During the mid to late part of November 2003, the client reports that she experienced fever, chills, and night sweats. She also developed recurrent left subclavicular lymphadenopathy, which was reported larger than previously noted. Again she thought that this was related to her vaccination and "just sucked it up" and did her assigned job. On 15 December 2003, she could no longer live with the symptoms. She reports that her supervisors said she "was not tracking right " and "was not herself". She report to sick call and was evaluated. In addition to her previous symptoms she developed a sore throat (9/10) and had difficulty staying awake. He hemoglobin was 11.2, hematocrit 31.3, WBC 2.8 and platelets 78. She was diagnosed with URI, R/O strep throat and anemia. She was placed sick in quarters (SIQ) for 24 hours. In addition, she received 1.2 million units of Bicillin IM and given instructions to return to clinic (RTC) if conditioned worsened.  On 16 December 2003, the client returned to sick call for follow-up care. She stated no improvement of symptoms, and had developed diarrhea. A Monospot and rapid strep test were done to R/O mononucleosis and strep throat. Both tests were negative, as was the throat culture (reported on 27 Dec 03). A complete blood count (CBC) was again drawn and revealed hemoglobin 11.2, hematocrit 31, WBC 2.7, and platelets 90. She was once again placed SIQ for 48 hours and started on Azithromax for suspected mononucleosis. She was instructed to follow-up in the AM, however no documentation exists in her medical file to document follow-up.  On 27 December 2003, the client once again reported to sick call at 1515 hours.  She stated that she experienced nausea and vomiting every time she ate for the previous week. She was also experiencing fever and chills that resolved with Tylenol. She was also experiencing night sweats from which she says she awakens "soaked". The medical records reflects an ~ 11 pound weight loss over a ~ 6 month period. The client related feeling very weak and without appetite.  Physical examination, according to the medical records, revealed left retro-sterno cliedomastoid lymphadenopathy along with left supraclavicular lymphadenopathy. Completed blood count revealed hemoglobin 10.1, hematocrit 26.8, WBC 2.9 and platelets 126.  In addition, her calcium was low at 8.1, phosphorus low at 2.3, alkaline phosphate low at 35 and LDH elevated 280. An analysis of a blood smear revealed hypochromatic, microcytic erythrocytes, few reactive lymph, no blast cells or teardrop erythrocytes or schistocytes. Her erythrocyte sedimentation rate (ESR) was elevated at 40. She was diagnosed with pancytopenia with associated neck Adenopathy and elevated ESR and LDH. The decision was made to Medivac the client for definitive anemia workup.  On 31 December 2003, the client was aeromedical evacuated.  The physical examination located in the client's medical records reveals bilateral anterior cervical lymphadenopathy with three (3) palpable nodes on the left and one (1) and one (1) lower occipital region, otherwise exam was normal. Review of laboratory data for admission revealed hemoglobin  10.1, hematocrit 31.1, WBC 2.2 and platelets 146. Her anti-neutrophilic cytoplasmic antibody (ANCA) was elevated at 814. While a patient, laboratory studies were done including sickle cell screen, Parvo, EBV, CMV and malaria titers. The EBV and malaria titers were negative, as was a sickle cell screen.  Her CMV and Parvo were, as expected, positive. Anemia work-up revealed a serum iron low at 45, ferritin high at 491, B12 and folate were normal. Her chest xray was normal. On 04 January 2004 the patients record reflects the following laboratory data:  hematocrit 30.5, WBC 1.9 and platelet of 131. Her neutrophils were 1100/mm3 and LDH was elevated at 1031. In addition her ANCA was reported as being  >1000. She was also evaluated by psychiatry during her stay at LRMC and was diagnosed with adjustment disorder with depression and anxiety.  On 11 January 2004, the client was aeromedical evacuated from overseas to the USA. Upon initial evaluation the client was found to have 1-2cm X 1cm anterior cervical chain lymphadenopathy, as well as 1 X 1 cm occipital lymphadenopathy. Her laboratory data revealed hemoglobin low at 9.4, hematocrit low at 27.6, WBCs low at 2.2 and platelet count of 125. Her complete blood chemistry demonstrated an multiple elevated values including  ALT 127, AST 72, LDH 786, and TSH 5.67.  She was seen and evaluated by hemo-oncology and a bone marrow biopsy was done which was reportedly within normal limits. She was also seen and evaluated by psychiatry. She was not diagnosed as having adjustment disorder as previously listed by team.  The client was prepared for discharge on 16 January 2004. Her final laboratory data included the following: hemoglobin 9.1, hematocrit 26.9, WBCs 2.7, RBC 3.16. It was decided to place the patient in a medical holding unit on neutropenic precautions until she is further evaluated 7 days after discharge.  The Vaccine Healthcare Center was asked to evaluate the patient to determine whether her clinical symptoms and presentation were related to her anthrax and smallpox vaccinations in October 2003.