Age: 26.0
Sex: F
Vaccine: ANTH, FLUX, SMALL
Symptoms: Borrelia test negative, C-reactive protein, Coxsackie viral infection, Coxsackie virus test negative, Differential white blood cell count normal
Clinical narrative: This case was received on 20 October 2011 via a third party query tool search on the VAERS database, under reference number 429091. A 26-year-old female patient who was in her normal state of good health, and who had a history of gluten sensitivity had received the following vaccinations on 30 April 2011: ACAM2000 (lot number VV04-003-A), BIOTHRAX (lot number FAV274), and influenza vaccine (seasonal, trade name, manufacture name, and lot number not reported). Prior the patient was totally symptom free. Approximately 24 hours after receiving the Smallpox, Anthrax and Influenza vaccinations, while flying, the patient complained of feeling hot, had mild dyspnea (that felt like she was not taking a full breath), generalized malaise, fatigue, weakness in her fingers bilaterally, and mild queasiness. She denied chest pain, palpitations, headache, abdominal pain, "V/D" (?), rash, wheeze, cough, myalgia, or arthralgia. There was no local reactions at the anthrax or influenza vaccination sites. A pustule formed at her Smallpox vaccination site after a few days and within a week or 2 she had a robust take with axillary adenopathy. The patient described her shortness of breath as a constant sense of not getting enough oxygen. She had no sense of restricted chest wall motion, chest wall pain, laryngeal obstruction, cough or wheeze. The shortness of breath was noted with walking, and most noted with climbing stairs, but was better with lying flat, however, she was still able to run her usual 3-5 miles without difficulty. The patient's joint symptoms were described as feeling as if the fluid in her joints had been replaced with glue. The small joints of her fingers were most obviously involved, but also involved where her metatarsals and neck. To a much lesser degree, the patient felt all joints were involved and most pronounced in the morning and improved with activity. The patient had no joint pain or swelling, no myalgia, or rheumatism. The patient took TYLENOL intermittently for the headaches that also improved the joint symptoms. The patient's post vaccination symptoms peaked at about 5/10 (on a pain scale of 0-10) and slowly improved over the next 8+ weeks. The beginning of June the patient noted a mildly pruritic rash on the nape of her neck and on 10 June 2011 the following laboratory data were performed with results: CBC w/diff: Within normal limits except: Eosinophils 8.5%, basophils 1.1%, and absolute eosinophils 0.41. Additional laboratory data performed on 19 July revealed TSH 1.28, thyroxine 7.53, T3 1.15; negative ANA, RF less than 6.3; CRP less than 5.0, ESR 0, C3D less than 9, TTG IGA/IGG less than 3; and a CBC w/diff that was within normal limits except: Eosinophils 5.3%; a Chem 12 was also within normal limits; Lyme AB total was negative; EBV profile was negative; Hep C AB RIBA was negative; and Coxsackie virus A AB was negative. All of the patient's symptoms totally abated around mid July. It was noted the patient had significant past medical history of symptoms of being hot, dizzy, short of breath, finger weakness, and new onset of hypertension after a head-to-head contact injury playing soccer in 2008. These symptoms persisted for weeks until she underwent chiropractic cervical adjustment for "a disk problem". Intermittently over that next year, she would have waves of feeling hot, air hunger, and hand weakness that became constant but never enough to interfere with her daily activities. She eventually went to a naturopath who after hair and stool analysis informed her that her symptoms were the result of toxic levels of titanium, copper, and "something else", and an unknown parasite and allergy to gluten. At that time, the patient underwent oral chelation and anti-parasite therapy and began gluten avoidance. Following this therapy, the patient associated her only recurrences of these symptoms with accidental ingestion suspected gluten containing foods. With her suspected accidental ingestions, her symptoms would last about 2-3 days. It was noted that her vaccine-associated symptoms, while identical, lasted over 2 months. Documents held by sender: None.