Age: 30.0
Sex: M
Vaccine: ANTH, SMALL
Symptoms: Laboratory test abnormal, Muscular weakness, Night sweats, Pain, Paraesthesia
Clinical narrative: Patient has been experiencing headaches, muscle weakness, night sweats and fever (also notes increased perspiration with minimal effort); chronic fatigue; joint pain; tingling in hands and feet. Received 1st anthrax vaccine on 01/26/03. Vaccine site was tender with a small knot that lasted 3-4 days. He experienced fever and headaches that lasted for 3 days. He denies experiencing chills, fatigue or body aches. Received 2nd anthrax vaccine (right arm) and smallpox vaccine (left arm) on 02/27/03. Denies significant local reaction at either vaccine site. Experienced headaches and fatigue during the first 3-4 days following receipt of vaccines. Denies fever or chills. Within 24-48 hours following vaccine receipt, noted onset of bilateral shoulder pain (R>L). Later, he went on to develop pain in his elbows, wrists, hands, hips, knees and ankles, as well as pain in cervical and lower back. Initially, the intensity was tolerable, but it gradually increased. By late April/early May 2003, the patient sought medical evaluation, primarily for his back pain. He had a history of a lower back strain in 2002 and initially thought he had aggravated that strain, but then realized that it was not the same kind of pain when he started experiencing pain in his upper back and his pain was so intense that it hurt when he took deep breaths. By early May 2003, the intensity of his pain as a level 9-10 on a pain scale of 0-10. Celebrex and Flexeril were prescribed and helped with the pain for about 3 weeks. By June 2003, pain intensified to a level 10 again. He also experienced numbness in his fingers and feet, shortness of breath and chest tightness that radiated to his neck and upper back. When he sought medical evaluation, he was told the pain was not his heart, but his chest muscles (costochondritis). He was placed on light duty for several weeks. In July 2003, he experienced left hand and arm swelling from elbow down; no redness or increased warmth, but joints were sore and his arm was tender to touch. He was unable to spread his fingrs or make a fist due to swelling. The swelling lasted about 3-5 days, but the numbness/tingling never left. He experienced pain in his left ring and pinky fingers, and all other fingers were numb. He also reported numbness and tingling in both feet (R.L) and in his right arm (shoulder down). His left arm was painful, with the pain starting at the back of his neck and radiating down. On his right side, the experienced arthralgia in his in his fingers, hand, wrist, elbow, shoulder and ankle. He was taking Motrin prn for the pain without significant change. This continued through July and the first part of August. By mid-August, he could not sleep due to the arthralgia and he could not carry out any PT (not able to run during April, so changed to walking; by July, not able to walk due to pain)/ He also noted the onset of fatigue in mid-August, and by September, muscle weakness was associated with fatigue. He continued to seek medical evaluation and treatment and was given more Motrin. Between August and October 2003, his evaluation of fatigue and weakness and arthralgia included several visits with an Internist. He had intermittent swelling of his hands when in a dependent position and increased numbness and tingling in fingers. His should and neck pain increased during September, and it was thought that he might have a dislocation; however, his A-C joint was normal on x-ray. In September 2003, he complained of shortness of breath, morning nausea and decreased appetite. After his liver function tests were found to be elevated, additional tests were submitted to rule out hepatitis. (In October, tests had to be repeated due to insufficient sample in September.) In October 2003, physical therapy was initiated for arthralgia in his neck and shoulders. He experienced left side chest pressure, which was not positional, but increased with deep breaths. Evaluation included an ECG, CXR, Chem 6 and Troponin I; he was treated with Toradol 60 mg IM with relief. The pain was felt to be chest wall pain. The chest pain came back 2-3 days later, but he just tolerated it, because he was preparing to redeploy; the pain gradually decreased, and continues intermittently, lasting 20-30 minutes; currently, frequency is 1-2 times a week. NO accompanying symptoms. Physical therapy continued through November without significant improvement of his arthralgia. Patient received influenza and Hepatitis A vaccines on 12/19/03. Denies significant local reaction. Denies worsening of headaches, body aches, or fatigue. No fever or chills. Patient returned stateside in mid-December 2003. He has been undergoing continued medical evaluation. He was diagnosed with chronic, inactive Hepatitis B, but multi-system complaints are not felt to be related to hepatitis.