Age: 30.0
Sex: M
Vaccine: ANTH
Symptoms: Insomnia, International normalised ratio normal, Joint swelling, Laboratory test normal, Liver function test normal
Clinical narrative: Received ANTHRAX vac 3/3/1999 (FAV036), 3/17/99 (FAV033), 3/31/1999 (FAV033), 9/13/199 (lot number unknown), 1/25/03, 2/3/04, 6/236/05, and 6/13/07. He remembers each injection site burning, being red and swollen, and having dull achy diffuse arthralgia (elbows, knees, hips) lasting approximately one week. Symptoms did not worsen with sequential vaccinations and did resolve with intermittent use of MOTRIN. (However, 2 days prior to AVA #2, he had been on 30 days of INDOCIN for right hip bursitis). He reported receipt of several other vaccinations before and after each Anthrax vaccine with no unexpected adverse events (1/25/2003 AVA #5, 2/13/2003 SPV) in February 2003 (< 30 days post vac) his wife reported onset of pruritic red pustular rash from anterior neck to navel in husband. His wife described this rash as a "heat rash with white heads". He denied any new clothing, food groups, detergents, deodorants, travel, pets, etc. There was no associated fever, malaise or chest pain. He treated with BENADRYL cream with resolution. (6/13/07 AVA #8) 23 Jun 2007 (day 10) focal pruritic skin rash c/o papules w/o pustules or other s/s over a 4" x 2" area over sternum x 1 day after working out. He was diagnosed with contact dermatitis and treated oral BENADRYL and hydrocortisone cream. 29 Sep 2008 he complained of 2 day history of lower right back pain, difficulty standing erect and sleeping after playing 18 holes of golf being diagnosed with back strain. That evening, he went to a local Emergency Room with additional complaints of "flu like"symptoms, chest pain, shortness of breath, and fever. He was admitted (9/30/2008-10/6/2008) for community acquired pneumonia and pleurisy per CXR. Following his release, he continued to experience generalized fatigue,  positional dizziness, and dyspnea on exertion (room air O2 sats 97-99%). By March 2009 he reported he felt able to return to his prior work status and was able to exercise reporting PRT run times as "good". However, he continued to report  persistence of fatigue, myalgia, arthralgia, chest discomfort, and wheezing with cold air (similar to Oct 2008 pneumonia). Follow up labs (March 2009) showed normal CBC with low platelets at 153 (169-413), elevated CRP 0.73 (0-0.33) and ESR 11 (0-9), normal chem, TSH, hepatic panel, testosterone, and negative nuclear Ab, RF, and Lyme Ab. His PFT's were normal with FVX 92% and FEV1 99%. Evaluation by Internal Medicine 4/7/09 documented his respiratory symptoms may be due to "post-pneumonia airway reactivity or irritant pneumonitis" and his knee/shoulder pains were likely due to "osteoarthritis". From 2/17/2010 to 3/23/2010 he presented to sick call complaining of recurrent shortness of breath. Providers diagnosed cold induced asthma exercised induced asthma. Given ALBUTEROL and SINGULAIR. He advised feeling only episodic relief. He was evaluated by medical several times between 7/13/2010 to 7/31/2010 initially complaining of a painful knot to right medial lower leg x 2-3 weeks and recurrent shortness of breath while running or at rest. Initial providers documented a tender palpable warm pink/purple knot suggestive of an insect bite and treated for cellulitis then phlebitis. Despite various antibiotic and steroid therapies, his symptoms worsened to include complaints of a deep constant 8/10 ache from his right groin to ankle, a palpable firm node to mid-medal calf, increased erythema and swelling to his ankle, and a tender palpable cord over the femoral vein. Bilateral lower chest pain and worsening shortness of breath began 7/30/2010 during a run being taken to near-by ER. He was admitted with right lower leg deep vein thrombosis and bilateral pulmonary embolism (see 7/2010 lab-diagnostic studies). AN IVC filter was inserted on 7/31/2010. As of August 2010, this SM is slowly recovering and is on COUMADIN. He continues to complain of shortness of breath with exertion. Symptoms: Swelling/mass/lump, localized superficial (782.2), Symptoms inv skin/integumentary tissue NEC (782.9), Shortness of breath (786.05), Rash, oth nonspecific skin eruption(782.1), Symptoms, inv skin/integumentary tissue NEC(782.9).