IMMUNIZATION  Vaccine Date Onset Date  SYMPTOMS Anthrax 1 1/5/1999  Day of vaccination Typical adverse events of localized edema, redness and soreness that lasted approximately one week.  Over the next 4-5 months he began to experience major mood swings, increased irritability, short term memory lose, inability to focus on tasks given, had difficulty answering questions, and was having severe "acid reflux".  Each vaccination made symptoms worse. Anthrax 2-4 1/20/1999 2/03/1999 5/17/1999   Anthrax 5 11/27/1999  Typical adverse events of localized edema, redness and soreness that lasted approximately one week.  He reports difficulty functioning, feelings of inappropriate guilt, fears of things falling apart, fearing the worst would happen, nightmares, short sleep intervals 1-3 hours each, fatigue, exhaustion and depression symptoms.  He states he lost all interest in activities of daily living, had morbid thoughts but no attempts made to harm him-self or others.  He complained of physical exhaustion as if all tasks were monumental and not worth it, things took longer to complete.   Anthrax 6 5/23/2000   Typical adverse events of localized edema, redness and soreness that lasted approximately one week.  Over the next year (2000-2001), similar depressive symptoms returned.  They became "intolerable" in August 2001 when he sought medical care. Anthrax 7 11/24/2003  Typical adverse events of localized edema, redness and soreness that lasted approximately one week.  Continuation of above symptoms: insomnia, depression, headaches, nightmares, etc.   History of Present Illness:    This 37 year-old entered the service in 1984.  Over the next fifteen years, his medical records document treatment for several episodes of folliculitis/keratosis pilaris (thighs, groin), yearly episodes of upper respiratory infections, sinusitis, pneumonia in 1987, tension headaches in 1989, lower back pain in 1991 and shingles in 2000 and chronic heartburn (age 8).   He received his first anthrax vaccination on 5 January 1999 with sequential vaccinations on 20 January 1999, 3 February 1999, and 17 May 1999.  He reports each vaccination had typical adverse events of localized edema, redness and soreness that lasted approximately one week.  However, 4-5 months after each revaccination he began experiencing major mood swings, increased irritability, short term memory loss, inability to focus on tasks given, difficulty answering questions, and was having severe "acid reflux".    GI problems: His medical records document numerous military evaluations for heartburn beginning October 29, 1999 to present.  Rolaids initially resolved his symptoms, then Zantac.  In 1999, he was referred to general surgery for an EGD procedure that documented two healing duodenal bulb ulcers ("25-DU'-clotest neg antral gastritis and no HH or GERD changes").  He was treated for H. Pylori and given Prilosec prior to deployment.  Over the next several months, he voiced improvement in his symptoms with resolution of the retrosternal burning pain; however, 4-5 months after starting the Prilosec he had a major depressive episode and it was discontinued (3/2000). He was compliant with low-fat diet, not obese, did not smoke or drink.  A trial of Zantac was begun; however he reports Zantac and Pepcid afforded minimal relief. It was determined the proton pump inhibitors (PPI's) were potentiating his symptoms of depression and stopped (4/2000).   Over the next 2-3 years he continued to complain of regurgitation of stomach contents with bending over with frequent flares of symptoms depending on his position and foods eaten.  He was seen on 27 November 2002 with a diagnosis of GERD, resolving bronchitis, depression history and sleep apnea.  He was treated with Aciphex.  He stopped the Aciphex approximately 14 April 2003 with onset of depressive symptoms. He was re-evaluated on 23 June 2003.  He was again diagnosed with classic gastroesophegeal reflux disease.  The options of lower dose H2 blockers versus injection of the lower esophageal sphincter or laparoscopic Nissen fundoplication were discussed after review of esophageal motility, ph monitoring and EGD results completed on 10 July 2003.  The motility test showed low LES pressure with complete relaxation, progressive peristalsis but decreased amplitude.  The Johnson+DeMeester pH threshold documented 212 episodes of reflux during  15 hours 40 minutes upright, 33 episodes during 6 hours 17 minutes supine with a composite score (normal <22) of 68.9.  The EGD showed a normal hypopharynx, grade II erosive esophagitis, sliding medium hiatal hernia, a probable Schatzki ring in the esophagus, three short tongues of columnar appearing mucosa above the GE junction which might represent Barrett's with open hiatus and normal pylorus and duodenum.  Referral for antireflux surgery and repeat EGD and biopsies for Barrett were recommended.  On 22 August 2003 performed a laparoscopic Toupet Fundoplication and colonoscopy.  Results documented a normal colonoscopy and laparoscopic Toupet fundoplication.  An esophageal biopsy 25 May 2004 showed gastroesophegeal mucosa with acute and chronic inflammation and reactive epithelial atypia with no intestinal metaplasia identified.  An EGD on 25 May 2004 showed a normal hypopharynx, pylorus and duodenum.  There was columnar appearing mucosa extending above the gastric folds for a distance of 2-3 cm with no erosive changes seen.  There was erythema present on retroflex view and the wrap was intact.   As of December 21, 2004 he continues to follow up with gastroenterologist for complaints of "gas, indigestion, diarrhea, and intermittent abdominal pain" that resolve within 1-2 hours after meals.   He continues his Nissen low-fat diet and is on Zantac.  Depression: He reports receiving his fifth anthrax vaccination on 27 November 1999.  During November 1, 1999 through February 17, 2000 he reports deterioration of his health despite feeling better using Prilosec and completing the antibiotic regime (H. Pylori).  He reports difficulty functioning, feelings of inappropriate guilt, fears of things falling apart, fearing the worst would happen, nightmares, short sleep intervals 1-3 hours each, fatigue, exhaustion and depression symptoms.  He states he lost all interest in activities of daily living, had morbid thoughts but no attempts made to harm him-self or others.  He complained of physical exhaustion as if all tasks were monumental and not worth it, things took longer to complete.  While deployed he began to cry for no reason and went to medical where he disclosed all the above symptoms.  