Developed symptoms of Grave's disease within 30 days of receiving his 3rd anthrax vaccine. (Grave's disease not dx'd until 12/05). Symptom: Depression (stared 4/03), Flu-like symptoms <96 hours (started 3/03), cough after eating, sweating, especially at night, heat intolerance, diarrhea (increase in loose stools). All symptoms resolved after treatment for Graves' disease initiated. Service member does not recall experiencing any unusual or significant local reactions with either of his 1st 2 anthrax vaccines. He does not recall experiencing any significant or unusual or prolonged systemic symptoms within the 1st few days to weeks following receipt of his 1st 2 anthrax vaccines. He believes he experienced some flu-like symptoms (generalized body aches and malaise lasting a few days). Within 30 days of vaccine receipt, he recalls being very depressed. However, he did not seek evaluation until the following year. At that time in 2004, he was placed on Zoloft, which seemed to help his symptoms. It was not until 2005, when he started treatment for his Graves' disease that he noted further significant improvement/resolution of his depression and stopped his Zoloft without experiencing a recurrence. Other symptoms noted between 2004 and 2005 were heat intolerance, increased perspiration (specifically at night, would wake up soaked) and more frequent loose stools; these symptoms resolved after initiation of methimazole in 12/05. Around 8/05, he noted numbness in his ring and middle fingers of his left hand and within 2 days, his left hand was totally numb. He was evaluated by a Neurologist in 12/05. By the time of his Neurology evaluation, he was also experiencing tingling in his left foot and right hand. An upper extremity nerve conduction study was consistent with carpal tunnel syndrome. He was treated with splints and elbow pads, and later, ibuprofen, without significant improvement. He is still undergoing neurological evaluation. In addition to service member's concerns regarding a possible relationship between his neurologic symptoms and the anthrax vaccines, he is also concerned about a link of these symptoms to possible Sarin and Cycloserine nerve agents he may have been exposed to during the Gulf War. Currently the service member continues to experience tingling in hands and feet, most prominent at base of palms, 3 middle toes, and balls of feet, and worse when boots off or when wearing tennis shoes (not so much when wearing boots). Also feels that his lower extremity strength may be "weaker". 12/2005, Goiter, toxic diffuse; Graves' disease, symptom onset with temporal association to receipt of anthrax vaccine (3). He also had sensory neuropathy. I recommend that he use a wrist brace on both hands and Advil or Aleve twice a day. Recommended  him to a neuromuscular physician. 1/18/06, Impression: Graves' disease, mild to moderate in severity; goiter, mild. Plan: I started Tapazole 10mg, 1 tablet po daily and I will repeat thyroid profile and comprehensive metabolic panel in the middle of April 2006 and re-evauate the pt at the end of April 2006. 8/15/05: Numbness and paresthesias in the left fourth and fifth digit of the upper extremities, onset after doing outdoor work 3 days ago. Numbness has for the most part resolved and he has been left with paresthesias. Sensory neuropathy as above, possibly due to ulnar injury/overuse or repetitive use. Encourage to use elbow rest with activities on the computer, vitamin B6 and avoid repetitive use if possible. 1/3/05: Also complains of occasional difficulty swallowing with a sensation of something being "caught in the throat". Assessment: Hypothyroidism; suspect autoimmune with subjective complaints as above. 3/27/06: He has an appt. with a neurosurgeon to address L5-S1 H&P which was noted on MRI. Assessment: Polyneuropathy questionable etiology, possibly related to Gulf War exposure as above versus autoimmune neuropathy particularly given thyroid disease. Permanent exemption to anthrax vaccine. If exposed to Bacillus anthracic: Give ciprofloxacin of AVA after risk evaluation by a person skilled in the management of vaccines adverse events. All future vaccine should be given on a risk vs benefit basis and should be given individually with 7 days between doses to assess for exacerbation of symptoms.