Age: 44.0
Sex: M
Vaccine: ANTH, ANTH
Symptoms: Balance disorder, Chest pain, Chronic fatigue syndrome, Coordination abnormal, Disturbance in attention
Clinical narrative: Currently he is experiencing constant dizziness, chronic fatigue and joint pain. Several physicians have evaluated his dizziness and fatigue and has yet to experience any relief. His joint pain consists of neck pain since April 2001 and right thumb pain since September 2001. He has been treated with a civilian chiropractor with no relief. He ranks his neck pain 5/10 and states that massage decrease the intensity of the pain. The thumb pain in the proximal knuckle is felt with grabbing. These pain symptoms are not relieved with NSAIDs. The first anthrax vaccination was administered on 01/08/2000. The next day he began experiencing nausea, upset stomach, fatigue and dizziness. The nausea and upset stomach symptoms spontaneously resolved in 7-10 days. The fatigue was mild at the onset. He simply noticed he was more tired than usual. He describes the dizziness as lightheadedness, as though he spun around in circles and suddenly stopped. The feelings of fatigue and dizziness became his baseline state of health. The second shot was administered two weeks later on 01/22/2000. At the time of the shot the fatigue and dizziness continued. One day after the shot he began to experience flu like symptoms of fever, muscle aches, decreased appetite. These symptoms lasted between 48-72 hours and he returned to baseline. The third shot was administered on 02/05/2000. Two hours later he experienced sharp chest pains, shortness of breath and dizziness. He was evaluated at a local emergency room where he had an increased blood pressure and pulse, a normal CXR and EKG. He was diagnosed with musculo-skeletal pain and released. He felt better by the next day. A private MD evaluated him for the chest pain and SOB, resulting in a normal cardiac stress test and EKG. At this visit he complained that the fatigue was increasing and the episodes of dizziness were more frequent. During the exam fluid was noted behind the eardrums and his distolic blood pressure was noted to be elevated. In March 2000, he experienced an episode of dizziness, shortness of breath, rapid pulse, and near syncope lasting approximately one hour. He sat down to relax and the symptoms subsided in approximately 15 mins. Two subsequent episodes occurred in the following weeks, lasting 15-30 minutes, resolving again with sitting down. About this time he also noticed a decreased ability to concentrate, explain things and understand directions. He also noticed some slight short-term memory loss. Neurologists evaluated him for his dizziness. His neurological exams and MRI were normal. ENG was suggestive of balance organ disturbance in the right ear, noted probably from viral infection. Doctor found right vestibular nerve damage and recommanded that he does  not received additional anthrax vaccinations, as he could not say if the vaccine was the cause of the complaints. In May 2000, he began treatment for insomnia x 3 months per his primary care physician. He was placed on Nortriptyline; however, he only took this medication for approximately 2 weeks before discontinuing on his own. He was placed on a profile and limited duty. By July 2000 a possible diagnosis of Meniere's disease was considered and he was referred for care to another neurologist, he was evaluated and found a normal neurological exam and no clinical evidence of vestibular neuropathy. Sleep study was requested, which also returned normal results. Allergy evaluation, ABR test and neuropsych testing were also recommended. The ENT service evaluated him for his dizziness, hearing loss and tinnitus. An audiogram showed left ear low frequency hearing loss and a possible diagnosis of meniere's disease was given for the left ear. A follow-up evaluation with a doctor in August 2000 showed a positive FUKADA test (marching in pace for 50 steps at normal march speed with the eyes closed-patient veered to the left). He followed up again in October. At this point the dizziness continued, follow-up ENG recommended. In November 2000, his medical records was reviewed and consulted with the Ear Institute and their ultimate decision reached was that there was no relationship between the Meniere's disease and any current vaccinations in use. In Feb 2001 the allergy service reviewed his records and determined tha this symptoms were not compatible with allergic basis for complaints and he was not seen for evaluation. He was re-evaluated in March 2001. ENT exam was normal and an electrocochleography was recommended. In April 2001, doctor evaluated him and ENG test was normal and his electrocochleography showed a slight abnormality for the left ear (SP/AP ration slightly elevated above 2 standard deviations for the left ear). He also received a mental health evaluation in May 2001. This evaluation yielded an axis I of rule out 300.02 anxiety disorder and rule out 300.01 panic disorder without agoraphobia; no axis II; an axis III of labrynthitis; an axis IV of severe stress with health problems and pending job loss; and an axis V of current GAF: 61, highest GAF in past year: est. 81. A follow up report received 6/23/2003 adds: Continues to experience the following chronic problems: dizziness/difficulties with balance - feels like motion sickness with minimal movement; fatigue - diagnosed with Chronic Fatigue Syndrome. Continues to follow-up in Chronic Fatigue Clinic. He is now in a regular exercise program through the clinic. He has noted a slight improvement in his degree of fatigue since exercise was initiated; muscle and joint pain - no changes in joints and muscles involved. Diagnosed with Fibromyalgia. Treatment for pain has included amitriptyline, Wellbutrin, Vioxx and glucosamine. None of these treatments have decreased the pain significantly. Had a Rheumatology evaluation, which was "negative"; Short-term memory loss and difficulty concentrating - cognitive symptoms have worsened. He is awaiting further evaluation, including neuropsychiatric testing; Elevated liver enzymes - no significant changes. Continuing to be monitored. New problems since last VAERS report: Has had approximately 5 URIs lasting approximately 2 weeks over the past 10 months; Double vision and blurred vision. Evaluated at Cataract and Laser Center. Visual changes thought to be caused by "corneal erosion". Treating with eye drops and ointment, and may require laser treatment; Diagnosed with PTSD per VA counselor. Continues to see local VA counselor on a regular basis. Current medications: multivitamin, calcium and magnesium supplements, Vitamin C 2000mg q day, Vitamin B complex. Medically retired in 16 months. In order to make ends meet, he is living in his motor home.