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EXPEDITED REVIEW

Incidence and follow-up of inflammatory cardiac complications after smallpox vaccination¹

Robert E. Eckart, DO^*,*, Suzanne S. Love, MD, MPH, J. Edwin Atwood, MD, Mark K. Arness, MD, Dimitri C. Cassimatis, MD, Charles L. Campbell, MD^||, Sheri Y. Boyd, MD^*, Joseph G. Murphy, MD^¶, David L. Swerdlow, MD^#, Limone C. Collins, MD^**, James R. Riddle, DVM, MPH, David N. Tornberg, MD, MPH, John D. Grabenstein, RPh, PhD, Renata J. M. Engler, MD^** Department of Defense Smallpox Vaccination Clinical Evaluation Team

^* U.S. Army Medical Command, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
Walter Reed Army Medical Center, Washington, DC, USA; Vaccine Healthcare Center
Naval Medical Center, Portsmouth, Virginia, USA
^** Naval Medical Center, Washington, DC, USA
Army Medical Surveillance Activity, Washington, DC, USA
^|| Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas, USA
^¶ Mayo Clinic and Foundation, Rochester, Minnesota, USA
^# Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Office of the Assistant Secretary of Defense for Health Affairs, USA
Military Vaccine Agency, U.S. Army Medical Command, Falls Church, Virginia, USA

Manuscript received April 10, 2004; revised manuscript received April 20, 2004, accepted May 4, 2004.

^* Reprint requests and correspondence: Dr. Robert E. Eckart, Attn: MCHE-MDC, 3851 Roger Brooke Drive, Brooke Army Medical Center, Fort Sam Houston, Texas 78234-6200, USA.
Robert.Eckart{at}us.army.mil

OBJECTIVES: The purpose of this study was to assess the follow-up of patients with vaccinia-associated myocarditis.

BACKGROUND: With the threat of biological warfare, the U.S. Department of Defense resumed a program for widespread smallpox vaccinations on December 13, 2002. One-year afterwards, there has been a significant increase in the occurrence of myocarditis and pericarditis among those vaccinated.

METHODS: Cases were identified through sentinel reporting to military headquarters, systematic surveillance, and spontaneous reports.

RESULTS: A total of 540,824 military personnel were vaccinated with a New York City Board of Health strain of vaccinia from December 2002 through December 2003. Of these, 67 developed myopericarditis at 10.4 ± 3.6 days after vaccination. The ST-segment elevation was noted in 57%, mean troponin on admission was 11.3± 22.7 ng/dl, and peak cardiac enzymes were noted within 8 h of presentation. On follow-up of 64 patients (96%) at a mean of 32 ± 16 weeks, all patients had objective normalization of echocardiography, electrocardiography, laboratory testing, graded exercise testing, and functional status; 8 (13%) reported atypical, non-limiting persistent chest discomfort.

CONCLUSIONS: Post-vaccinial myopericarditis should be considered in patients with chest pain within 30 days after smallpox vaccination. Normalization of echocardiography, electrocardiography, and treadmill testing is expected, and nearly all patients have resolution of chest pain on follow-up.

Abbreviations and Acronyms   CK = creatine kinase   DoD = Department of Defense   ECG = electrocardiogram   MI = myocardial infarction   NYCBOH = New York City Board of Health

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