Age: 27.0
Sex: M
Vaccine: ANTH
Symptoms: Post-traumatic stress disorder, Red blood cell sedimentation rate normal, Serum ferritin normal, Sinus disorder, Sleep disorder
Clinical narrative: This 30 year old communication technician and firefighter reported good health prior to receipt of ANTHRAX (AVA) series. He received AVA #1 04 Feb 2003 reporting site irritation and burning with mild nausea <24 hours. His second AVA was administered 19 Jan 2004 with complaints (<24 hours post vaccine) of headaches with severe bone pain, nausea and dizziness lasting one week. The headaches were localized to left side of his head, were "migraine like" lasting 1-2 hours 2-3 times that week. MOTRIN/ibuprofen resolved these headaches. He denied any neurological deficits, speech impediments, weakness, visual or hearing disturbances or change in activities. He reported his headaches continued 2-3 x a week for the next 3-4 years. Approximately 2-3 weeks (feb 2004) after AVA #2, he also complained of various joint and muscle pain and change in sleeping patterns. He described an intermittent non-descriptive joint -muscle pain progressing from bilateral knees, hips, then shoulders and hands. There was no trigger or cause remembered or limitation in activities. he remembered difficulty grasping or maintaining his grip due to stiffness and pain (unable to clarify further). He stated he was diagnosed with arthritis, but did not remember seeing any orthopedic or rheumatology providers. He described his sleep changes as problems getting to sleep secondary to irregular work schedule.  He reported sleeping 3-4 hours increments. He would go to bed about 2 am and was up at 6 am. At home, his wife reported he moved around at night in bed, and did not snore. He has tried sleeping pills (OTC and prescribed) with poor results. He received an honorable discharge in 2005 returning to middle east as a private contractor doing telecommunications work. In July 2006 the intensity of his headaches changed from a 7/10 to an 8-10/10 pain scale. He described the pain as "head splitting open" with pain extended behind his left eyeball. Complaints included intermittent  double/blurry vision with headache, change in smell (cut grass smelled like caramel to him), and problems concentrating. These headache would wake him from sleep and lasted 1-2 hours. He denied any facial droop, muscular weakness, numbness, nausea, vomiting, photo/phonophobia or head trauma, injury, sinus pressure or ENT disorders. An MRI of brain 9/2005 identified left cavernous sinus enhancement (possible meningloma  vs inflammation). His PCP treated with TRAMADOL which eased but did not resolved the headaches. On 10 Oct 2006 he transferred healthcare due to financial hardships and for second opinion of chronic health issues. He advised providers in the clinic that his health began to deteriorate in July 2005 with multiple evaluations, tests and procedures,  by providers completed for chest pain, chronic headaches (with and without dizziness), anxiety, fatigue, erthralgia, insomnia, weight gain, memory loss, dyslipidemia and seizure or "black outs". Attempts to obtain records were unsuccessful.  As of 2009 continued comprehensive and detailed evaluations by neurologists, psychiatrists, cardiology, and other healthcare providers have diagnosed him with headaches, PTSD, depression/anxiety disorders, psych-pseudo seizures, and hyperlipidemia. he reported he has been on disability since 2006 for above disorders.  Symptoms: Weakness, seizure disorder, anxiety, fatigue, abnormal sleep patterns, NOS, joint pain, multiple joints, muscle pain, headaches, migraine. nausea w/o vomiting, dizziness, insomnia.