Age: 43.0
Sex: M
Vaccine: ANTH
Symptoms: Anxiety, Apnoea, Atrioventricular block, Back pain, Carpal tunnel syndrome
Clinical narrative: "They can't figure out what's wrong with me. They wanted to know if it could be from the vaccines. My health has gone bad since I deployed." A 46 year old male who was referred, for evaluation of possible vaccine adverse reaction. (The following HPI was obtained during an interview with pt and his wife on 3/31/06 and available military medical records.) On 1/2/03, Anthrax vaccine, SC, LA. Pt is unable to recall specific details related to his first anthrax vaccine. He believes he had some soreness and aching around the vaccine site, otherwise, does not recall an unusual local reaction or onset of significant systemic symptoms.  Note from medical records, dated 1/15/03: 44 year old complains of anthrax shots two days ago. Can't move right arm and is very painful. Lost voice. Pain is 9 or 10 when moving fingers or arm. Pt walked in holding right arm. Painful to touch on arm. Reduced range of motion. Squeezing hand around something creates pain. Erythema and edema at site of vaccination. Local reaction to anthrax. Motrin with light duty and return in the morning. 01/16/03, Anthrax vaccine, SC, RA "Date of vaccine is not consistent with above note dated 1/15/03 with description of vaccine receipt 2 days ago. Likely vaccine was received on 1/13/03, which would have been 3 days before scheduled dose. Pt recalls redness, tightness, tenderness and swelling to the elbow, with decreased range of motion due to pain that lasted about 2-3 days. He called his wife and told her that his arm felt like it was "beat up". He also reports passing out about 12 hours after receiving his 2nd anthrax vaccine. At the time he passed out, he was setting up the perimeter in camp and the next thing he recalls is his unit members taking him in a pick up to the medical detachment. He was given IV fluids and later cleared to return to duty by a physician. He does not recall experiencing any nausea, vomiting, fever, chills, headache, fatigue or body aches. Note from medical records dated 1/19/03: Returns for follow up. Right arm with erythema and tenderness. Resolving local reaction. Return as needed. 1/20/03 Smallpox vaccine, PC with revaccination on 2/4/03 per service member, pt recalls receiving 15 jabs with the smallpox per service member. He went in for a site check and was assessed as a "no take" and given a second smallpox vaccine (15 jabs). He does not recall experiencing a significant local reaction or robust take. He does not recall experiencing any significant systemic symptoms, specifically chest pain or SOB. 2/11/03, Anthrax vaccine SC. Pt is not able to recall specific details surrounding receipt of this 3rd Anthrax vaccine, but denies a significant local reaction. He does not recall significant systemic symptoms, other than around this time, he began experiencing chronic headaches. At the time, he attributed his headaches to dehydration, jarring from riding is vehicles over very rough terrain, and on tiredness. Note from medical records, dated 2/15/03: Sick slip-Sinuses, head cold, plugged ears. Chief complaint: Plugged ears, headaches, sinus congestion x 3 days. Also corns on bother feet and was given Moleskin. No allergies. No tobacco, no alcohol. Past History negative. Notes from medical records: date 3/8, 3/9 and 3/20 and 5/22/03 and 5/30/03, address right 4th finger pain following twisting injury. Placed on limited duty x 2 weeks. X-ray negative for fracture. Later, had cast applied and then splint. Notes from medical records: dated 5/30/03: 44 year old with c/o vomiting immediately after eating x 4 days. Stomach cramps with headache. Loose stool with cramps. Unable to drink water. Impression: Gastroenteritis, Plan: Phenergan IM. Discharged from holding area with po Phenergan and Imodium. Notes from medical records: dated 6/8/03: Pain lower left quadrant, abdomen and left flank for 4 days. Physician's note includes treatment with IV normal saline, Toradol, IV push Phenergan and Demerol as needed for pain. Assessment: Acute left flank pain with hematuria, rule out stone. Plan: Discussed with other doctor. Pt still has difficulty with urination. Recommend IVP and Urology consult. Discharge note: 44 year old with 5 day history of intermittent left abdominal pain. Referred on 6/8/03 to rule out kidney stone. KUB on 6/8 showed marked stool, and IVP on 6/9 was negative for stones and/or obstruction. 