Age: 41.0
Sex: M
Vaccine: ANTH
Symptoms: Arthralgia, Atonic urinary bladder, Back pain, Condition aggravated, Constipation
Clinical narrative: This 43 year old was honorably discharged in 1996 secondary to a MEB following a back injury from 1993 where he experienced numbness, paresthesia, and lower back pain. His symptoms progressed from 1993-1994 to include bilateral foot tingling, numbness to the right buttock/thigh. He was diagnosed with mechanical lower back pain, lumbar strain and herniated nucleus pulpous (HNP) L4-5.  He was reactivated in 1999 with exacerbation of symptoms occurring 2000-2006. In 2002 he was diagnosed with urosepsis (neg STD and wnl IVP), and constipation secondary to ileus. His AVA series began in March 2003 where concurrently he was diagnosed with exacerbation of HNP & LBP after exercising. His first 4 AVA were administered there 6 Mar 2003, 20 Mar 03, 04 Apr 03, and 06 Oct 03.  He denied any adverse event other than immediate burning down vaccinated arm lasting for a few minutes. However, his back symptoms amplified with subsequent injuries in 6/03, and he was given a diagnosis of plantar fasciitis 10/6/03 (AVA #4 also given 10/6/2003). His fifth AVA vaccine was administered 09 July 04 again with no remembered adverse events except site burning. He stated his health was "good" until 2004 with a history of migraine headaches between 1994-1997 with no reoccurrence and periodic back strains since 1993.  He had chronic sinusitis - ragweed allergies with an occasional frontal headache as of 2006 evaluated by ENT.  Approximately two weeks after receiving his 5th AVA (7/04) vaccination he began to notice difficulty riding long distance on his bike or running due to "weakness in legs and lower back pain".  He reported he had been training for various marathons without difficulty.  He denied any trauma, injury, or recent illness and attributed his back pain and leg weakness to "over training" so he rested and used Motrin. He remembers riding his bike past open fields that were being sprayed and irrigated but unknown with what. Over the next few weeks he completed his PRT/PHA completing required sit-ups and pushups within time but noted increasing lower back pain.  During the run he got 1/3 of the way through when his feet felt like they were on fire only to go completely numb within the next few 100 yards.  He did not fall or lose function of his legs and completed the run.  The pain was a 9/10 scale in his lower back with radiation down both legs. He was diagnosed with exacerbation of HNP, LBP/strain, due to over-exertion. No evaluation for pesticide poisoning was considered. By October 2004 he was experiencing extreme bilateral lower extremity weakness, paresthesia L>R, LBP, constipation, bladder dysfunction and erectile dysfunction. He was treated for lumbar strain, herniated disc, and atonic bladder. By December 2004 with persistence of his symptoms, repeat films/MRI spine diagnosed him as possible Cauda-Equine Syndrome with bulging of L3-S1 discs. He was med-evac to the hospital.   His diagnosis was changed to Idiopathic Transverse Myelitis in January 2005. He was evaluated by neurology with a diagnosis of idiopathic transverse myelitis as "all tests have been negative/non-specific". These included two normal lumbar punctures (see results below); negative VDRL, HIV, West Nile Virus, HSV 1&2, and Lyme AB (bug bite in Rota Spain); normal/negative TSH, sex hormones, ANA, RF, CMP, CBC, UA, Bone scan, ESR; and normal EMG of lower extremities. Tests for heavy metals included mercury, lead, arsenic, cadmium, thallium, and cobalt were negative. Re-review of the lumbar spine MRI completed 12/20/2004 showed Degenerative Disc disease L3-4, 4-5 and L5-S1 with a small bulge to L4-5 with later scans 2/2006 showing decreased T2 signal consistent with degenerative disc disease L3-L4 with a possible small tear to left neural foramina. There were mild bilateral facet degenerative changes to L3-4; and L4-5 disc protrusion right>left with another small annular tear, abutment of exiting right L4 nerve root, and degenerative changes.  