This 32 year old patient contacted HC with concerns that his health issues resulted from receipt of "contaminated" AVA vaccinations. On 12/11/2002 he received AVA #1 (FAV065). He denied any health issues "bench pressing 200+lbs and was very active". Immediately after his vaccination he complained the site was burning and it quickly resolved leaving only soreness at the vaccine site and a nodule formation that lasted 2 weeks before fully resolving. On 12/29/2002 he received AVA #2 (FAV066) with similar site reaction and resolution. On 2/03/2003 he received AVA #3 (FAV066) with similar site reactions (burning, soreness, nodule); however on 2/15/2003 (day 12 after 3rd AVA vaccination) he complained of 3 days of nausea, vomiting, blood in urine/bowels. He reported being treated "in country" with diagnosis of kidney stones (per patient). A review of his medical records identified evaluation on 5/3/2003 (3 months after AVA #3) for 3 days with n/v/d with dizziness and "blood" in urine described as "orange colored urine". His initial UA showed 3-5 RBC/hpf with normal chemistry and CBC. A repeat UA after IV hydration was normal with no RBC. He was treated with 3 liters IV fluids (LR), oral CIPRO and PHENERGAN, TYLENOL and BENTYL as needed. He was diagnosed with upper gastroenteritis (UGE), microhematuria and dehydration (resolved) and released 24 hours later. On 7/28/2003 he received AVA #4 (FAV075) with no remembered reactions and does not recall any problems with any other vaccine given in 2003 (typhoid 10/09/2003). Concurrently, he was evaluated 7/28/2003 for wrist injury (hit tent pole) with possible scaphoid fracture per x-ray. Records show follow up with medical about every 2-5 months (2003) for "blood in urine and stool" with two episodes of 5-10 RBC in separate urine samples and 3 guaiac negative cards of "red stuff on stool"; an anal scope on 9/29/2003 and 11/13/2003 diagnosed him with anal fissure and right anterolateral hemorrhoids. A renal ultrasound of kidneys (11/12/2003) for hematuria showed "asymmetry in renal size with left slightly larger than right, question of caliceal stones to pole left kidney...no renal mass or cystic disease". Providers treated prophylactically for possible parasitic infection with 14 days of CIPRO and FLAGYL. A colonoscopy 2/3/2004 was normal. On 3/26/2004 AVA #5 (FAV081) was administered with no remembered adverse event. Sometime in April 2004 (date unknown so about 5-34 days after AVA #5) he reported problems with back and joint pain (bilateral knees, hands, shoulders and hips) with low energy and feeling tired. He described his joint pain as "hurting with deep ache sensation for no reason" that was worse upon awakening in the morning and after exercise. He complained of feeling "as if he ran 10 miles" upon awakening. He also stated doing PRT exercises made his pain and fatigue worse. However a review of medical records documents blunt trauma injury to coccyx on 3/8/2004 with chronic pain to lumbosacral spine thru Nov 2004 and a lower back injury (lifting) in Nov 2004 in which he received physical therapy and treated with pain medication (NSAID, FLEXERIL, etc). A medical record review for myalgia/arthralgia noted the following: 2003 wrist injury (above); 8/18/2005 complains of "insidious onset of stiffness to bilateral hands, DIP joints, wrists, shoulders, and knees times 2 weeks with 35 pound weight gain in 6 months. Lab studies included ESR 23, ANA <1:80, and RF <20. He was given a diagnosis of arthritis based on symptoms only and treated with NSAIDs and TYLENOL (not helping per patient). Follow up evaluations on 9/22/2005 noted joint pain/stiffness 2-3 times a month was exacerbated by prolonged walking, standing or squatting. He had morning stiffness for 1 hour with diarrhea and bright red blood on stool and abdominal pain. He complained of fatigue, weakness and depression with diagnoses of PTSD and anxiety since 2003. His exam was unremarkable with providers documenting "appearance of swelling to bilateral hands and fingers at MCP and PIP proximal joints" with tenderness on exam. Lab studies: 9/1/2005 ESR 5 and 9/23-30/2005 extractable nuclear ab panel negative, autoantibody panel <1:1:20 (nl), cryoglobulin 0, HLA-B27 negative, nuclear ab panel 1:80, RF 20.9, cortisol 11.60 (nl), thyroid panel normal and magnesium 2.3. On 10/11/2005 x-rays of bilateral hands noted proximal joint space narrowing and mildly elevated RF at 22.5 with ESR 16 and 12. On 10/27/2005 Internal medicine diagnosed with arthropathy unresponsive to prednisone taper or INDOCIN (patient had stopped therapy due to jittery feeling). On 1/11/2010 Rheumatology evaluation documented reoccurring "1-2 week flares" of swelling over MCP, knees and wrist and ankles with mild erythema, stiffness and inability to make a fist. Lab studies ordered included RF, CCP, ESR, CRP, PPD, Hep B/C, G6PD, and x-rays of hands and feet; however no test results were identified. This patient advised he was told he did not have arthritis and was on no medication; however his joint pains continue as of 2012. He also complained of stomach problems and migraines within 6 months of 2003 trip. His stomach problems centered on episodic bouts of diarrhea, abdominal pain - cramps, and indigestion. He reported being diagnosed with acid reflux and Irritable Bowel Syndrome (IBS) in 2005. A medical record review documented GU evaluation 10/6/05 for bleeding and abdominal cramping 5 times a day 2-3 times a week with alternating stool patterns (diarrhea - normal stool) and being placed on ACIPHEX. There were no further GI tests identified; however providers continued 2003-2004 diagnosis of hematochezia (NOS) due to anal fissures/hemorrhoids. Further urology evaluations continued on 9/29/2009 (CT scan kidneys normal with non-obstructing renal calculi <2mm in inferior pole left kidney similar to prior scans), 1/28/2011 (UA with 5 RBC and 25 WBC after stone passage), and 1/30/12 (24 hour urinalysis normal, negative GC/Chlamydia cultures) with three separate providers diagnosing renal stones as cause of hematuria and abdominal pain. In 2012 one provider documented (2/28/2012) urine cytology showed atypical cells suspicious for low-grade malignancy with negative cystoscopy and negative colonoscopies. These GI/GU issues persist as of 2012. His "migraines" (reported onset 2003) were described as squeezing to the entire skull with nausea, vomiting, photosensitivity, head pain that required him to lie down in dark room and use IMITREX. However he did experience a head injury with no loss of consciousness and migraines began afterwards. A medical record review documented evaluations for headaches on 11/25/2005 with "history of headaches 1-2 times per week usually exacerbated by poor sleep and was on IMITREX" (unknown when first evaluated for headaches). Further evaluations were documented on 12/27/2011 with headache were unilateral with aura and nausea. He advised this provider headaches resulted from "several blows to the head but denied any blast injuries". