Local reactions, chronic fatigue, persistent upper extremity weakness. A 36 year old active duty soldier reports ongoing weakness, fatigue and hand pain and swelling that may be related to receipt of the anthrax vaccine. Patient current undergoing evaluation of chronic low back pain, with initiation of an MEB pending. Prior to OIF deployment, patient considered himself to be in good health and since receiving anthrax vaccines 4-6, he has experienced multiple persistent symptoms. Patient experienced mild local reactions and flu-like symptoms following receipt of anthrax vaccines 1-3. (He reports that there 14 mechanics in his unit who had similar reactions following their first 3 anthrax vaccines.) His local reactions included a small knot at the vaccine site, with redness, swelling, itching and tenderness surrounding site that lasted about 3-4 days. His systemic symptoms included fever and chills (felt too hot to sleep and his legs were sweating, but he felt chilled), mild headaches, feeling weak and fatigued. These symptoms usually resolved after 2-4 weeks. After patient received anthrax vaccine #4 in August 2003, he experienced a local knot which surrounding redness and swelling ( about 3 inches in diameter) that lasted about 1 week. He experienced tenderness at the site with muscle use, movement, and pressure to area, which lasted 1-2 months. After receipt of Anthrax vaccine #4, patient's feelings of weakness and fatigue did not resolve after 2-4 weeks. He found that the needed to pace his activities and that most task were taking longer to perform. He often had to ask for assistance. This has continued and he describes as "not feeling energetic" and not having "gumption to get things done". If his baseline energy level before March 2003 is rated has 100 and being bedridden due to lack of energy is rated as 0, patient rates his current energy level as 85.  He also noted new onset of upper extremity weakness that started about 2 months following vaccine receipt. As an example, when patient is holding something overhead for more than 5-10 minutes, he notes shaking of upper extremities and feels like he is going to drop it; at times, the weakness has prevented patient from doing his job. Weakness only noted when carrying or lifting. Notes accompanying joint stiffness and muscle aching that lasts a few hours. He denies any numbness or tingling in extremities. Although the weakness continues, patient has not sought evaluation or treatment. Patient reports new onset of pain and swelling in both hands, located over the palms and around the thumbs. Pain described as "soreness". Onset was 2 months following anthrax vaccine #4. The aching continues intermittently. It usually lasts 3-4 hours. It is aggravated with increased use of his hands. As an example, if using computer mouse for more that 1 hour, his palmar area and forearm become sore and stiff and ache and throb. Sometimes, when he is experiencing the pain, he is not able to open his hand and describes as having "to pry open grasp". He has no history of hand trauma. He denies a history of cold weather injury, but notes that cold exposure increases the aching. The pain is severe enough that he is not able to carry out activities of daily living or work related activities as a mechanic. After patient received anthrax vaccine #5 in February 2004, he had a large local reaction. His local reaction was worse that previous reactions following receipt of anthrax vaccines. Redness and swelling  surrounding the vaccine site extended from just below should to his elbow. This area remained tender, red and swollen for 4 weeks. He also had a small knot (about the size of a quarter) that lasted about 3-4 months. The area is till tender if bumped or if deep pressure is applied. He does not recall a definite worsening of any of his other symptoms (fatigue or upper extremity weakness). Following anthrax vaccine #6 in August 2004, patient had a moderate local reaction; he describes as less swelling and redness than following anthrax vaccine #5. the tenderness lasted about 1 month. He does not recall a definite worsening of any of his other symptoms (fatigue or upper extremity weakness). Current problem list: history of local reactions and viral type symptoms following anthrax vaccines, upper extremity weakness, mild, chronic fatigue, mild edema and myalgia in hands. Prior to August 2003, patient would generally feel rested after 4-5 hours. Now, he is usually sleeping 4-5 hours a night, but does not feel rested upon awakening. Denies longstanding history of snoring, restlessness, apnea, gasping, or lower extremity sensation of crawling or itching. Over last month, roommate has noted snoring and patient awakening to catch breath.