Age: 33.0
Sex: M
Vaccine: ANTH
Symptoms: Urticaria, Vaccine positive rechallenge, Weight increased
Clinical narrative: Following 3 AVA and primary smallpox vaccination had white raised bumps under the skin, red hives to torso/arms, joint pains, muscle aches, cold/hot sweats, fatigue, loose stools, anxiety, and abdominal pain.  History of Present Illness:    Immunization: Anthrax and primary smallpox. Vaccine Date: 1/22/03, 2/6/03, 3/5/03, 8/6/03, 2/24/04, 9/4/04 Onset date: 06 Feb 2003 white bumps; 05 Mar 2003 and Primary smallpox on 3/18/05 Symptoms:  This healthy 35 year old patient reports receiving his first anthrax vaccination 22 Jan 2003 while stationed overseas. He reports no untoward adverse events except for typical redness and a "tennis ball" size lump to the vaccination site that slowly resolved.  He received his second AVA vaccination on 06 Feb 2003 with resulting onset of "white bumps" to both forearms (unsure date of onset).  They were nonpruritic, without paresthesia or swelling.  On 05 March 2003 he received his third anthrax vaccination and deployed overseas in April-May 2003 with no memory of any adverse events persisting at that time. He also received his primary smallpox vaccination 18 March 2003 with no reported adverse events. Over the next few years, these bumps intermittently spread to the tops of both thighs and his forearms. As of July 2005 the rash persists to both forearms and the tops of both thighs.   He also complains of "red blotches" located to the medial aspect bilateral inner arms and upper torso that radiate towards his back since his return (Sept 2003).  He reports his physician placed him on Claritin for "hives" (unknown date).  He reports exacerbation of the rash in hot temperatures/environment and it is most prominent mid afternoon or evening.  As of August 2005 with temperatures in the 100's the rash is now "five inches in length" all over his back.  He reports his left axillary lymph node as swollen, mobile and tender 2-3 times a month since receiving his anthrax and smallpox vaccination in 2003. He has never been evaluated for allergy testing.    8/15 questions asked on duration rash, f/u on, exam by, meds used any dx for. He began to experience problems with abdominal bloating and diarrhea (>6x/day)in July 2003 while stationed overseas that lasted for ½-1 week several times over a 6 month period (7/03 to 1/04).  He described the problems as stomach swelling and rumbling upon awakening regardless of food/liquid intake.  He denies any nausea or vomiting.  He reports follow-up with medical attributed his problems to change of diet, environment and treatment with medication (doxycycline and possibly Imodium) resolved only the diarrhea.  In September 2004 he thought he had internal hemorrhoids after noticing red streaks of blood in his stool for two weeks.  In December 2004 the bleeding reoccurred for three days. He completed a full gastrointestinal evaluation including a CAT scan and colonoscopy with Crohn's disease dismissed. He reports persistent bloating as of July 2005, except if just ate.  His stools alter in consistency from normal to "melted ice cream". Increasing his daily fiber intake has helped his bloating however his weight has increased twenty pounds over the last 1½ years. 8/15 Questions asked on duration, frequency, consistency activity prior to abd bloating, diarrhea, other associated symptoms (fatigue after/before), etc. He complained of a cyclic pattern of 3-4 days of fatigue and lack of energy with alternating days of "boosted energy" for one week since his return from Iraq in 2003 that persists as of August 2005. He reported his sleeping pattern vary from 2-10 hours a night with an inability to sleep past 2 am.  The quantity of sleep did not help his fatigue as he would wake up exhausted.  Exercise improved feelings of fatigue.  He denied any increase in stress, history of anemia or depression.  His medical provider referred him for a psychiatric evaluation for possible Post Traumatic Stress Disorder that he declined.  Over the last two years he has noted increasing problems with myalgia, arthralgia, fatigue, lack of energy, sleeping irregularities, headaches, hot and cold sweats, and dried flaky red patches to his eyes and skin that began while overseas (2003).  He describes his joint pain as located to both ankles, knees, hips, back, and shoulders as an aggravating "little pain" that varies from joint to joint depending upon the day and activity performed.  His pain is worst upon awakening 4-5/10. His pain eases/resolves after moving around but it returns after resting at the end of the day.  He states the discomfort limits his ability to move quickly and crawl around while instructing others at work (on top of aircrafts). He denies redness, swelling to any joint and uses no medication for this discomfort.  His myalgia (muscle pain) coincides with his joint pain.  He stated he exercises five days a week in spite of his discomforts playing racket ball, bike riding, or lifting weights without restrictions or needing to change daily activities.  8/15 questions asked on onset joint pain, daily occurrence if not how often, or just after shots. He complains of a "rare" frontal/occipital headache (throb) once every 4-5 days for five minutes for the last 2 years (2003-2005).  He is unsure of the onset as he does not pay much attention to it.  His only complaint is blurry vision, as if a clear film is over his eyes, and periodic hot-cold spells.  His blood pressure ranges 136/78-81.  He denies any past headaches, family history of migraines, trauma, nausea, vomiting, pressure, or radiating pain.  He has had three conjunctival eye infections from 2003-2004. He was later told he had "allergies". oHealthy ? Received first AVA 1/22/03 w/nodular formation vac site o2nd AVA 2/6/03 c/o white bumps to forearms that have spread to torso, thighs o3/05/03 3rd AVA ? Primary Smallpox on 3/18/05. o4/16/03 Hep B #1 and Meningococcal #1 ? deployed Iraq 4-5/05 ? 5/05 c/o abdominal bloating, diarrhea. o8/05/03 Meningococcal #2 ? 8/06/03 AVA #4 ? return to states 9/03 with c/o red blotches-hives to torso, arms and periodic axillary lymphadenopathy, myalgia, arthralgia, fatigue, lack of energy, sleeping irregularities, headaches, hot and cold sweats, and dried flakey red patches to his eyes and skin o10/20/03 Hep B #2, typhoid ? 10/22/03 Influenza Vac. o2/24/04 Hep B #3, AVA #5 o9/04/04 AVA #6 o10/26/04 Men #2, Typhoid #2 o11/22/04 Influenza