Age: 39.0
Sex: M
Vaccine: FLU3, TYP, YF
Symptoms: Dehydration, Dyspnoea, Endocarditis, Fatigue, Laboratory test abnormal
Clinical narrative: This 41 year old received routine influenza, typhoid, and yellow fever vaccinations on 23 Feb 2004. He reported experiencing fatigue, muscle aches and bilateral arm soreness for two days following this group of vaccinations. He denied any fever, chest pain or breathing difficulty, nausea or vomiting.  He continued training which included shooting at the pistol range. He reported undergoing a dental procedure (tartar removal) without prophylactic antibiotics in December 2003 with a past medical history of "heart murmur", GERD, mononucleosis as a teenager, and various orthopedic ailments (see past medical history below). He was questioning the association of Anthrax vaccine given 17 March 2003 and his endocarditis. [NOTE: 3/17/2003 AVA #1 marked DO NOT GIVE on one SF 601 and a PHS 731 form but entered into DEERS and onto DDF 2766 as given. No further AVA vaccinations documentated.] He was deployed one week later on 01 March 2004.  By 04 March 2004 he awoke feeling "bad" with severe thirst and feverish.  He reported to medical 6/7 March 2004 with persistent fevers, chills and maliase.  He was advised he may have the flu versus travel fatigue, given an unknown shot and prescribed Motrin. His symptoms persisted and worsened over the next few days. On 11/12 March 2004 he returned to the medical clinic and was administered "3 IV's" as his hands and feet were "yellow", had xrays and was advised he may have an STD or sinus infection.  He was treated for sinusitis and dehydration. His symptoms would begin to resolve only to relapse again.  On March 26, 2004 he again experienced reoccurrence of fevers, chills, nausea and vomiting, a non-productive cough without shortness of breath or chest pain.  He reported to clinic complaining of fatigue upon awakening, climbing a flight of stairs requiring him to sit down due to fatigue, and inability to do any physical training or stretching due to illness.  He denied any chest pain or shortness of breath but admitted he got winded with exertion. He had lost approximately 27 pounds (unintentinal) over the previous 2 months due to lack of appetite. He was drinking increased amounts of gatorade due to fevers. He considered "low iron" as possible cause for his fatigue and self-treated with vitamin B supplements, iron pills and ate leafy green vegetables.  He was treated with another course of antibiotics following normal laboratory studies.   By 25 April 2004 he had completed 14 days on Z-pak and was again ill with fevers, chills, nausea, vomitng, fatigue.  He complained of being "sick as a dog."  He returned to the doctor for further evaluation and lab studies.  His labs from 25 April were repeated on 27 April due to inconsistency in lab data results. His ESR was now positive.  He was sent to a cardiologist on 28 April 2004 for cardiac evaluation and admitted with endocarditis for ten days.  Review of available medical records document in April 2004 an evaluation and subsequent admission for "emergency suspicion of mitral valve endocarditis, mitral valve insufficiency third degree."  It was reported he complained of "2 month history of night sweats, fevers and shivering with considerable reduction in his physical efficiency/athletic abilities; treated for suspected sinusitis with bactrium then Zithromax without improvements. History of heart murmur for several years with tartar deposit removal 2 months ago without prophylactic antibiotics".  His exam showed "pale skin color, ipsilateral vesicular breathing noise, tachycardia, loud systolics through all auscultations with a p.m. in IV, TCR left parasternal.  His color Doppler echocardiogram showed a 4.6 cm left auricle enlargement, clearly degenerated mitral valve with suspicion on the front mitral valve velum.  Left ventricle was enlarged end diastolic with 6.3 cm at above normal systolic function (EF 78%).  Mitral valve insufficiency III-IV was evident by coloor Doppler sonography with no pericardial discharge."  He was admitted, placed on oxygen for dyspnea, streptococci viridans was identified via blood cultures and he was given 1x10 mega-penicillin G IV antibiotics per day. A transesophageal echocardiography revealed "a high degree of mitral valve insufficiency with tearing of chordae and slightly hardened mitral valve; physical exam documented a loud, holosystolic cardiac murmur radiating to all areas of the heart with a third heart tone auscultated in the diastolic region. Due to increasing heomdynamic impairment an Urgent mitral valve reconstruction was indicated".  He underwent mital valve reconstruction with a Medtronic Duran Ancor Ring 20 R (SN R49795, Diam 29mm) on 14 May 2004 without complications. He was treated with IV Vancomycin and Penicillin G then changed to oral Augmentin.  Follow up echocardiogram 21 May 2004 showed "normal left ventricular function; mitral valve after annuloplasty and quadrangular resection of posterior velum showed a very good result, anterior velum is freely movable, posterior velum is very competent with normal gradient." He developed a "thoracal pain syndrome" due to previous left shoulder surgery treated with physiotherapy and medication.  He was discharge from hospital 25 May 2004 to a rehab hospital where he developed a drug-induced exanthema to Augmentin and was change to Elobact (Cephalosporin) which increased the allergic reaction. He was treated with IV Gentamicin then oral Sobelin (to take for 3 months) with no further adverse events. He also fell into post-op depression which resolved with 2 weeks of discussion therapy.  Follow up evaluation with cardiologists (July 04-Jan 05) documented h/o MVP with possible bacteremia exposure after a dental procedure without prophylactic antibiotics two months prior to onset of his endocarditis. He is s/p mitral valve repair in May 2004.  He is doing well since surgery doing light weight-training 3x/wk, and a total of 30 minutes of aerobic exercise (stationary bike, walking, elliptical machine) 2-3x/wk.  He denies any chest pain or unusual shortness of breath during exercise.  Two months ago, he had one episode of persistent tachycardia 1 hour after doing 10 laps in swimming pool, and denied any associated symptoms.  Three nights ago (1 Jan 05) he had five episodes of sudden onset of SOB as he fell asleep.  Sleeps on one pillow with no SOB while lying at this angle.  These episodes resolved spontaneously without recurrence.  He denied any lightheadedness or syncope since May 2004. Meds include ASA 81 mg, MVI, Tums prn."  His exam was normal with normal EKG biphasic P in V1-2 w/o ST elevation/depression, normal CBC, chol 232, Tg 265, HDL 40, LDL 139, Normal CXR w/MV prosthesis, TTE Aug 2004 LVEF 55-65% (see below results), GXT 3 Jan 2005 normal indicating "no evidence of exertional cardiac ischemia".  Doctor notes indicated he was clinically doing well with no functional limitations. Recommendations were to continue annual routine cardiology follow up with annual ECHO not required.  He remains asymptomatic as of this interview 19 April 2005 and follow up contact in Jan 2006. Review of available medical records noted the onset and documentation in pre/post deployment forms 2004 for migraine headaches with recommendations for speciality evaluation 12/2004. No further evaluation or medical records are available to describe these headache.  These headaches were described as frontal aches that began in 3/2004 and were only monthly by 12/2004.  No further characteristics of these headaches were identified.