Age: 37.0
Sex: F
Vaccine: ANTH
Symptoms: Myalgia, Nausea, Nuclear magnetic resonance imaging brain normal, Pain, Pain in extremity
Clinical narrative: 43 y/o patient queries website (07JAN13) regarding her diagnosis of chronic migraines and fibromyalgia following receipt of 6 anthrax shots from 07DEC03 to 12JUN09. Onset of chronic daily HA's/ myalgias after AVA #5 on 24AUG07 and AVA #6 (12JUN09). Two "black-outs" in JUN 2007 and MAR 2008. Three episodes of sudden dizziness a/w visual "static," rapid HR, sweating, nausea, blacking-out (02JUL09 / JUL 2012 / DEC 2012) s/p receipt of AVA#6 (02JUN09). Of significance, patient reported suffering a mild concussion in theatre (19DEC06), when the AAV she was riding in was going too fast and swerved to avoid an obstruction and jumped off the tracks with significant force. The left side of the vehicle hit a wall and she was airborne from her seat and flew forward into the side of the vehicle head first. The patient was wearing her helmet and safety glasses at the time. She chipped the right lens of her safety goggles, but denied any true LOC. She experienced immediate dizziness and was dazed, disoriented and confused for several days afterwards. Her dizziness persisted, unabated x 1 month and then began to subside. Patient saw a medical provider in theatre x several months, but was never placed on light-duty or "pulled from going outside the wire." (Theater records not available for review). Patient returned in MAR 2007. Patient first sought medical evaluation of dizzy spells on 02NOV07 when she c/o "severe dizzy spells occur few times a week and last a few minutes, which occurred with walking or sitting and suddenly moving head. Negative non-contrast CT of Head performed. (09NOV09) Ref to CIV neurologist (Normal EEG (29OCT09) and negative unenhanced MRI of Brain (30OCT09). Dx: Muscle contraction / Vascular headaches. Recommended a low-glycemic diet, on which patient endorsed more energy and being able to walk her dog x 1 mile. (MAY 2010) patient developed Shingles, which began with a prodrome of muscle aches and pain x 2 weeks prior to onset of an exquisitely painful rash and blisters, which wrapped around her right arm. Patient was seen at clinic (no note available). "After shingles, I could barely get off the couch for a year...I experienced a kind of paralysis, couldn't move. I had head-to-toe horrible epidermal pain all over my body and on my arms." Patient rates her whole body pain at that time as "15" on a scale of 0-10. She had to take codeine for pain relief. Her Command was very understanding and let her take a lot of time off and did not make her drill. Prior to developing Shingles, she ran 3-4 miles a day. (30DEC10) Self-referred to MD (CIV Neurologist) for consultation regarding her history of shingles and headaches. After patient recovered from the shingles rash and blisters, she developed severe aching pain of her right arm. She experienced fatigue with any physical activity or stress at home or work, exacerbating "full body aches and pain." Just stirring would cause pain and weakness of her right arm. Even the thought of touching her skin was painful. Her sleep was poor and she noticed changes in her memory and difficulty remembering words. Per record review, the patient reported her onset of headaches to Dr. following two head injuries: (19DEC06) and (02JUL09), when she experienced a concussion and laceration of her scalp associated with an episode of dizziness and syncope, while working. The patient intermittent dizziness and described her HA's "like an ax on the top of my head." she also endorsed + photophobia. Dx: 1. Likely fibromyalgia; 2. Headaches (?) Migraines. PLAN: SAVELLA, subsequently increased to 100mg q AM / 50 mg qhr at next visit. (28MAR11) patient referred to MD (CIV Neurologist) for Botox injections in scalp for treatment of chronic migraines. At that time patient endorsed HA's occurring >10 times a month, since receipt of AVA# 5 (24AUG07). Patient initially experienced a dramatic improvement in her pain with after 1st Botox