Age: 26.0
Sex: M
Vaccine: ANTH, HEPA
Symptoms: Swelling, Syncope, Tenderness, Thirst, Tremor
Clinical narrative: This 32 year-old was reported to be in good health prior to developing Ross River Virus after being bitten by a mosquito while stationed overseas in February 1997.  He states his initial illness lasted four days with symptoms of myalgia, arthralgia starting in his left hand that spread to his hands, elbows, knees, and ankles bilaterally with severe fatigue.  He does not remember having a high fever (99-100), but he did notice a small red raised rash on his right second finger that gradually spread to his entire body that was non-pruritic.  His symptoms returned later in April 1997 with severe fatigue, diffuse muscle and joint pains, and low grade fevers from 99 to 100.5 maximum per the patient. He had one episode of syncope while running in April 1997 with no diagnosis made.  He states he was put on 5 days quarters, and then ended up taking leave and stayed in bed for "a whole month".  He stated these symptoms persisted over the next 3-4 months with a weight gain from 195 to 235 pounds.  He stated the fatigue and myalgias caused him to sleep 18-20 hour intervals with fatigue upon awakening.  He had difficulty completing assigned physical training until December 1997.  At that time he was finally able to complete a 12 mile road march in less than three hours, run four miles in under 26 minutes, and passed the APFT.  His medical records document a diagnosis of "viral illness" with the service members reporting he was diagnosed with "Dyshidria eczema".    He continued to seek medical attention over the next few years for intermittent exacerbation of polymyalgia and polyarthralgia complaints with and without fatigue (see medical records below).  His symptoms would flare up every 2-3 months triggered by stress, cold, etc. and last for 3-7 days.  Sometimes these flare ups were incapacitating requiring bed rest while others he could work through.  He was treated with Tylenol, Motrin, Ecotrin or Tolectin with initially good then poor results. Indocin was also considered. During June 1998 - May 1999, he began to repeatedly voice concerns over his inability to sleep due to the increasing neck, back, knee and elbow pains with morning joint stiffness.  He was given a trial of high dose prednisone 40 mg daily for one month in June 1999; however he experienced problems with gaining an erection, shakes, palpitations, chest tightness and shortness of breath.  He reports a self taper with decreasing tremors but felt numb all over.  He was also being treated for depression associated with a divorce and was following up with community mental health workers.    He began receiving his Anthrax (AVA) series on 02 February 1999 along with his first Hepatitis A vaccine.  He reported his "arm" became red, swollen and tender with cervical lymphadenopathy for two weeks with worsening myalgia and arthralgia.  He received his second AVA vaccination on 16 February 1999 with reoccurring and worsening myalgia and arthralgia for several days.  He stated his muscle aches, arthralgia and fatigue diminished between July  December 1998 while in school.  This was the last time he reports actually feeling "healthy".  His third AVA was 02 March 1999 where he reports developing a fine red rash that bled when scratched with no open cuts and periodic nose bleeds without any known illness, injury or trauma. He complained of multiple joint pains to his hands, elbows, and neck.  He reports being unable to open soda bottles due to lack of strength and inability to grab the bottle and turn.  His hands were intermittently red and swollen but upon medical evaluation he was advised they were normal.  He stated he was unable to pass the two mile run as he would begin to see spots, developed chest pain, and passed out falling to ground.  He reported this has occurred three times lasting a few minutes to 15 minutes.  He states his chest hurt (6/10 scale) when he breathed that resolved with leaning forward and not deep breathing.  He was transported once to a clinic where he was advised he was dehydrated and given IV fluids with positive orthostatic tilts.    He denied any fever, illness, cough or chemical exposure.  He described the chest pain to a previous experience of costochondritis.  These symptoms persisted for 2-3 days as "tolerable but uncomfortable".  He reports having "normal PFT's" and advised he had asthma which was induced by the climate change.  He did not have any cardiac diagnostics performed.    His fourth AVA was given 01 September 1999.  He reports exacerbation of existing fatigue, myalgia and arthralgia over the next few months while under review by a medical evaluation board (MEB) for acid reflux which was later appealed and terminated after a diagnosis of Ross River Virus was identified.  On 13 December 2000, "the patient is determined fit for active duty and disposition will be made in accordance with the provisions of paragraph 4-24, AR 635-40".   He re-enlisted as an Apache electrician.    Since the year 2000 to present day, this service member continues to have exacerbations or "flare-ups" of his chronic fatigue, myalgia and arthralgia.  He reports his hands are mainly affected with radiating pains to other major joints.  He was given a permanent P3 profile for PT addressing no running, bike for PT, performs PT at own pace and ability when having pain.  He was evaluated for subfertility in 2001, diagnosed with depression in 2002 secondary to a divorce that was treated with Zoloft with adverse events and stopped; chronic fatigue, myalgia and polyarthralgia in association to the Ross River Virus infection; GERD (pre-existing); positive PPD treated with INH (2004).   He was evaluated for hypothyroidism and diabetes in 2003 with complaints of increased thirst and urination and weight gain of over 20 pounds in 2-3 months. There was comment made to a possible exacerbation of symptoms in association to the anthrax vaccine and it was recommended he not receive further anthrax vaccinations (15 Jan 2000 and 10 Jun 2003). He reports his deployments made him feels better due to the flexibility in work-rest schedules.   Upon his return in February 2004, he reports exacerbation of his symptoms and was referred to a rheumatologist and ENT specialist.  A Rheumatology evaluation in 2000 diagnosed him with chronic recurrent polyarthralgias, myalgias, fatigue, etc, that was consistent with Ross River virus infection.  Further scheduling for the year 2004-2005 is pending. He uses 4800 mg Motrin daily for neck and joint pain.  A previous diagnosis of "sleep apnea" was re-termed "upper airway resistant syndrome" per sleep apnea studies completed in 2003.  A cat scan of his sinuses showed right nasal septal deviation with bilateral mucosal hypertrophy and chronic maxillary sinus floor MPT.  His tonsils and adenoids remain intact. He has recently undergone a nasal septoplasty and bilateral IT coblation 16 November 2004.