Age: 30.0
Sex: M
Vaccine: ANTH
Symptoms: Oedema peripheral, Pain in extremity, Paraesthesia, Rash, Swelling
Clinical narrative: In July 2003, he reports that he began to experience swelling and pain in his bilateral feet and within the next 2-3 weeks the joint pain encompassed his knees, wrists, shoulders, wrist as well as his feet. He was active with exercise and weight lifting prior to onset. He experiences on-going difficulty with intermittent joint pain which is aggravated by exercise, and relived somewhat by rest. In addition, he developed tinnitus and bilateral ear pain that lasted for weeks and reoccurred in June 2004.   In addition, in July 2003 he began experiencing a rash that he describes as initially looking like bug bites that formed along his waist line. By the end of the first day the rash had progressed to "welts" over his trunk and head. He states that his arms and legs do not become involved in the rash. He states the rash is red, raised and warm to touch. When the rash loses its "swelling" the redness remains for several days. The rash is abated only by oral steroids and occasionally by EPIPEN®.   During recent deployment, he began to experience severe swelling in his feet. In addition, he began to experience severe hives. On July 13, 2004 he reported to the Emergency Department because of severe hives. He reports that the hives started on his chest and clustered moving to shoulder blade, eyelid, base of neck and his throat started to swell. He was given prednisone, intravenous bendryl, epinephrine, intravenous steroids. He was placed in the medical hold barracks for two (2) weeks and was then transferred.   He is currently working as a job bank supervisor. He reports that his hives are getting better and are not coming on daily as before. However he is on six (6) different medications to control his symptoms. He has been worked up for rheumatoid arthritis, lupus, osteoarthritis, hepatitis C, celiac disease, and autoimmune disease, which were all negative.  This is a 31 year old who was in good health until approximately April 2004. He received his primary anthrax on 02/23/03. He denies any nausea, vomiting, diarrhea, fever or chills in association with receipt of vaccine. He received his second injection on 03/08/03. He began to experience severe headaches in early April 2004. He went to the local Emergency Room where he was evaluated and treated for migraine headache. The severe headaches subsided over the following two (2) weeks. Delayed pressure urticaria with chronic idiopathic urticaria and angioedma and associated polyarthralgias, responsive to corticosteroids. Patient decreased Medrol dose to 4mg q day approximatley 2-3 weeks before coming to WRAMC without a significant increase in his urticaria or joint pains. However, he continues to experience intermittent flares of hives primarily on his flank and trunk. He also describes "pressure hive" on his hands and feet that are always associated with activities using his hands or weight-bearing. He has also previously noted "pressure hives" around knees after wearing knee pads. He continues to experience joint pain in all of his hoints (sholders, elbows, wrists, fingers, hips, knees, ankles and feet) with physical exertion or staying in one position for a long period of time, like holding hands on steering wheel or sitting in the same position. Angioedema of hands and associated pain are triggered by physical activity, especially prolonged activity. Last episode of angioedema not involving extremities was on the way to WRAMC; his lips became swollen and tingling; his tongue was also swollen, but his throat did not tighten. Episodes of angioedema involving the face, mouth, and/or throat occur sporadically; episodes occur abot once/month. Patient only uses Epi-pen with throat swelling. He has only used his Epi pen 1 time (self) and a healthcare provider administered epinephrine once this year and 3 times during 2003. Myalgia: In addition to the above symptoms, patient experiences muscle aching in his thighs which started about 2-3 weeks ago when his Medrol was decreased. Along with the muscle aches he describes "soft knots" in his muscles which he notes 2 x/week and resolve spontaneously. Fasciculations: Over the past 1-2 months, patient has noted muscle twitching affectging his eyelid, thighs and upper arms. Episodes occur about 2-3 x/week and last about 1 minute. He has not noted a change in character since onset. Hand tremors: Begin noticing mild hand tremors about 1 month ago. Describes as mild tremors noted when using hands/upper extremities (i.e reaching or holding something). Episodes usually last < 1 minute before resolving spontaneously. No noted change with decreased sleep, stress or changes in medications. Patient does not routinely drink alcohol, so he is unable to tell if his tremors change following alcohol intake. While at WRAMC between 9/23/04 and 9/30/04, patient underwent evaluation by Allergy and Immounology and Pheumatology. On p.m. of 9/24/04 patient did 3 sets of bench presses and reported palmar hand swelling, redness and pain about 6 hours later. On 9/25/04, examination of his hands was notable for angioedema, erythema and tenderness to palpation on his palmar surfaces.  On 9/29/04, patient had provocative presure testing done in the Allergy and Immunology Clinic and had no urticaria or angioedema noted where sling was placed when observed 6 hours after testing. However, when he returend to the VHC the morning of 9/30/04, he reported (and demonstrated) urticaria and angioedema of his left shoulder and left lateral neck (where the sling had been placed with 15 pound sandbag), which was present upon awakening. No significant changes in patient's medication regimen were made while at WRAMC except that Sulfasalazine was initiated. (Because of his reaction the day following Celebrex initiation, the first dose of Sulfasalazine was given under observation