Age: 26.0
Sex: M
Vaccine: ANTH
Symptoms: Diarrhoea, Dizziness, Fatigue, Feeling hot, Flushing
Clinical narrative: This 27 year old reported great health prior to receipt of 2 Anthrax vaccinations 13 October 2004 and 28 October 2004 while deployed April 2004 to February 2005. Other vaccinations received during this time period included a primary smallpox vaccination 03 Mar 2004, Hepatitis B #2 15 Mar 2004, Influenza vaccine 06 Dec 2004 (records 2 vaccines one month apart), and Hepatitis B #3 with a PPD on 24 Feb 2005.  He remembers no atypical adverse events immediately following receipt of either anthrax vaccine. However he began to notice a decline in his health from November 2004 to February 2005 listing gastrointestinal discomforts as runny diarrhea five times a day for several weeks with a rumbly stomach, denied nausea, vomiting, indigestion, or bloody stools. Other symptoms unexplained included headaches, back pains, dizziness, and generally feeling bad-fatigue. His duties included numerous marches with various weighted packs and body armor. He was a marathon runner and a "lanky guy". He reported his height as 71.5 inches weighing 175 pounds 11/29/06. He attributed many symptoms to his environment and secondary to doxycycline for malaria prevention. His diarrhea resolved a few weeks after relocation and changing from doxycycline to Primaquine. While at facility March/April 2005 he experienced dizziness and difficulty breathing after walking up a flight of stairs that did not resolve. He presented to the base emergency room, was evaluated and sent home with no known diagnosis (medical records unavailable). He was also being treated for mole changes on his back with three excised and biopsied ("benign"). Concurrently a temporary dental fracture repair completed prior to deployment failed while overseas was repaired with dental surgery and a permanent crown @ Mar/April 2005. He denied any illness, fever, pain, problems chewing, but did c/o intermittent palpitations once back home (2005). He reported a prior incidence of palpitations in March/April (deployment ceremony) 2004 described as his "heart jumping out" and he could feel his heart beat. These symptoms lasted a few seconds every few weeks. He denied any shortness of breath, sweating/diaphoresis, nausea, vomiting, weakness or dizziness. No medical treatment was sought. Meanwhile previous feelings of fatigue, body aches, back pain/spasms (cervical, thoracic, lumbar) with radiating neck, shoulder and right buttock pain, and headaches continued as he performed normal activities and exercise regime. He listed symptoms of cervical, thoracic, lumbar back pain with intermittent radiating pains to his right shoulder, buttock and headaches since April 2004. He initially described a non-radiating "freezing pain" with intermittent sharp bilateral pains to the lumbar region lasting several hours, 2-3 times a week, pain scale 8-9/10 triggered by prolonged standing, sitting, bending over, restricted movements in helicopters with body armor on, etc. He denied any bowel or urinary incontinence. These discomforts have worsened over the last several years with intermittent radiating spasms/pains to his head and limbs. He continued to believe his aches and pains were insignificant associating them to activities of daily life and tried not to think about them. During his deactivation physical in July 2005 he recorded problems persisting with his back, mole biopsies, and repair of a dental fracture that occurred while overseas which required a crown and tooth extraction. Evaluation of neurological complaints of dizziness, syncope, headaches with coinciding arthralgias began in earnest approximately July 2006 with worsening symptoms. While standing in line, he reported a sudden inability to stand, difficulty with balance due to dizzy feelings and "felt like he wanted to pass out". He felt hot and flushed without any other symptoms identified. This lasted a few moments but has gotten progressively worse as of December 2006. He reported periodic feelings of heaviness in his legs. From June until December 2006 he stated syncopal feelings were attributed to stress at work, health problems, graduate school, military/home responsibilities, and prolonged standing (over 1-2 minutes). He recalled one previous syncopal episode (feelings of weakness and dizziness) in April 2004 during his deployment ceremony (standing in full gear) where he needed to sit that resolved within 10-15 minutes that was never evaluated.  In July-August 2006 he reported to the clinic with complaints of right sided headaches lasting 2 days every few weeks with decreased range of motion while turning his head to the left and having a stiff neck in the morning. He described these headaches as severe sudden piercing pain upon standing in the middle of his head with throbbing pains that persisted over night and would wake up with. He self treated with Aleve with no response. He reported intermittent "unsteady walking" as his legs were tight without tingling, numbness or pain. These symptoms had been increasing for 3 weeks prior to seeking medical attention. Various physicians documented various complaints of cervical knots, tenderness-pressure to the right posterior-occipital region that radiated to the right frontal and scalp areas and 2 episodes of left hand paresthesia (Dr. Physical medicine and rehab). Exams noted tenderness to occipital attachment ligaments otherwise normal neurological evaluations. An MRI was performed with the neurosurgeon advising "he was too young for thoracic spine wedging seen on the films"..."his spine had protrusions as if in a MVA". The MD recommended cervical epidural injections and physical therapy with a diagnosis of degenerative disc/joint disease. He reported a familiar history (father) with lower back-disc problems and no history of arthritic diseases. As of December 2006 he has radiating right shoulder blade discomfort with no other joint involvement. His primary care physician initiated referrals to a clinic and subsequent referrals to cardiology, neurology, neurosurgery, pulmonary medicine, physical medicine & rehabilitation, anesthesiology pain clinic, physical therapy, and Audiology in November 2006. Laboratory and diagnostic studies included c-spine x-rays, cervical to lumbar spine MRI, EMG, audiometry tests, tilt test, pulmonary function test, a cat scan of head and other studies. Physicians diagnosed vasovagal syncope with mixed vasodepression & cardio inhibitory component, possible postural orthostatic tachycardia syndrome, or neurally mediated hypotension; right occipital neuralgia, cervical myofascial pain, and mild degenerative disc disease cervical and thoracic spine with loss of cervical lordosis. A complete spinal MRI in July 2006 noted disk desiccation C3-5 with mild bulging, osteophytes with foraminal stenosis; T5-9 small bulging discs with lower thoracic wedging; and lumbar lordosis, L1-2 degeneration with minor bulging L1-2 & L5-S1. There were no neural compressions.   He reports being advised by cardiology to increase his water intake after "passing out during his tilt table evaluation" and to use salt tablets and Florinef. He stopped all medications voluntarily following evaluation by "renal heart physician" and was placed on Midorine and Metoprolol. He reported one relapse 2 weeks ago (mid November) after "pushing himself at work and school" and attributed to chronic fatigue. Evaluation by a cardiologist recorded normal vital signs standing/sitting despite sensation of wanting to pass out. Lying supine for a few minutes resolved the sensation but not always. Approximately November 2006 he stopped all medications without physician orders as medications were "ineffective". He reported "feeling better and he did not hear/feel blood flow rushing into his head".  As of December 2006 his main concerns center on returning to work being able to walk from point A to B without falling or passing out. He began to carry/use a cane (Nov 28, 2006) to help maintain his balance when standing still and while conversing with others. He will lean against the wall or hold a near-by object for stability (decrease sensation of passing out). He has been advised of having cervical kyphosis with headaches and back pains, a neuro-syncope disorder and prescribed salt tablets with other medications above, and DDD with wedging. He reports less fatigue since stopping all medications approximately November 2006. He completed prescribed physical therapy about 3 weeks ago. He runs 2-4 times a week for 2-3 miles periodically having to walk home, and then sit/rest for next 1-2 hours. He cannot run 4 days concurrently due to resulting fatigue and interference with work performance. Prior to onset of symptoms in July he could run 5-6 times a week for several miles with minimal post fatigue.