Received Jan 8, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 1 | 3052671 | IM / UN |
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | 1 | UT7377MA | IM / UN |
Patient is a 16 year old patient with presumed COVID-19 vaccine associated myocarditis. The patient received his vaccine on September 10, 2025 at 3 PM. His first symptoms were 10 PM on September 13 and included fever myalgias and chest pain. This progressed to numbness of the chest left flank shoulder and arm. Patient was assessed at Hospital. EKG was normal but troponin I was elevated at 1423 ng/L (normal less than 20 ng/L). Patient was transferred to (higher level of care) Hospital where serial EKGs were performed and echo and repeat troponin. Repeat troponin was now 291 ng/L but this was a troponin T. (Normal troponin T is less than 22 ng/L). Patient's pain resolved with ibuprofen. He has been on ibuprofen 3 times a day with no residual pain numbness fever or myalgias. The patient is restricted from activities but does not have any complaints of dyspnea swelling diaphoresis or pain. He is not carrying his book backpack and is limiting his weight lifting to 10 pounds. His vaccine was Moderna vaccine booster that was administered at pharmacy. Mom has the pharmacy app and will download the data on the vaccine so we can report to VAERS. Per hospital records "pain started in the left upper chest, radiating down his left arm. Pain then migrated to his left axillary area. Characterized as sharp and severe. He has a history of musculoskeletal chest pain, but this episode was different and worse that that. During admission he reported mild fever and body aches in the past day or so. Fever was responsive to NSAID, and the illness seemed mild. His history is notable for COVID vaccination one week prior to admission. He had no apparent adverse effects from that vaccination. Other than the musculoskeletal chest pain, no prior cardiac concerns, including no syncope, no palpitations, no activity intolerance. No excessive fatigue or activity intolerance. He is active in theater in the fall, and anticipates playing water polo in the spring. No family history of congenital heart disease, dysrhythmia, young people with pacemakers, or young people with heart transplant. OSH Labs significant for troponin 1423 ng/L. Normal ECG per report.
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ECHO