treatment; however after the 2nd, she still experienced frequent migraines. "Patient's HA's typically begin at the top of her head and radiate bilaterally to her temples and to the back of her neck; + phono/photophobia- can't look at a computer screen for very long. Occasional nausea w/o vomiting and 'ice-pick jabs.'" Patient cannot identify any food or other triggers; + clustering of HA's x 3-4 days. She has been tried on a number of different medications and currently takes Nadolol daily to block her HA's and MAXALT for crisis/rescue. F/U's with Dr. on 23NOV11 and 21FEB12 for Botox injections, after which Botox injections were temporarily suspended due to insurance issues. (12SEP11) F/U Dr. (Neuro) "She has had a tough summer in regards to fibromyalgia- when she pushes herself, her pain increases." Dx: 1. Fibromyalgia triggered by Shingles; 2. Migraine HA's- under treatment. Had to stop Botox injections secondary to insurance issues and cost. PLAN: SAVELLA increased to 100mg qAM/ 100mg qhs with Promethazine 25 mg po qhs for nausea/sleep. F/U's Dr. for E&M Fibromyalgia / HA's: 19SEP11, 23NOV11 and 05MAR12- endorsed symptomatic improvement with "low GI diet;" (19APR12) not much response to Botox in February. Had to stop TOPAMAX due to cognitive issues. 2 HA's a week- taking Naproxen and TYLENOL. Has MAXALT, but causes sedation. Reports dizziness (vertigo) that has been increasing. Fibromyalgia doing well- cut back SAVELLA to 100mg qAM/50mg qhs. Start BYSTOLIC 2.5mg qd > bid if needed; (05JUN12) BYSTOLIC effective for HA's, but patient reported significant palpitations, which improve with sitting up. Pt notes that when she "overdoes things" with her right arm, she gets a severe migraine. Currently take ALEVE qod to stop HA's. She has had to increased SAVELLA to 100/100 because of overall pain and takes PHENERGAN at night to help with sleep; (09OCT12) Migraines have increased in frequency and severity- had migraine which lasted 6 day last week- had to take MAXALT x 6 days. Migraines characterized by throbbing pain "7/10," with photophobia and nausea. States she would like to fully wean off SAVELLA, which she feels is main contributor to her more frequent migraines. Currently taking 2 dose of ALEVE every day for HA's and had to use MAXALT 14 days in the past 30 days--> IMPRESSION: 1. Fibromyalgia triggered by Shingles- under good control; 2. Migraine- intractable. PLAN: Decreased SAVELLA to 50 mg qd- if doing ok in 3 wks can D/; continue PHENERGAN 25mg po prn nausea and nightly for sleep; continue BYSTOLIC 2.5 mg qd. May d/c once HA's under control; MAXALT for rescue and naproxen and TYLENOL; MEDROL DOSEPAK; start Amitriptyline 25 mg po qhs. (14NOV12) Ref by Neuro to CIV Cardiologist. Normal EKG. Patient wearing 24-hr Holter Monitor at time of LD interview with NP. Provisional Dx: "Neurocardiogenic Syndrome," patient scheduled for a f/u visit w/ Dr. on 21JAN13 to review the results of her testing w/ him. (See 14 and 21JAN13 notes by Dr. below). (17DEC12) Ref to MD (Civ Neuro) 43 y/o with hx of TBI, headaches and fibromyalgia. Seen previously by Drs. Pt c/o increased frequency and intensity of HA's "moderate to severe headaches at least 15 days a month, lasting at least 4 hours...she has tried and failed several preventive medications, including, but not limited to anticonvulsants (TOPAMAX- experienced mood changes), beta blocker (BYSTOLIC), antidepressants (Amitriptyline), therefore, she is a candidate to re-initiate Botox treatment, approved by FDA for management of chronic migraine. Dx: 1. Chronic Migraine; 2. Migraine with and w/o aura, intractable; 3. Palpitations; 4. Syncope; 5. Fibromyalgia. PLAN: 1. Recommend Botox inj q3months --> We will aim for at least 50% improvement. She will be re-evaluated and, if ineffective, after 2-3 treatments, Botox will be discontinued; 2. In view of the complexity of this case, recommend referral for evaluation and comprehensive multimodality treatment, pharmacological (IV infusions) and non-pharmacological treatments, including PT with trigger point massage, neuromuscular