Age: 46.0
Sex: M
Vaccine: ANTH
Symptoms: Joint swelling, Lumbar puncture, Memory impairment, Musculoskeletal stiffness, Nausea
Clinical narrative: Patient who received anthrax vaccine on 21 May 2010, around 1400 or 1500. He thinks the vaccine was administered in his left arm. After his evening meal, he noted some redness, swelling, and soreness surrounding the vaccination site, and he reported a knot at the site which was about the diameter of a golf ball. All of these local symptoms resolved after 1-2 weeks. Within approximately 3-hours of vaccine receipt, patient noted abdominal cramping, nausea, and frequent soft stools. He vomited 3 times over the next 48 hours. The following evening (Sat, 22 May), patient developed some shortness of breath and chest discomfort. He also experienced pain in his hips and knees to the point he could barely walk and noted his knees were red and swollen. By Sunday, 23 May, patient was also experiencing stiffness in his elbows and shoulders. Throughout the weekend, he experienced fatigue and generalized weakness. He describes intermittent episodes of "trembling" which are difficult for him to describe, but in addition visible trembling of hands, patient felt like his whole body was trembling. He reports episodes of cold sweats alternating with feeling feverish. Patient developed a persistent headache with associated nausea, phonophobia, "tunnel vision" and photophobia which increased in intensity over a 24 hour period, leading him to seek evaluation on 25 May 2010. At the time he was evaluated by Preventive Medicine, his blood pressure was elevated and he was tachycardic. He was transferred from the Preventive Medicine Clinic to the Emergency Room where a lumbar puncture was completed and patient was administered TORADOL, REGLAN and DILAUDID. At a follow up visit on 26 May, his headache and weakness had improved and his GI-related symptoms had resolved. He was prescribed a 5-day course of Prednisone, but patient recalls taking Prednisone for a total of 10 days. Patient reports his symptoms almost subsided within 4-5 days of starting the oral steroids. Due to the severity of his reaction, his deployment was delayed, but patient was cleared for deployment following a follow up evaluation on 7 July. At that time patient reported "feeling better" and he was off all medications. He reports that he never did return to his baseline and describes that he felt "gamey". Patient was evaluated again on 16 July 2010 (approximately 10 days after deployment, 54 days post-vaccine receipt) for a 2 day history of chest pain and dyspnea with sudden onset. Patient also reported flu-like symptoms (fatigue, headache, body aches, and nausea) during the week prior to onset of chest pain. He underwent an extensive evaluation including admissions to hospitals. He was then transferred stateside. Since coming stateside, his evaluation has continued at other hospitals. Patient reported feeling well on the days of and days prior to vaccinations. He denied allergic reactions to drugs, foods, latex, and insect stings. He denied other known exposures prior to vaccine receipt. No prior vaccine reactions. On day of vaccine receipt, he denies flushing, itching, angioedema, rashes/hives, wheezing or swelling of the throat. Patient received Anthrax and typhoid vaccines on 13 April 2010. He does not recall which arm each vaccine was administered, but he denies significant local reactions at vaccination sites. Patient reports he experienced mild flu-like symptoms for approximately one week. Dyspnea-Constant, seems to be related to chest pain. Dyspnea worse with exertion. Unable to walk 1/4 mile. Had recent trial of Prednisone as his symptoms had responded to prednisone in the past, but no significant improvement with this 2-week trial. Chest pain-Almost constant. Described as a dull pain located "inside my chest cavity". Pain intensity is typically 3-4/10 using pain scale of 0 (= no pain) to 10 (= worst pain ever experienced), but prior to coming stateside, intensity was typically 7-8/10. Pain does not change with changes in position, but is increased with exertion. Has period brief episodes of sharp, intense pain usually lasting about 5 minutes. Headaches-Has constant dull aching headache which he describes as tolerable. About 2-3 times/month, experiences sudden onset headache behind the eyes, extending across top of skull. This headache "hurts like hell" and is rated as 10/10 using pain scale. These headaches are associated with nausea, photo- and phonosensitivity, as well as visual changes described as "tunnel vision"and also sees stars, wavy lines and compares vision to "blurry TV". Has had a number of medication trials. Says at this point, he would rather deal with the headaches than to take medications. He does continue to take MAXALT with sudden onset headaches, which takes the edge off the pain, and then with rest in quiet room, over 12 hour period, headache is usually resolved. Fatigue-Intermittent episodes of feeling "exhausted". Reports having near baseline energy levels on some days, but energy usually decreases after activities. No episodes where patient has been bedridden due to fatigue. No associated arthralgias or myalgias, chronic swollen glands or sore throats, recurring fevers, or depression. Reports forgetting things more than (he) used to. He does not get restful sleep and will be completed sleep study this month to rule out sleep apnea.