Age: 57.0
Sex: M
Vaccine: ANTH
Symptoms: Nephrotic syndrome, Oedema peripheral, Pleural effusion, Rash macular, White blood cell count increased
Clinical narrative: Dermatomyositis after AVA #3 with subsequent pleural effusion and nephrotic syndrome. Pt underwent intense physical tactical training.  He slept in a single room with smooth flooring and no evidence of mild, or water damage.  He was is a good usual state of health until 02/06/04.  On that day he received the smallpox immunization as well as the first anthrax immunization.  He reports that by that night he had knee stiffness and was unable to perform his usual physical training of running up to 3 miles (typically 3 days per week).  Instead he took 400mg of Ibuprofen and the next morning he felt "a little stiff".  He continued to take Ibuprofen 200mg in the AM and 400mg in the PM for the duration of his time at the FT. and upon departure out of country.  At this time he states he was able to resume his normal activities but continued to have knee stiffness.  He had no local reactions at the site of his immunizations.  Over the course of the next two weeks his smallpox site was read as a take (per his report) and the scab fell off without complications.  He continued to have the stiffness of the knees and began to develop hand swelling and was not able to make a fist as well as mild loss of appetite.  He underwent his second anthrax immunization on the 25th of 02/04.  He reports that night and the next day he had worsening of his previous knee stiffness and hand swelling and stiffness, loss of appetite was worse and now he was not able to perform his running and exercise routine.  In addition, he reports that he developed a mild shortness of breath with exertion and a nonproductive cough with exertion.  He had no fevers, night sweats, no nocturnal dyspnea, no chest pain.  He reports over the next several days these symptoms mildly improved with Motrin 200mg in AM and 400mg in PM.  On 03/09/04 he received his third anthrax immunization and reports that the next morning he "could barely get out of bed" secondary to joint pains and mostly stiffness.  He reported 2 hours of morning stiffness and the Motrin improved his symptoms by "50%".  He now also reported having fatigue.  He continued to have these symptoms and did not seek medical attention.  He was deployed on the 15th of March out of the country.  He reports he was started on Doxycycline during this trip for malaria prophylaxis and during the first leg of the trip  he felt well and all of his symptoms were improving.  However, by the time he reached the country he was "not feeling well".  Upon arrival he had fatigue (felt secondary to all of the tactical training and the very ling trip).  He states all the incoming people were given 2 days to recoupe from the travel.  During this time he reports, "I slept all of the time".  He reports that he did also develop a dry cough at this time, without fevers.  All of his other symptoms were unchanged and still present.  He presented to sick call and was given a Z-pack for possible URI.  There was no affect on his cough or shortness of breath.  He notes that during this approximate time (after approximately 1 week of doxy), he developed a macular nonpruritic rash on his chest, upper arms, upper legs, and back.  He again presented to sick call and the doxy was stopped and he was given a 5 day burst of steroids (unknown dose or formulation).  During this 5 days of steroids he had no change in his respiratory symptoms but his stiffness, and hand swelling greatly improved.  He stated that he felt "very good" during this time.  One day after completion of the steroids he had return of all the symptoms and now stated that they were now the worst ever and he had minimal help with ibuprofen.  In addition, he states at this time he had brown urine production.  He underwent lab evaluation (none present for review) and states he had elevated WBC, liver enzymes as well as an elevated CK.  He was admitted to the local aid station and given IVF and prepared for evaluation.  He was evacuated 2 days later arriving on the 03/29.  He underwent a CXR and was noted to have pulm process as well as multiple abnormal labs c/w myositis.  He underwent a bronch with BAL that revealed eosinophils per report (exact % is not available at this time).  He was noted to be hypoxic and was treated with o2 via nasal canula.  He was started on oral prednisone and evacuated to medical center.  He arrived at medical center on 04/05/04.  At that time he was able to do ADL's but continued to have stiffness, and now worsening weakness of his muscles proximal greater than distal.  In addition his rash had worsened and involved his face and hands.  Upon arrival he was noted to have bilst pleural effusions and a small pneumothorax that has been stable since admit and has not required a chest tube.  He has been seen by derm who stated the rash is c/w with a helitrope rash and gotrans papules, neuro who facilitated an ENG that revealed a myopathic process with myonecrosis and some neuronal involvement, rheumatology who currently reports his presentation is c/w a inflammatory myositis, possibly dertomyositis.  The final labs and pathology reports are pending.  He has had a echo that was unremarkable per report.  Thus far he has been treated withpulse doses of methyprednisolone and has been receiving IVF with bicard as he has had evidence of rhabdo.  Finally he has been noted to have nephrotic sydrome with 24 hour protein of 4 gm and albumin of 1.4 with le edema.  Since he has been at medical center he has progressive weakness and is now unable to get out of bed and unable to do ADL's.  WE were consulted to involve, and file a VAERS and assist with possible IVIG therapy.   Follow-up: On cyclosporine and prednisone and IMURAN. But has improved greatly over past year - walking well, driving, exercising at home.