re-education and psychotherapy. (21DEC12) Ref to Dr. (Neuro) on 17DEC12- started on Nadolol. She will also re-evaluate for Botox. She reports a history of vertigo and Dr. feels this is related to her HA's. She was told to undergo vestibular testing and she would like to do this. She reports having several episodes where she passes out. She's had about 5 episodes. The last one occurred 2 weeks ago. She stated she will get a sensation of feeling anxious and as if she is crawling out of her skin. She then develops cold sweats and palpitations. If she does not lay down, she passes out and has actually hit her head a few times. With the last episode she was able to lie down and abort the attack. She continues to take PHENERGAN at bedtime. IMPRESSION: 1. Fibromyalgia triggered by Shingles- under good control; 2. Migraine- intractable- followed by Dr.; 3. Vertigo- likely related to migraines; 4. Episodes of passing out like syncope. PLAN: 1. Continue SAVELLA 50 mg twice a day; 2. Refer to CARDIOLOGY to be evaluated for syncope; 3. Refer to Dr. to undergo ENG testing; 4. Continue PHENERGAN 12.5 mg at night; f/u in 2-3 months. (21JAN13) F/U MD (Neuro) Pt returns for review of recent Cardiac Testing for evaluation of her recent syncope. Her echocardiogram was WNL with normal ejection fractions and no significant valvular lesions. Holter Monitor showed occasional PAC's only. She has had no syncopal spell since the previous visit here. Physical Examination: BP 90/60 sitting decreasing to 80/70 standing. IMPRESSION: Pt has a neuro-cardiogenic syncope possibly related to previous head trauma. She has mild postural blood pressure changes at this time which did not cause symptoms. PLAN: I would consider using other medications to treat her migraine headaches other than Nadolol, as this may be contributing to this problem. She will return on as-needed basis for reassessment of her cardiac status. (15FEB13): 3-way LD teleconference (TC) conducted with patient to review pt's symptoms with regard to possible autonomic dysfunction. NP has worked closely with Director in the E&M of many patients with symptoms of Chronic Fatigue and Dysautonomia in temporal association with receipt of Anthrax (AVA) series. Pt filled out "Symptoms of Dysautonomia Checklist" prior to TC. Pt responded "Yes" on checklist to + dizziness/lightheadedness, especially upon standing, HA, muscle pain vs. joint pain, extreme fatigue, exercise intolerance, cognitive slowing/memory deficits, sleep disturbance, abnormal sweating and palpitations. NP reviewed the checklist in detail with patient and noted that, based on the pertinent positives which the patient endorsed on the checklist, the pt appears to meet the diagnostic criteria for Chronic Fatigue Syndrome (CFS) more than Dysautonomia. The patient was diagnosed with Fibromyalgia in DEC 2010, following a very debilitating case of post-herpetic neuralgia, which began after she developed Shingles in MAY of 2010. Dr. and the other Civilian Neurologist who evaluated the patient all were in consensus in their assessment as "Fibromyalgia triggered by Shingles." The pt has not been formally diagnosed with CFS, but the diagnosis of Fibromyalgia and CFS are closely related and often go hand-in-hand. The patient has a well documented history of a TBI while deployed on 19DEC06. Her CIV Neurologists are all in agreement concerning a causal relationship between her TBI event and the onset of the patient's headaches, dizziness and syncope/near syncopal episodes. Vaccine Causality is a diagnosis of exclusion, given the absence of other possible underling disease. NP noted that pt's episodes of dizziness/near syncope/syncope seem to be well-defined, but that these sx would occur all the time with a diagnosis of Dysautonomia, but perhaps not to the degree of blacking-out or losing consciousness. Thus, the pt's episodes of dizziness/syncope/near syncope and her HA's seem to favor an association with the patient's TBI event, which took place on 19DEC06, while the patient was in theatre, serving in Line of Duty.