Age: 54.0
Sex: F
Vaccine: ANTH, ANTH
Symptoms: Activities of daily living impaired, Alanine aminotransferase normal, Anion gap normal, Anti-cyclic citrullinated peptide antibody positive, Aspartate aminotransferase normal
Clinical narrative: Within 3 days of vaccine receipt patient developed the following symptoms: 1) Reaction at vaccination site: patient reports significant redness and swelling from her (R) shoulder to her hand. There was an area surrounding the vaccination site that encompassed most of her deltoid that was warm, firm and tender to touch (4-6/10). She did not experience any itching, nodules, bruising, or streaking at or near the vaccination site, nor did she note any axillary tenderness or lymphadenopathy. She denies any RUE numbness or tingling. Patient sought initial evaluation for her symptoms on 26 FEB (after calling clinic and reporting symptoms and being told to monitor symptoms and that her reaction was not unusual. The swelling, redness and tenderness completely resolved after about 4 weeks. Patient denies anything out of the ordinary regard to vaccine administration or where vaccination was administered (upper deltoid). She had experienced swelling, warmth, and tenderness following her first two anthrax vaccines (1st: JUL 2012, 2nd: AUG 2012), but area affected was not more than 3" surrounding sites, patient did not seek evaluation, and symptoms resolved after approximately one week. 2) RUE pain: Patient experienced significant pain of her deltoid and shoulder area. Pain described as dull pain, with pain intensity ranging between 4-8/10. Patient felt her right shoulder was "fixed" as movement was limited due to pain. Lifting or using muscles in upper arm causes pain. Patient describes RUE as weak. Pain extended to neck. Pain impacted her daily activities, but she did her best to "work through it." Although she was carrying out her duties, due to pain, she has not been as productive. Patient sought evaluation for persistent RUE pain on 6 MAR (3 weeks post-vaccination). Rest and avoidance of strenuous activities, along with Ibuprofen 600 mg 3 times per day were recommended, which were somewhat benefit. Patient has been receiving Physical Therapy for chronic lower back pain (LBP) and neck pain s/p motor vehicle accident in 2012. Therapist showed patient some exercises that she could do to help her RUE pain, but recommended further evaluation of pain through her PCM. RUE pain (4-8/10) continues at present. She takes MOTRIN 600 mg three times a day, primarily for her LBP and neck pain, but it helps her RUE pain as well (decreases pain about 30%). Patient denies a history of RUE pain or trauma. 3) Nasal discharge from right nostril: patient specifically recalls episode around post-vaccination day (PVD) 3, where she felt warm, clear nasal drainage dripping from only her right nostril. She denies any allergy symptoms like itchy eyes or nose, redness of eyes, sneezing, post-nasal draining, cough, etc. but did experience onset of muscle aches and fatigue around the same time. During the next 2-3 weeks, she recalls having an intermittent runny nose on right side, with no accompanying URI, sinus, or allergy symptoms. She occasionally self treated with BENADRYL with some benefit and noted resolution by end of MAR. She denies a history of seasonal allergies or hay fever. 4) Swollen, tender lymph nodes: patient recalls experiencing right-sided groin pain when going from sitting to standing and vice versa. When she palpated the area, she noted a swollen, tender lymph node, which resolved within a few days. Around that time, she also noted several bilateral swollen cervical, and supraclavicular lymph nodes, and right-sided submandibular lymph nodes which have persisted, sometimes more prominent than others. She denies a history of swollen and tender lymph nodes unrelated to sore throats. She denies recent scratches or bites. While activated, patient traveled to another country, in an urban, office setting. She denies any travel-related environmental exposures. 5) Rash: patient noted burning sensation under right side of chin/right side of upper neck and when she felt the area, she said it felt like "a welt". The burning sensation resolved within 24 hours and the area was later described as pruritic and crusted. The rash never extended beyond the original area under her chin/upper right neck. On 27 MAR, on exam, Dr. described the area - "nonerythematous patch with slightly raised borders that have been papules that are nearly healed"; Dr. thought the rash was c/w tinea corporis and prescribed 1% hydrocortisone cream, which patient applied and helped to relieve the itching and diminish the size of the affected area. However, patient reports rash has still not resolved. Areas where rash has healed is hyperpigmented. Patient denies a history of eczema or chronic skin conditions. She denies a history of bites or changes in personal care products. 6) Fatigue: patient initially thought fatigue was a normal part of post-vaccine reaction. On PVD 4 and 5, which were on the weekend, patient stayed in bed and rested for the majority of each day. She felt a little better on PVD 6, but during the next several weeks, she was awakening feeling unrefreshed and found herself going to bed shortly after arriving home from work. She pushed herself in order to meet job requirements, but generally was always feeling tired or drained. She scored 275/300 on the PT test she took in late FEB, but was "wiped out" for several days following testing. Patient has started napping more when she is able due to daytime sleepiness. She generally sleeps about 6 hours per night which has been typical for her over the past few years, but her pain has diminished quality and quantity of sleep. Patient rates her endurance level as about 60% of her baseline level and her fitness level is about 80% of baseline, as she performs daily head-to-toe stretching exercises and is able to walk for exercise. She denies new onset or new pattern headaches, changes in memory and concentration, hypersensitivity to environmental stimuli or emotional overload, confusion, slowness of thought, muscle weakness, ataxia, dizziness or lightheadedness, palpitations, pallor, exertional dyspnea, irritable bowel syndrome, nausea, cold extremities, sweating, intolerance to heat or cold or low body temperature, reduced tolerance to stress, unexplained weight change, sore throats, fevers, and new sensitivities to food, odors or chemicals. She has chronic LBP and neck pain after MVA, and is currently experiencing RUE pain. Interestingly, patient has a history of significant joint swelling and pain in her hands following her travel in 2005. Initially, her pain was diagnosed as CTS, but her evaluation later included a Rheumatological evaluation. Patient was diagnosed with seronegative Rheumatoid Arthritis. She was treated with steroids for a period, and then on methotrexate with Folic Acid for a period of months. After a second opinion these medications were discontinued. Patient reports chronic pain in bilateral hands (4/10) with nodules of joints and intermittent swelling. She denies redness and increased warmth of joints. Patient experiences morning stiffness, but is able to carry out activities of daily living. [Records related to these symptoms are currently not visible to VHC, but patient has agreed to supply VHC with copies of records for review.] Patient denies a history of anemia, Gestational diabetes or prediabetes, symptoms consistent with hypothyroidism or sleep apnea, and denies symptoms of depression. Evaluation for above symptoms has included at least 6 calls or visits to clinic. She has been prescribed medications as described above. Of note, some of H&Ps report no swelling or tenderness of lymph nodes, but patient reports she has had swollen, tender lymph nodes since PVD 3; swelling and tenderness of her inguinal nodes resolved, but others have persisted. Some labs have been completed-refer to LABS section below for results. The plan is for patient to continue evaluations for ongoing symptoms through the network following defrag, within the next 6 months, with input to local providers per VHC. Patient describes her overall health prior to FEB 2013 as good. She was feeling fine on the day of vaccine receipt and denies symptoms of infection antecedent to or at time of vaccine receipt. Patient has no history of previous adverse events following immunizations (AEFI) except in 2005, after Yellow Fever vaccine, patient experienced significant swelling of RUE, which was diagnosed as cellulitis. Patient was treated with antibiotics and the swelling resolved within a few days. Patient denies experiencing flushing, itching, dyspnea, hives, facial swelling, itching or swelling of throat and/or tongue, and nausea, vomiting, or diarrhea following receipt of vaccines.