Age: 35.0
Sex: F
Vaccine: ANTH
Symptoms: Exposure to chemical pollution, Fatigue, Gastrooesophageal reflux disease, Hyperaesthesia, Irritable bowel syndrome
Clinical narrative: Pt is a 33 year old female who noted shortly after her anthrax (AVA) #2 on 04 Jan 99 that she developed an itchy rash on both her legs from her knees down to her ankles. She described this as itch, raised bumps (a little bigger than size of pencil head) in clusters that would drain fluid when she would scratch them. She said it looked something like "cold sores". She denied any cultures. She reports that she still has the rash on the lower part of her legs but it is not as bad as before. The rash never completely goes way and has not had a dermatological evaluation. Her MD told her it was dermatitis and to use Eucerin cream. She reports no worsening with subsequent shots and that the rash never extended past her legs. She received her AVA #3 on 20 Jan 99. She reported that her arm was red and swollen to her elbow and that it lasted approx. 2 weeks. She reported recurrent hip problems since an injury she sustained during basic training in 1996. Between Mar-Apr of 99, she began to notice pain in both her knees. This knee pain is persistent today. AVA #4 on 29 Jun 99 - She had arm swelling as before and reported no increase in her rash or knee pain. She did note that this time she had tenderness described as an intense workout feeling in her upper legs. She also noted around this time that she was getting ready to deploy and was exerting herself more than usual. She noticed at this time that her PT scores had decreased and she had decrease stamina. She stated that it felt like her whole body was tired. Later during the fall of 99, she noticed pain in her lower back and had problems with prolonged standing. She also began to experience bilateral hip pain. After a medical evaluation, she received a diagnosis of Iliac Crest Syndrome. Around this time, she was diagnosed with irritable bowel syndrome and gastroesophageal reflux disease. With her AVA #5 on 6 Jul 00 she again noticed arm swelling. She reports that her stamina continued to decrease and her tiredness continued to increase. It was around this time that she started receiving steroid injections for management of back and hip problems. It was between AVA #5 and 6 that she began to suspect that the anthrax might be making her sick. She went to her provider who told her that her symptoms were not the result of the shots. In June 2000, she had a chemical exposure of Lithium Sulfur Dioxide that resulted in chronic asthma. AVA #6 in July 00 while still recovering from the previous exposure and was hospitalized due to the breathing problems. She reported no worsening with the anthrax. While hospitalized she had decreased activity which resulted in increase back, hip, and knee pain. She reported increase fatigue to the point where her arms would get tired and heavy while blow-drying her hair. She also reported that her whole skin became sensitive touch. During 2002, she received a diagnosis of fibromyalgia. AVA #7 In Jul 04 in which she reports no new symptoms but has noticed problems expressing herself and getting her thoughts out. She also reports increase tiredness, pain, and exacerbation of symptoms after any type of exertions.