Age: 41.0
Sex: M
Vaccine: ANTH, HEP, SMALL, ANTH, HEP, SMALL
Symptoms: Injection site erythema, Injection site pain, Injection site reaction, Joint stiffness, Laboratory test normal
Clinical narrative: This case was received on 09 August 2010 via a QScan search on the VAERS database, under reference number 386666.  A 41 year-old male patient had received the following vaccines on 05 October 2008: a percutaneous ACAM2000 (lot number 4020076), a dose of BIOTHRAX, manufacturer Emergent, lot number FAV158 (route and site unknown), and an intramuscular injection of RECOMBIVAX HB manufacturer Merck, lot number 0399X (site unknown).  The patient had no concurrent illness.  Within 20 seconds after receiving the above vaccinations [also reported as after receiving the AVA (anthrax vaccine), and occurring on 08 October 2010], the patient experienced severe burning to the site as if he had been "hit by a bee" that resolved to a sore arm (pain score 3-5 out of a score of 10) about 15 minutes later.  However, bystanders noted his complexion went white.  He sat down and was monitored for 15 minutes until complexion was normal.  He denied any dizziness, nausea, visual changes, chest pain, difficulty breathing, or any paresthesias.  Approximately one hour later while driving home, he began to feel achy, sick with generalized joint and body aches, headache, and his throat was sore.  He had swollen neck lymph nodes bilaterally.  That evening (less than 12 hours post-vaccinations) he developed a fever of 100.5 degrees Fahrenheit with increased malaise, body aches, muscle weakness, and nausea (no vomiting).  He slept fitfully awakening about midnight with difficulty breathing, and had a sore throat, and sensation of his throat closing.  The patient reported his uvula was red and swollen.  He was evaluated the morning of 06 October 2008 by his primary care physician who noted 2+ uvula swelling.  The patient's weight was 212 pounds and his temperature was 98.6 degrees Fahrenheit.  The patient was prescribed Claritin, Benadryl, and Medrol dose pack for presumed allergic reaction.  Follow-up evaluation 3-4 hours later (06 October 2008) documented continued complaints of a sore throat (but better) without difficulty breathing, fever 100.5 degrees Fahrenheit, body-joint aches, severe muscle weakness, and axillary lymph node tenderness.  The patient's exam documented: temperature 98.1 degrees Fahrenheit, weight 213.2 pounds; a deviated septum; hyperemic; mildly edematous uvula, normal tongue with cobblestone appearing pharynx; AVA vaccine site was mildly hyperemic with dressing to SPV site, and normal Hep B vaccine site; left axilla was mild-moderately tender to palpation without swelling/nodules; otherwise exam was normal.  Neuro and musculoskeletal exams were intact with normal reflexes and without weakness.  The patient was diagnosed with axillary lymphadenopathy and allergic reaction to anthrax vaccine.  No further AVA vaccine was recommended.  Over the next week (6-12 October 2008) the patient was unable to work and complained of increasing weight gain.  Additional adverse events of abdominal pain, fatigue, dyspnoea, and diarrhoea were coded by VAERS but not mentioned in their narrative.  These events were added to the coding and narrative above.  The patient has not recovered.  Laboratory data: Labs completed on an unspecified date: Antinuclear antibody (negative), blood cholesterol (increased), Lamine aminotransferase (normal), blood immunoglobulin G (normal), blood immunoglobulin M (result not reported), thyroid stimulating hormone (decreased), blood triglyceride (increased), C-reactive protein (Normal), computerised tomogram (abnormal), stool culture (negative), differential white blood cell count (abnormal), flow cytometry (result not reported), and full blood count (normal).  Labs completed on 22 December 2009: 2009 CBC, SGPT, UA and CMP were all normal with Cholesterol 209, triglycerides 296, HDL 38, and TSH 5.692.  Labs completed on 19 January 2010: CBC, renal function tests (normal), ESR (normal), SMA12, LFT, ANA negative, RF 9.5 (normal), CRP 0.7 (Normal), Flow Cytometric and analysis peripheral blood shows heterogeneous.  Other medications: The patient had none prior to vaccinations, but post-vaccinations was administered Toprol 25mg daily, Imitrex (prn), Lisinopril, Synthroid, Tramadol, Cyclobenzaprine.  Medical history: Recurrent aphthous ulcers to soft palate (1986), high frequency hearing loss right ear (1998), pneumonia times 4 (1994-2000), chronic lower back pain and new onset headaches (2001), hypercholesterolemia (2002), diagnosed hereditary spherocytosis (2002), anxiety, MVA multiple injuries/fractures, ulnar nerve entrapment (2004, 2005, on Wellbutrin), hypertension (2006, medications used in 2010), and migraine headaches (2006).  Documents held by sender: None.