Age: 21.0
Sex: M
Vaccine: ANTH
Symptoms: Biopsy, Dermatitis, Dry skin, Impetigo, Injection site erythema
Clinical narrative: This 31 year old male reported receipt of ANTHRAX vaccine 8/26/1998 while stationed at AFB, as an airfield management journeyman.  He reported the first AVA vaccines 8/26/1998 and 9/9/1998 resulted in only a red spot at vaccine site and a sore arm for 3-4 days.  No other vaccinations were given and no exercising the day of vaccinations.  Following receipt of his third AVA on 9/23/1998, he remembers his arm being red (vac site only) and sore that day/night with nodule formation and problems sleeping (woke up if laid on arm X 1 week).  His arm hurt for next 3-4 days then began to itch over the next 9 months.  He reported awakening day 3 or 4 (after AVA # 3) with a "dime size dry skin patchy area" on left pectoral area that progressed to a white scaly, pus like, flakey skin area that itched over the next 3 months to include "80%" of his body.  (Unsure exact day of onset rash but dessert heat worsened the rash).  He denied any  new foods, clothes, contacts, soaps, detergents, deodorants, chemical exposures, Insect bites, or medications.  He admitted to using an unknown lotion to the dry skin but symptoms worsened.  On 22 Oct 1998 he was diagnosed with "impetigo plaques" to left chest and prescribed BACTROBAN & ZINC Ointment.  Patient reported this caused the rash to spread even further about his chest, neck, torso, and extremities so he stopped all medications.  Follow up evaluations described irregular bordered, smooth macular lesions over chest, abd, arms without scale or pustules.  A punch biopsy (11/18/1998) identified changes consistent with psoriasiform spongiotic dermatitis.  He was treated with TRIMINCINALONE 1% and moisturizing creams with minimal results.  He was medevaced back home for further treatment.  The rash finally resolved 3-4 months later with some hyperpigmentation to skin areas and periodic flares to fingers, hands, arms, chest and legs 1-2 times every other month of varying duration.  Approximately 23 March 1999, Dr. contacted another Dr. at Military hospital to discuss psoriatic or eczematous rash being temporally associated with ANTHRAX vaccine and need for AVA vaccine exemption.  Dr. documented there were "no prior reports" and he would repeat the AVA vaccine now that the SM had improved.  On 9 April 1999, this service member received his fourth AVA reporting reoccurrence of the above rash for <30 day duration to his entire body which he self-treated with EUCERIN cream and Dove soap.  This rash would wax/wane in severity and duration never fully resolving utilizing all above therapies.  His fifth AVA was given 8/16/1999 with no change or worsening or rash.  His sixth AVA was given 3/17/2000 with resolution of rash.  Medical records document continued used of EUCERIN cream from 2000-2005 for relief of psoriatic rash with addition of TEMOVATE in Nov 2005.  In 2004 he was treated for chronic onychomycosis to bilateral feet (>1 year duration).  Dermatology evaluation 05 April 2007 focumented periodic psoriatic flare ups to hands 1-2 X every other month.  Skin lesion KOH prep was negative to hand and foot and he was diagnosed with dermatitis - dyshidrotic eczema and treated with CLOBETASOL.  On 13 April 2007 Dr. consulted with other Dr. at Healthcare Center to discuss exemption to the AVA vaccine due to psoriasis.  After several unsuccessful attempts to reach this service member, telcon contact was finally initiated 27 March 2008.  He continued to experience periodic flare-ups to webs of hands, neck, and legs lasting few days to months.  As of March 2009 medical records showed providers documenting only pruritic complaints but no skin rash, lesions, sores, or erythema noted.