CC:  Left arm swelling x 3 days following AVA #4; myalgia, arthralgia, fatigue, headaches, sexual dysfunction, and short term memory loss with forgetfulness and word association problems 2-24 months following AVA #4.  History of Present Illness:    This healthy 34 year-old began his anthrax vaccinations on 11 November 1998.  He received the next two sequential shots on 27 November 1998 and 29 December 1998 with his only complaint being pain and soreness to the vaccinations sites lasting one day.  Motrin relieved this pain.  He received his fourth anthrax vaccination on March 27 2000.  He reports within 8-12 hours his left upper arm was red, swollen to twice its normal size, tender to touch with his left hand feeling numb, cold and tingling.  He denies fever or limitation in movement.  He reported to medical clinic on 30 March 2000.  It was documented the left arm with "moderate edema with erythema noted from the mid inner arm to just below the elbow, FROM, extremity intact, no red streaking full distal sensation and circulation."  He diagnosed this patient with rule out cellulitis due to the anthrax shot.  He was treated with Motrin, Benadryl and cold compresses with resolution of symptoms within three days.   Approximately May 2000, he reports periodic episodes of forgetfulness, being absent minded, and having difficulty with word recollection.  He reports his wife and co-workers began to comment on this over the next two years.  He is vague in describing these symptoms stating he believes he is saying one thing only to be saying another or the intent of his message is not properly voiced.  This has become problematic at work when assigning tasks to others.  He reports he frequently reverses numbers and writes items down wrong. This has increased his frustration levels and he finds his patience is not what it use to be.  His wife tells him his temper is getting worse. He has consulted a psychiatrist who advised him he has Attention Deficit Disorder approximately January 2005.  He was placed on a "Concerta (Ritalin)" with minimal results; however, he does admit to feeling calmer. (Medical records are unavailable.)  He also complains of increased frequencies of headaches since receiving AVA #5.  He denies headaches prior to this anthrax vaccination except in association with upper respiratory infections (URI) or flu like symptoms.  He states his headaches are centered to the top of his head and radiates to the occipital region.  He describes the pain as a "pressure sensation" at a 4/10 scale with rare visual blurriness.  He reports this pressure can last one day resolving with sleep or by taking an aspirin or Motrin. He reports a history of seasonal allergies (dogs, cats, dust), frequent URI's, viral-flu syndromes and sinusitis, and was advised he needed glasses for distance in 2004.  He does not routinely wear them.  He also reports a history of high blood pressure for 9 months in 2002 that resolved with diet and lowering his cholesterol.  He reports a gradual onset of fatigue with periodic myalgia and arthralgias since May 2000 that has become progressively worse.  He describes his fatigue as needing to sleep longer.  He slept six hours nightly five years ago and now requires nine hours nightly.  He denies the need for naps.  He reports muscle aches to bilateral arms and legs after a variety of activities from rest to moving ten boxes.  He reports a vague periodic joint stiffness to his ankles and fingers bilaterally that can inhibit his ability to grip objects.  Motrin or aspirin relieves these discomforts.  He lives with his wife and three children and works as an aviation mechanic.  He has not sought medical evaluation for any of these complaints (headaches, myalgia, arthralgia or fatigue) except in association with the flu.   He is concerned about the gradual loss of hair as no one in his family is balding and questioned relationship of anthrax with sexual dysfunction-low sex drive.  He denies any problems at this time however on 28 September 2000 he did seek medical evaluation for both; diagnosed with malaise.  Laboratory studies were normal (TSH, CBC, Chem 12) with a negative ANA, Mono and ESR.