6/12/03: c/o sharp pain in stomach. Stabbing pain in left lower abdomen. Painful urination with blood 2 days ago. Symptoms started around 6/4. Was seen for kidney stones. Seen on 6/8 and transferred for stone evaluation with positive blood in urine, flank pain. Had negative INP and pain improved. Returned back here. Now out of pain RX and ongoing discomfort in spasmodic fashion. Impression: Ureteral spasm post-stone. Plan: RX for Toradol 3 times a day x 7 days and Tylox. Antifungal cream for 3 weeks to groin. Notes 6/16/03, sick slip, push fluid and recheck for elevated temp, nausea, vomiting, pain and any concerns. Right groin pain at midnight. Felt sharp stabbing pain radiating to right testicle. Urine was dipped with 3+ large blood, no leukocytes, negative nitrites and glucose. Given IM Demerol and Phenergan and liter of saline at 150cc/hour. Pain went away around 02:50 and then returned at 05:15. At 07:20, pt continued to be uncomfortable and holding right flank area; given Phenergan and liter of saline at 150cc/hour. Pain went away around 02:50 and then returned at 05:15. At 07:20, pt continued to be uncomfortable and holding right flank area: given Phenergan and Tylox at 07:15. Pain decreased to a level 3 on scale of 0-5 and at 08:25, pt was released to unit. 7/9/03 Anthrax vaccine, SC. Pt unable to recall specific details following receipt of his 4th anthrax vaccine. Notes 8/15/03: Post-deployment health assessment, pt noted headaches, joint and muscle aches (back, right ring finger, ankle), dizziness/fainting, feeling tired after sleeping, numbness or tingling in hands or feet, ringing in ears, rashes and diarrhea. 8/29/03: Hep-A vaccine, SC and Hep-B vaccine, adult, IM. Pt received these 2 vaccines following onset of most of his ongoing symptoms. He does not recall a significant local reactions or systemic symptoms. 2/11/04 Anthrax vaccine, SC and Hep-B adult. Pt does not recall exacerbation or worsening of any symptoms with onset prior to prior to 2004. Admission 4/11/06, discharge 4/11/06; chest pain. Admitted and discharged on 4/5/06. Pain sometimes associated with SOB. Used nitroglycerin spray. Pain "pounding" and right jaw aching. Pt states the pain took his breath away. Only remembers being the ambulance taking him to ER. He received SL NTG x 3, morphine, nitro patch with improvement of pain. Pt subsequently, admitted to cardiology service for further evaluation. Admission complicated by aspiration pneumonia, multi-organ failure and coma requiring intubation, v. tach vs. v. fib, CHB s/p pacer implant. Syncopal episode yesterday first since pacer implanted on 3/1/06. He also developed voice disorder in 9/04 after suffering a "seizure". He was advised not to drive and at this time, stopped work at civilian occupation. In 12/05, he started having episodes of "blacking out". Hospitalized x 15 days with no dx made. Then he was in ICU x 9 days. On respirator x 9 days. Wife says he had heart failure, renal failure and bilateral pneumonia. On 3/1/06, permanent pacemaker inserted because of 3rd degree heart block. His medications are Gabapentin 1200mg tid, Tramadol 50mg qid, Zoloft 200mg q day, Trazodone 100mg q HS, Topiramate 25mg 2 q HS and Mirtazapine 45mg q HS. Neurological testing were within normal limits. He has blurred vision and diplopia all the time. Has hypertension, dysmetria of bilateral lower extremities. Current problem list: complete heart block s/p pacemaker placement (3/06); obstructive sleep apnea; hyperlipidemia; chronic daily headaches; anxiety disorder NOS; non-epileptic spells/syncopal episodes; non-cardiac chest pain; carpal tunnel syndrome (left and right); possible vocal cord disorder, hoarseness; chronic diarrhea of unknown origin; low back pain; history of HTN; chronic fatigue; history of renal calculi; sensorineural hearing loss, bilateral tinnitus; mild cognitive deficits; photosensitivity; night sweats; rash, biopsy consistent with pustulovesicular folliculitis; left ankle sprain.