Age: 48.0
Sex: M
Vaccine: ANTH
Symptoms: Back pain, Chills, Dyspnoea, Hypoventilation, Injection site erythema
Clinical narrative: This healthy 50 year-old received his first anthrax vaccination on March 8, 2003 in combination with Hepatitis A #2 and Hepatitis B #2 vaccination and his second anthrax vaccination on March 27, 2003 with reports of common adverse reactions of soreness and redness at the vaccination sites.  Approximately two to three days after receiving his third anthrax vaccination, on April 23, 2003 he awakened feeling feverish (temperature not documented) with cold chills and some muscular aches to the right arm.  Later that morning while on training exercise he complained of sudden difficulty breathing stating he was "unable to catch his breath with increased pain from his right shoulder to back/kidney region."   He was only able to take shallow breaths while sitting forward and straight up.  Lying back or down caused a marked increase in his inability to breathe.  He denies any chest pain, palpitations, nausea, vomiting, sweating, abdominal pain or headaches. (Of note: He received his Smallpox vaccination on March 13, 2003, one month prior to onset of breathing difficulties.)   He was transported to the medical clinic and subsequently to Hospital for admission of possible myocardial infarction, SARS or pneumonia.  He reports his breathing slowly improved over the next 5 days after numerous inline and antibiotic treatments.  He was discharged with an unknown diagnosis from the civilian hospital with follow-up with Physician Assistant advising him he had had pneumonia.  He was instructed on breathing exercises and the use of an Albuterol inhaler with resolution of the breathing difficulties over the next two weeks.  He was then deployed for one year. He states he still had periodic muscular aches and pains to his right shoulder and arm varying in degree and intensity per activity performed.  He received his 4th anthrax vaccination on September 25, 2003. One week later he again reports difficulty breathing with congestion and cold-like symptoms.  He was treated with inhalers and antibiotics for 2 weeks with resolution of these symptoms. He further stated he had had a constant burning sensation to the right upper abdomen radiating to his back. He was advised to follow-up with medical once back in country for a full evaluation.  A recent endoscopy reveled he had "3 esophageal ulcers and 3 ulcers in his intestines", and an ""ultrasound showed a normal gallbladder".   With his return May 2004, he continued to voice persisting discomforts to his right upper shoulder and arm that were now radiating to his left arm. He describes this right arm discomfort as a sharp, gripping, pull-like pain that began just below the right shoulder in the deltoid area where the 3rd anthrax vaccination was given.  This pain currently occurs "24/7" without relief on a scale of 4-5/10 at rest that he just tolerates (as of September 13, 2004).  He states this pain interferes with normal activities, such as: limiting the amount of weight he can pick up or pull (groceries, books, wood, etc); he drops or misses glasses when reaching for or tries to pick up when his arm is extended; he cannot do yard work requiring arm extension or lifting for more than five minutes due to the pain, he cannot use a weed eater due to the vibrations causing severe pain, etc.  Over the last 3-4 months his right upper arm pain has developed a radiating sharp tingling pain extending down the posterior side of his right forearm into his 4th and 5th fingers with similar burning sensations developing in the left anterior wrist and shoulder.  About June 2004, he began to notice reddish spots on both his hands and forearms that looked like "splotches and bright red dots," numbness and tingling to the left foot, diminished duration in walking distances greater than 100 yards or climbing more than 5 stairs without leg pain and fatigue, and problems with his short-term memory. He also reports "sores on back of neck that itched" just below hairline from shoulder to hairline since August 2003.    He associates his memory loss with difficulty in remembering names or comments and forgetting objects or tasks heading for. He reports his wife stating there was a large difference in his memory retention abilities compared to prior to going to versus his return.    He has seen multiple physicians and providers for these concerns with numerous labs, x-rays and MRI scans.  He was advised he initially had carpal tunnel syndrome and placed in wrist splints with an exercise program then had arthritic changes and now has rotator cuff problems.  He has been referred to neurology, orthopedics and now infectious disease.  Because his physicians have him documented as "medical", he has been unable to return to full active duty and thus has problems maintaining an active versus a reservist activation status.