L5-S1 had small disc protrusion with facet. MRIs of brain and C-L spine in 21 Jan 05 showed no brain abnormalities with DDD at C6-7, a C5-6 bulge and normal C3-4. Repeat C-spine MRI in May 2005 showed mild posterior bulges of the C4-5, C5-6 and C6-7 discs with "no signal abnormalities to suggest transverse myelitis". However, his SSEP's revealed "conduction delay in the lower cord with normal EMG/NCSs suggesting a diagnosis of transverse myelitis slowly resolving". Treatment with steroids produced a rash, headaches, arthralgia, and myalgia so was discontinued Feb 2005. A repeat MRI of the brain Jan 2006 showed Pineal region cysts otherwise unremarkable. As of May 2006, no definitive diagnosis has been made. He has an appointment with Dr. on 08 June 2006. Concurrently with his complaints of bilateral leg weakness and increasing mid-lower back pain he began to notice difficulty urinating and maintaining or obtaining an erection in November 2004. He lost the urge/sensation to urinate and had difficulty initiating a stream, described as "urine just fell out or unable to push/initiate". He would put on a seat belt or bend over not realizing his bladder was full and any pressure caused urinary incontinence. Medical records for 5/05 note self catherization yet patient denies stating vagal maneuvers and bearing down/pressure initiated stream. He complained of constipation. His normal bowel pattern was 1-3 times a week and now could wait up to 3 weeks. He tried ex-lax and other over the counter medications without results and was placed on MiraLax by his MD with resolution. He denied any diarrhea, bloody stools, or bowel incontinence.  He stated he was also unable to initiate an erection or maintain for several months. He was evaluated by urology with a normal IVP, lab studies, videourodynamics showed an atonic bladder "not suggestive of neurologic disease" in 8/2005, and an urethrogram showed bulbus ureteral stricture. He was taught muscle strengthing exercises. Use of Viagra was ineffective. There are no lower GI evaluations and constipation was attributed to low fiber resolving with MiraLax. As of 2006 he has regained some ability to initiate/maintain an erection. His urinary and bowel habits are improving but need monitoring. In January 2006 he awoke nauseated and began to vomit all day. He was evaluated by gastroenterology with an EGD and diagnosed with gastroparesis. His nausea has resolved to "daily nausea" worse in am and about 1-4pm that is eased taking Zofran 1-3x/day.  He also stated his extremities felt numb, tingled with the left arm worse than the right. He was now unable to play his guitar due to decreased coordination of his fingers with the strings -- "too slow". He did not lose function in his arms/hands just sensation. His legs felt numb and weak with decreased sensation and fair strength.  He began to use a cane for balance as he periodically felt dizzy with positional changes and didn't want to fall. He denied any headache, visual problems, tinnitus, vomiting, breathing difficulty, palpitations or chest pains.  The dizziness was described as the room spinning for a few seconds and then normal.  Quick movements often triggered the dizziness but not consistently.  As of May 2006 he continues to experience varying intensities of bilateral upper and lower extremity weakness, bladder dysfunction (does not require catheterization), erectile dysfunction ("better"), gait disturbance due to weakness requiring use of cane for balance, occasional migraine headaches (prior hx of) and new diagnosis of gastroparesis in 2006 (hx of UGI sxs 2001). There are no known triggers; he awakens with decreased sensation daily which amplifies during the day depending on activity/stress of the day. His dizziness persists with positional changes only and was sporadic but requires continued to use a cane for balance (safety issue). He heard about AVA reactions from a friend and requested evaluation hoping the VHC may give light to his problems and make him "normal again" if possible. Travel history included marathon bike races: 2002-2003, 2/04 advised GI problems in area but none for him or team, 5/04, 7/04 and 9/05. He was deployed in 2003-2004 then returned to home. 7/17/06 Received medical records from hospital which revealed patient experienced bilateral leg weakness, lower back pain, atonic bladder, stress incontinence, constipation, erectile dysfunction & gait disturbance beginning 2 wks after 5th dose of Anthrax vax on 7/04.  Patient had been active athlete in training for marathons & triathalons w/o difficulty prior to this.  Also had been stationed in Spain where he was exposed to environmental toxins but no testing done for toxicity.  Exam revealed HNP & LBP/strain due to overexertion. S/S continued & MRI done 12/04 revealed cauda-equina syndrome w/bulging of L3-S1 discs & patient was med-evaced from Spain to Navy & dx w/idiopathic transverse myelitis 1/05 by neurosurgeon. Patient did not tolerate treatment w/steroids.  Transverse myelitis is slowly improving & as of 5/06 continues to have bilateral extremity weakness, bladder & erectile dysfunction, gait disturbance, dizziness & gastroparesis./ss