Age: 47.0
Sex: M
Vaccine: ANTH, FLU3, HEPAB, SMALL, TD, TYP
Symptoms: Actinic keratosis, Arthralgia, Asthenia, Back pain, Basal cell carcinoma
Clinical narrative: This patient reported receipt of AVA #1 (FAV096), Td (U1347AA), IM influenza (U1936AA), DRYVAX (4020072), Typhoid ViCP (Z0042-2), Hep A/B (AHABB030BA), and TST-PPD (C2155AA) on 3/06/2006. Less than 24 hours later he recalls the white portion of left eye turned bright red, upper and lower lids itched, and eye drained clear watery fluid. He also noted brown skin patch to left side of forehead. He went to office and was placed on steroid eye drops and given cortisone cream to use about eye which helped. He recalls being told he had psoriasis on forehead. He reported it took about 6 months for redness in left eye to resolve; however the itching continued. A review of medical records documented 12 skin evaluations from August 2006 to 2008 including evaluation by Chief Dermatology for flesh colored plaques to right temple; scaling tan macules to left temple; numerous tan macules to trunk 2-3 mm in size with 3 mm flesh colored papule on right lower back; and complaints of "black dots under the skin" to his left foot. Shave biopsies of right chest in March 2007 had histopathologic findings consistent with basal cell carcinoma (BCC). Diagnoses given included seborrheic keratosis (SK), actinic keratosis (AK), nevi, and intradermal nevus (IDN) with unknown rash to left foot (had resolved so no rash to review). Orthopedic evaluations were identified in April 2008 for chronic pain down medial aspect of right knee. He reported a long history of right knee problems of NSAIDS, brace and various pain medications since 1979 when fractured femur with spine compression following a parachute accident. Provider gave diagnosis of DJD-trauma. On 11/4/2008 prior to trip as contractor, he received TIV influenza (AP lot # not reported), typhoid ViCP (AP B03472), Hep A/B (GSK AHABB132AC), and TST-PPD Intradermal (PMC C1812AA) On day 4 (Saturday 11/7/2008) he reported onset of a skin rash to his left collar bone as small red bumps that itched. His right shoulder was sore from the shots. He advised in an email correspondence to clinic on 11/29/2008 that he had not gone for any medical care but self treated with anti-itch medication which did improve skin redness stating it "just itches under the skin". His medical records document on 7/3/2009 he reported being in a mortar attack which resulted in sweats, headaches and "thought I was having a MI with tight ball on chest". He reported going to bed with a fever, palpitation, myalgia, joint pain-stiffness, fatigue and was hyperventilating. He awoke the next morning with 3 chest blisters that itched badly and this aching continued for 2-3 days with exhaustion. He reported these 3 lesions had pus on top and they went away in 2 weeks. He also had non pustular macular lesions on his legs. These blisters returned 8/20/2009 but were dry. On 8/20/2009 he reported lesions inside his mouth that would come and go for 2-3 days at a time. Patient advised a "physician told him  (8/28/2009) it was an auto immune response and that they saw a lot of this in the area". An interpretation of the provided note documented complaints of a painful, itchy rash to arms and chest for 1 week. Exam listed microvesicles, papules from scratching and furnicles. He was diagnosed with osteofolliculitis. He was treated with alcohol solution 1x/day, doxicaine ointment x 5 days, given prescription for multi -complex vitamin B and to bathe in diluted K-permanganate solution. He advised another provider placed him on doxycycline that cleared up the "psoriasis" on his forehead but it had no effect on abdominal lesions. He questions whether this rash is related to prior "vaccine rash in 2006". On 2/9/2010 patient reported to Internal Medicine at hospital complaining of pruritic rash with severe joint aches. His wife stated he has a dry hacking cough, chronic fatigue and had intermittent diarrhea. Provider documented normal exam with skin showing 1 mm erythematous dry lesions without central ulcerations to his abdomen, arms, chest, shoulders, and neck. "Although in right demographic area and right risk factors, appearance of skin lesions and clinical history not consistent with leishmaniasis". Will check baseline labs, CBC, CMP, HIV, RPR, eosinophilia and liver enzymes, antibody test to rule out cutaneous leishmaniasis." Will refer to dermatology for RAST (result not located). Further evaluations continued through 2011-2012 with providers giving diagnoses of folliculitis, xerosis and irritated SK. In 2011 he also reported he saw a chiropractor and had physical therapy for chronic neck/back/hip pains.  In 2011 he moved and was seen at a hospital where dermatology performed 3 shave biopsies on 3/10/2011 with following results: shave biopsy right leg: papulosquamous dermatitis; right temple: hypertrophic actinic keratosis; and upper back: papulosquamous dermatitis There has been no change to these skin outbreaks as of 2012. In April 2012, he reported outbreaks of skin lesions about 2-4 months for 2 weeks at a time for a total of about 10-12 events since 2010. His last episode was 2 months ago (about Feb 2012) and one before that about Nov 2011 which lasted about 2 weeks each. He advised 1-2 days prior to skin rash eruption, he experiences chills, muscle cramps and sometimes subjective fever, sweats, weakness, or irritability. Dermatological diagnoses in 2012 included actinic keratosis and papulosquamous dermatitis. He described his myalgia/arthralgia as a constant crampy tight feeling to all muscles with tight achy feeling in a ll large joints (knees, hips, ankles, wrists, back, etc). He reports increased fatigue but can work, perform normal ADL, and does run (ran up to "50 mile" but now can only go 5-7 miles before feeling drained). He reported being "wiped out" after runs and goes home and sleeps. He does have refreshing sleep. These symptoms appear to worsen a few days before the "rash" outbreaks occur. On 3/15/2013 patient emailed clinic stating he found another individual with similar symptoms who was treated for "unknown parasite similar to scabies" with Ivermectin and permethrin. Patient will discuss with his PCP in the treatment of his rash. Note: this provider had no hard copies of any medical records for review (no PCP name provided, no labs, diagnostic studies, etc) despite requests for. Causality assessment completed with available medical records and HPI from pt.