Age: 36.0
Sex: F
Vaccine: ANTH, TYP, ANTH, TYP
Symptoms: Joint swelling, Laboratory test, Lactose intolerance, Lipase normal, Lymphocyte count normal
Clinical narrative: During training between 12 and 27 Aug 2016 (about 12 weeks post-vaccination), patient experienced severe abdominal cramps and explosive diarrhea, with nausea, but no vomiting. Episode was not preceded by fever, and no similar symptoms were reported among close contacts. Patient sought evaluation and was removed from training, and returned. On 29 Aug 2016, entry noted 3-week history of abdominal discomfort, diarrhea and bilateral shoulder, elbow and wrist pain. On 2 Sep 2016, during an evaluation for abdominal symptoms, abdominal ultrasound showed a 2-3 mm non-mobile polyp in patient's gallbladder, but no gallstones. Patient was diagnosed with suspected irritable bowel syndrome (IBS) and treated with Dicyclomine, which decreased symptoms somewhat, but patient later stopped due to side effects. Also, on 2 Sep 2016, patient reported 3-week history of new onset right wrist and bilateral shoulder pain, which was not preceded by injury. She was evaluated and treated with Etodolac. When these symptoms worsened, she was referred to Orthopedics, but this evaluation was not completed. On 12 Sep 2016, patient arrived in preparation for travel. Screening form noted onset of explosive, non bloody diarrhea in Aug 2016, during training. On 13 and 14 Sep 2016, patient was evaluated by Gastroenterology. At that time, patient was still experiencing abdominal pain and diarrhea. She reported 3 loose watery stools/day. It was noted she was lactose intolerant and had been treated with antibiotics the previous month (for bacterial vaginitis). The etiology of patient's diarrhea was not determined, but it was assessed as possibly being multifactorial (History of lactose intolerance, history of recent antibiotic use, history of caffeine induced gastrocolic reflux, high fiber diet.) Patient was instructed to try LACTAID, and additional studies and follow up were recommended. On 14 Sep 2016, patient reported worsening of bilateral shoulder pain and right wrist pain over the previous few days, and requested further evaluation. The remainder of patient's evaluations have been through the office and affiliated treatment facilities. Chronic diarrhea and abdominal pain: Since Sep 2016, patient has been evaluated by Gastroenterologists. She completed EGDs, Colonoscopies, abdominal ultrasounds, stool studies, and abdominal imagery. Differential diagnoses included Crohn's, gastritis, and irritable bowel syndrome, with gallbladder polyp thought to be benign. Treatment included dicyclomine, Omeprazole, and diet modifications (low gluten). Based on diagnostic workup and clinical course, diagnosis is irritable bowel syndrome. Polyarthralgias: Patient has been evaluated by Rheumatology, with additional imaging studies and laboratory studies completed. In Sep 2016, initial Rheumatology evaluation for polyarticular arthritis noted joint pain in shoulders, hands, right wrist and feet. Patient also complained of muscular back and arm pain and numbness and tingling sensation in her right 4th and 5th digits. No report of joint swelling, and morning stiffness. No improvement of joint pain with NSAIDs, and unable to tolerate due to GI-related pain. In Mar 2017, patient experienced 2nd and 4th MCP fullness with fluid and bilateral hand pain and swelling and stiffness. Differential diagnoses included osteoarthritis, Lupus, seronegative rheumatoid arthritis, inflammatory bowel disease-related spondyloarthropathy, and spondyloarthritis. Medications have included acetaminophen, capsaicin, prednisone and methotrexate (Apr 2017, and HUMIRA (May 2017). In addition to the Lab and Studies listed below, patient had an ophthalmologic exam, which showed no evidence of uveitis. She was also diagnosed with fibromyalgia/central pain perception syndrome, with trigger points in her neck, trapezius, and thigh muscles. To evaluate for poor quality nonrestorative sleep, she completed a sleep study, which was normal.  She continues regular Rheumatologic follow up and is taking HUMIRA every 2 weeks with a working diagnosis of spondyloarthritis.