Age: 21.0
Sex: M
Vaccine: ANTH
Symptoms: Flushing, Mouth ulceration, Photophobia, Rash macular, Skin discolouration
Clinical narrative: Multi-system ongoing clinical rx. Multiple skin lesions: develops painless, non-pruritic, raised, circular lesions in various locations including UE, LE, chest, back and abdomen. These lesions range in size with the largest the size of a "pencil eraser." He has had 2 of the lesions removed and pathology results indicate "of unknown ideology." Pt can identify no pattern nor association to their appearance. New lesions appear monthly. Since he has not been given a diagnosis or treatment for these lesions and he believes them to be cosmetically disfiguring, he regularly removes these himself with "escharotic salve" from a complementary medicine manufacturer. Generalized eczema: since 1999 has developed total body eczema and new allergies to OTC soap and detergents. Reports he now has a flushed look overall and dermatographic skin. He has had 2 instances in 2001 and 2000 of acute allergic dermatitis of unknown ideology, which encompassed the entire body and necessitated systemic steroid treatments to resolve. Multiple cystic lesions: has developed numerous cysts ranging from "quarter to eraser-size" on arms and "half dollar-size" on chest. They extended the width and breadth of the chest and down biceps bilaterally. They are tender to palpation, do not change size, are not visible on the surface. Was told it was "breast tissue" by civilian MD. Photosensitivity: skin burns more rapidly when in sun. Also develops "beet red" color of the skin when exposed to fluorescent lights. This discoloration fades when is removed from the lights. He regularly "appears flushed." He experienced 1 incident in Nov 99 of "all of my skin burning." Was seen at that time by the VA who was unable to diagnose or treat the condition; symptoms resolved spontaneously in 3 days. Also has "white blotches" on arms, hands and palms since summer 99, which "come and go." Some of these discolorations have "a tiny red dot in the center." Photophobia: began in late 99. An ophthalmologist told pt he has "unusually large pupils." Reports he also sees halos at night and his eyes burn frequently. Bilateral knee pain: continuous, began 8 mo ago. Walking0 aggravates the discomfort and states he can no longer run. Palpilations: began in 2000 "feels heart beating in the neck." These episodes last 2-24 hours. They are not related stress, anxiety or any other identifiable factors. Intermittent axillary tenderness: axilla became tender to palpation 2-3xs in 2000. Symptoms were not associated with fever or systemic illness. Received no treatment, symptoms resolved spontaneously. Intermittent tinnitus: lasts minutes to a few days since 2000. Reports this is sometimes unilateral, sometimes bilateral. Has not had an audiology evaluation. Change in bowel habits: reports loose stools 2-3x week, with occasional diarrhea and abdominal pain. Intermittent discoloration of hands: since 2000, hands" turn purple and cold" when pt stands and hands hang to the sides. Symptoms resolve when pt changes hand position. Chronic fatigue: feels ongoing lack of energy, often sleeps 12 hours/day. History of seizure: states this occurred x 1 in 2000 and paramedics were called-lost consciousness, hospitalized x 1d. Received no follow-up care. Mouth lesions: since fall 2001, has developed painless lesions on left tongue, lower buccal mucosa, and under the tongue. Oral surgery consult pending. Left leg tremors: has periods of leg "shaking uncontrollably," usually when driving occurs 1-2x week.