33 year old male received anthrax #4 and smallpox vaccines concurrently two weeks after anthrax vaccine #3.  He was deployed at the time and attributed his fatigue, arthralgias and myalgias to flying combat missions 9  10 hours a day.  He is unsure of the exact time of onset, but thinks it was about two weeks after receiving anthrax #4 and smallpox on 16 Feb 03.  These symptoms progressively worsened through Fall 2003.  He currently has joint and muscle pain most commonly in his back, neck and legs.  The pain is migratory throughout muscles and joints.  He rarely has pain in his arms.  The pain is intermittent and occurs suddenly.  He rates the sudden pain as 5-6 on a 0-10 pain scale.  The pain sometimes responds to repositioning and/or Tylenol, but it usually resolves spontaneously.  The duration of the pain in any particular muscle group or joint is variable.  The pain is worse in the mornings when he has "stiffness" and then lessens with movement.  He does not ever note swelling or warmth of any joint.  He has had a bone scan that was unremarkable.   In the summer of 2003 he began having abdominal cramping and diarrhea intermittently.  This now occurs daily and varies from 3  9 stools per day.  He has tried vitamins, changing his diet and supplements without any benefit.  He has not been able to identify any exacerbating or alleviating factors.  At this same time, he began to have headaches.  Prior to this, he had headaches about once a year.  They now occur daily.  He continuously has a headache that he rates as 2-3 on a 0-10 pain scale.  This headache will worsen without warning intermittently and then subside.  He has been evaluated by Neurology and is taking Tylenol as needed.  Chest pain or tightness began during this time also.  He felt constantly short of breath and had frequent chest pain so he went to the emergency room.  His EKG was normal.  He continues to have tightness and sharp, migratory chest pains daily.  The pain is not changed with deep breathing and is not positional.  Twice since last summer he has had palpitations that resolved spontaneously. In September or October 2003 he began to notice short-term memory problems that have worsened so that he now has difficulty with some long-term memory.  Dizziness began to occur during this same time frame.  It is occasional and does not result in vomiting.  Numbness and tingling in digits 3, 4, and 5 of both hands occurs intermittently, but not always simultaneously.  There is no associated pain and this does not restrict his ability to use his hands.  He is unable to estimate the duration of these occurrences.  Occasionally, he develops a "catch" in either shoulder that makes lifting his arm overhead impossible.  There is no sensation of weakness or pain, just the inability to lift the arm over his head.  This occurs once or twice a month and does not restrict his activity.  He also noted blurred vision in his right eye in the Fall 2003.  This is still present, but has not worsened.  He notices this only when he reads.  He has not been evaluated by Ophthalmology.  Tinnitus began during this time period also.  The sensation is bilateral, L>R, and intermittent.  It is loud "like a locust" when it starts.  This lasts for about 10 seconds and then fades to a dull ringing.  He is unsure of the duration of these episodes.   Sleep "was really bad" Fall 2003 to early Summer 2004.  This is improving so that he now gets about 6 hours of uninterrupted sleep a night.  He also feels refreshed upon awakening.  If he sleeps longer than 6 hours, his back pain awakens him. VAERS Update filed: 31 October 2006: An initial VAERS was filed on behalf of this patient by the Vaccine Healthcare Centers Network in October 2004. There has been no significant change in this service member's functional and physical condition, except subjectively CFS and memory have worsened since retirement. The service member continues to experience prolonged and disabling fatigue symptoms with intractable migratory arthralgia/myalgia, headaches, unrefreshing sleep, chronic diarrhea, impaired memory and concentration, and unexplained syncope. Last year he was placed on the Temporary Disabled Retirement List (TDRL) and he will undergoing re-evaluation to determine his medical disability. He was recently evaluated by Neurology and Rheumatology services (notes enclosed). He is pending GI consultation and repeat Neuropsychological Testing.