He stated symptoms began in 1999 but he just tolerated believing it was stress related.   He was evaluated February 2000 where he was diagnosed with a Major Depressive Disorder and placed on Zoloft.   He was transferred where his command placed him on shore duty for continued monthly psychiatric care and weekly discussion groups.  His depressed moods improvement with no further tearful breakdowns, but did experience "distracted state" with severe insomnia, anhedonia, low energy, fleeting suicidal ideations without plan or intent, feelings of anxiety and guilt, morbid thoughts of death and appetite inconsistency. Prior to receiving the Anthrax vaccinations, he states he never had any of these depressive symptoms and could handle stressful situations.  He received his 6th anthrax vaccination on 23 May 2000.  He reports increased energy after being placed on Zoloft but had leg tremors, continued insomnia and early morning awakening (2:45-3 am).  He could exercise again but felt exhausted afterwards, was apathetic towards his self safety and was more aggressive when challenged by others.  He was place on limited duty for 6 months while under review for medical board (07 March 2000-13 July 2000).  At his 6 month evaluation on 13 July 2000 documented resolution of all symptoms of major depressive disorder while off Zoloft for three weeks and psychologically fit for full duty.  He recommended that this service member be returned to full active duty.  He was reassigned to a special boat unit within his squadron for the next two years as there were no ships available.  He reports being frustrated but not upset as this was "outside his career path."   Over the next year, similar depressive symptoms returned.  They became "intolerable" in August 2001 prompting him to re-seek medical attention.  He was restarted on Zoloft and Ambien which "took the edge off his suicidal thoughts" and thus he believed the medication was "effective".  He continued using Zoloft for several months considering retirement as his career was not progressing and was transferred back to sea. He later stopped taking Zoloft due to complaints of sexual dysfunction (all three types). Symptoms of early wakening, decreased sleep, motivation, attention/concentration and energy fatigue, tiredness and apathy began approximately March 2003.  By April 2003 he again required psychiatric intervention for reoccurring depressive disorder.  He was restarted on Zoloft 100-200 mg BID.  Follow up evaluation 07 May 2003 documents no improvement and his medication was changed to Wellbutrin SR 150-300 mg.  He reports the Wellbutrin helped; however feelings of inappropriateness, guilt, fatigue, a heightened fear of heights which he never felt before, et al continued but at a tolerable level.  He admits to continued nightmares where his wife wakes him to stop.    Sleep disturbance Multiple psychological evaluations document difficulty with gagging, insomnia, sleep disturbances (2-5 hours a night) with early rising began with the diagnosis of depression in 1999.  On 24 July 2003 for  "evaluation of obstructive sleep apnea (OSA)" secondary to complaints of headaches, excessive daytime somnolence, Epworth sleepiness scale = 17, positive snoring and witnessed apnic episodes.  His snoring was affecting his relationship with his wife.  Doctor documented cardiopulmonary studies showed positive RDI=19.2 and low O2 Sat = 89%. His past surgical history included history of a deviated septum (boxers nose), orthognathia adjustment and maxillary surgery.   He was diagnosed with OSA with EDS and placed on CPAP 8 cm H2O titration.  An overnight polysomnogram/CPAP titration study completed 14 August 2003 documented lowest O2 saturation at 89% with average at 98%, overall positional-respiratory at 0.1 apnea-hypopnea index (events/hour), with recommendations of CPAP setting at 8 cm H2O.  By September 2003, he was sleeping better and his snoring had resolved.    Headache and Cognitive dysfunction He also complained of daily headaches since 1999 he associated with stress, fatigue and exhaustion.  He describes the headache as located behind his right eye that radiated/moves to the back of his neck.  He describes the pain as a "stiffness that needs stretched out."  His headaches would change with coughing, worsen when bending over or standing up too fast.  He complained of blurry vision stating it took extra effort to see at a distance.  He reports normal eye exams with no need for glasses.  He complained of one headache that "put him on the floor a few times". He voiced the "sudden onset of sever headaches that come on with sex".  He describes the pain as an "explosive" usually before orgasm but happens even with foreplay.  He describes the pain as a mild, throbbing, occipital, bilateral neck pain that feels tight but with full range of motion. Evaluation on 29 August 2003 diagnosed new onset severe headaches probably sex-associated migraines, rule out AVM, s/p fundoplication, OSA with CPAP.   A cat scan of his head on 17 September 2003 documented no acute intracranial process and unremarkable Circle of Willis when evaluated for an AVM.  There are no further medical records available pertaining to evaluation of his headache.  He stated he continues to have 1-2 severe headaches every few months without regularity.   He complains of periodic dizziness with positional changes giving a sensation of feeling "off centered" when kneeling or squatting that causes him to fall.  Because of his major depressive symptoms, he is "more aware of these symptoms now verses 2-3 years ago".   He further voices complaints of difficulties with short term memory retention/recall, he is unable to retrieve past memories, is slow to respond, loses thoughts, has problems with word association, numbers and phone numbers, has problems performing more than one task at a time, and stutters in front of others.  He states it takes more effort to remember or retrieve data.  For example if he looked at phone number he could not dial the number or if making an omelet and toast he could not do both.  He needs people to speak up and slowly for him to comprehend.  He needs to reread books, data because his mind frequently wanders or is distracted and he must start over.   He states alteration in activity of daily living or routines will cause him anxiety.  He gets lost easily requiring notes to advise what he is doing and directions to get to a location.  He is unsure when these symptoms began, but associates them with onset of depression and anthrax vaccinations.