, severe MR, ejection fraction of 40% and elevated means pulmonary capillary wedge pressure of 21 mm HG. coronary artery bypass surgery with placement of saphenous vein graft to RCA and mitral valve repair were recommended and undertaken without complication. The vaccinee was discharged 10 days later. In Dec 2000, the vaccinee received anti influenza vaccine (brand unspecified) and Pneumovax 23. Subsequently the vaccinee developed recurrent reversible dilated cardiomyopathy secondary to viral and streptococcal pneumonia vaccine associated myocarditis. On 12/29/2000 the vaccinee presented to the emergency department after having been awakened by shortness of breath. The vaccinee denied chest pain, palpitations, dizziness, nausea or diaphoresis. Physical examination was significant for any oxygen saturation of 82 percent on ambient air, lower extremity edema and pulmonary edema in the chest x ray. ECG revealed sinus tachycardia with Q waves noted in the inferior leads ant T wave inversions in the same leads. A TTE was performed, which revealed mild left ventricular enlargement, severe segmental LV dysfunction with severe hypokinesis of the septum, anterior wall, apex and distal lateral wall and hypokinesis of the inferior and posterior walls, representing a significant interval change from her previous study on 12/21/2000. The vaccinee was taken to the cardiac catherization lab where angiography revealed a patent SVG to the RCA, normal left anterior descending artery, normal left circumflex artery but now also showed an ejection fraction of 18 percent with akinetic inferobasal and mid inferior walls, mild apical hypokinesis, mild anterobasal hypokinesis and severe anterolateral hypokinesis. The vaccine was treated in the coronary care unit and treated successfully with diuresis, IV inotropic therapy, digoxin, angiotensin converting enzyme inhibitor and beta adrenergic receptor blockade. The vaccinee was discharged on 1/5/2001. In March 2001 the vaccine was admitted to the hospital for elective bronchoscopy for workup of a recently discovered lung nodule. TTE at this time revealed mild segmental LV dysfunction, severe hypokinesis of the mid and basal inferior and posterior walls. As compared with the study done on the last hospital admission, there was mild improvement in LV function. In late 12/2001, the vaccinee was readmitted to the hospital with symptoms of an upper respiratory tract infection,  complaining of shortness of breath, wheezing and cough productive of white sputum. The vaccinee had recently received her yearly flu vaccine. Her symptoms began 6 days prior to hospital admission. She denied chest pain, nausea, vomiting, diaphoresis, fever, dizziness or palpitations. IV antibiotics and bronchodilator therapy were initiated. On pulmonary examination, crackles were heard and an echocardiogram were performed to assess LV function and valve anatomy. TTE revealed severe global LV dysfunction again worsened from the previous examination. Five days later cardiac catherization was done to evaluate SVG and coronary artery anatomy, revealing 90 percent stenosis of the proximal segment of the first right posterolateral branch of the RCA and normal LAD. A coronary stent was successfully placed in the posterolateral RCA branch. Ejection fraction at this time was reported to be 39 percent. There was no evidence of infarction at this time. Repeat TTE, performed as an outpatient, on 2/26/2002 showed an improvement in LV function with mild segmental LV dysfunction. Over the next 3 years, the vaccinee was followed as an Outpatient and had routine echocardiograms performed. A coronary stent was successfully placed in the posterolateral RCA branch. In Feb 2002 and Nov 2002, TTE showed mild segmental LV dysfunction with akinesis of basal inferior and basal posterior walls normal function of the repaired mitral valve. In 2002 the vaccinee did not receive the flu vaccine and she did not have any variation in vaccinee presented to the hospital with URI symptoms, complaining of cough, rhinorrhea and shortness of breath starting the night before admission. AT this time, the vaccinee also reported orthopnea. It was reported that in Jan 2004 the vaccinee had undergone an exercise thallium stress tests, which revealed no ischemia, and ejection fraction was 62 percent. Cardiac biomarkers were elevated. The vaccinee was admitted to hospital to rule out myocardial infarction and was treated for URI. A TTE revealed severe segmental LV dysfunction with akinesis of posterior and inferior walls and hypokinesis of the remaining segments. Cardiac catherization was performed and revealed patency of the SVG to the RCA and a patent stent in the first right post lateral branch of RCA. There was mild diffuse disease seen in the mid segment of the LAD, During the hospital stay, the vaccinee and non sustained ventricular tachycardia, which was evaluated with electrophysiology study and treated medically. The vaccine was discharged without complications. Repeat electrophysiology was performed as an outpatient 1 month later, again showing the reversal of LV dysfunction. The TTE revealed mild segmental LV dysfunction. Since then the vaccinee has done well and has continued to follow up as an outpatient. The authors reported that myocarditis leading to cardiomyopathy was caused by viral upper respiratory infection and post streptococcal pneumonia vaccine. No further information is expected.