IMMUNIZATION  Vaccine Date Onset Date  SYMPTOMS Anthrax #3 05 Aug 2004 18 Sept 2004 Nodule to right deltoid for 1 ½ months following AVA #3 vaccination.  In Sept he complained of pain in both wrists that resolved in 1-2 days as it radiated to both knuckles and fingers for 2 weeks. Complains of periodic swelling to upper lip with hive like swelling to left forehead, right chest, left back that resolves with prednisone use.  History of Present Illness:    This healthy 23 year old reports receiving three Anthrax (AVA) vaccination in 2002 with a fourth AVA in April-June 2003.  However, his vaccination records record his first AVA as 30 Jan 2003, second AVA on 03 Mar 2003 and the third AVA on 05 Aug 2004.  He reports the 05 Aug 2004 vaccination was given in the right deltoid with a resulting nodule for 1 ½ months.  There were no associated symptoms (flu, paresthesia, myalgia, arthralgia or headaches).    He reports awakening on 19 September 2004 with "severe" pain to both wrists that prevented him from twisting or bending his wrists. Review of available medical records document he had been "working out and bent his wrists back bench pressing on 18 September 2004 with radiating pain into his right elbow". He went to medical on 20 September 2004 with resolving wrist pain; however the pain was radiating into both knuckles and fingers with accompanying swelling and pain (10/10 pain scale).  He complained of an inability to grip, hold objects, write, turn door knobs and that his fingers were curling.   He was diagnosed with left and right wrist strains and bursitis of the right elbow.  He was treated with Naprosyn.   From 9-14 October 2004 he complained increased bilateral hand swelling with decreased mobility.  He was re-evaluated on 14 October 2004 with a "normal exam with bilateral swelling".  Radiographic studies of his wrists/hands were normal and he was treated with Prednisone.  He reports awakening on 02 November 2004 with a painful hard swollen left "latissimus muscle" after driving all night.  He does lift weights 3-4 times a week, but denied any trauma, injury, weight lifting the day prior to traveling or alteration in routine.  He was seen by a family physician who treated him for a swollen back muscle, "anemia and an elevated sedimentation rate" with Prednisone and an "L" named medication for hives and allergies.   Allergy and Immunology examined on 24 February 2005 for persistent random episodes of angioedema to his joints, back, shoulder and lips. He denied any history eczema, respiratory distress, change in ADL, no new foods (seafood), detergents or oral/skin products.  He reports hive allergy to "cillins" with no recent exposure, seasonal allergies and has a dog with known history of long hair dog-cat allergies.   He was restarted on a Prednisone taper, Allegra, Zantac and emergency Epinephrine Pen use was reviewed and supplied.  He is for follow up in two weeks.  As of 01 March 2005, he reports sleep deprivation and or insufficient sleep as the only known triggers for this swelling. He continues to exhibit periodic "hive like swelling" to his forehead along the hairline, the left lateral latissimus muscle, and his right anterior chest wall when not taking Prednisone.  He reports the swelling occurs 2-3 times a week depending on his activity.    He was also evaluated by Rheumatology for "recurrent episodes of questionable angioedema treated with prednisone" on February 24, 2005. He reported "frequent episodes of swelling of various areas of his body (lips, back and hands) that were vague in nature, severity and frequency."  His last occurrence was January 31, 2005 where he was seen in the ER (no records available). Laboratory studies obtained on 13 December 2004 showed a positive ANA 1:320 homogenous, a low hemoglobin/hematocrit (13/38), normal TSH, a negative Rheumatoid Factor, low total protein at 6.2, and albumin at 3/2 otherwise normal lab.  Doctor diagnosed him with questionable angioedema with lab work still pending, no evidence of systemic rheumatic disease, reactive airway disease-exercise induced asthma and to follow up with allergy and Immunology.  Pending labs as of 24 March 2005 included C3, C4, CH50, ESR, CRP, Cr esterace inhibitor and urinalysis.  He reports being diagnosed with asthma in 2004 and questions association of anthrax vaccinations with exacerbation of asthma.  Medical records document an emergency room visit for new onset wheezing, exertional shortness of breath on 14 August 2003 with a "probable diagnosis of asthma".  He was placed on Albuterol and Prednisone with refills given twice between August-September 2004 for a diagnosis of "exercise induced asthma".  He reports initial evaluation of his asthma in April 2004 (no records available) after failing his second PRT.  His medical records document pulmonary function test (PFT) from January 9, 2004 as "normal spirometry" (pre FVC 6.08 & FEV1 4.87).  He denies nocturnal awakening, feels short of breath with moderate exercise and wheezy all day.  Albuterol helps but he still was unable to pass the run portion of his PRT.  On 2 February 2005 after failing his third PRT, his command requested further evaluation of his asthma by Pulmonology, Rheumatology, and Allergy and Immunization.  He was re-evaluated on February 24, 2005 where he was diagnosed with uncontrolled asthma, controlled rhinitis and monoarthritis to the right hand.  His repeat PFT's again were interpreted with "normal spirometric values indicating the absence of any significant degree of obstructive pulmonary impairment and/or restrictive ventilatory defect."  FVC 5.94 ? 5.81 and FEV1 4.63 ? 4.56.  He continues to deny nocturnal awakening. He continues to note shortness of breath with moderate exercise and feels "wheezy all that day".  He was instructed to continue use of Advair, Flonase, Albuterol and Singular.  As of March 1, 2005 he reports no exacerbation of his asthma and uses the rescue inhaler with exercise only.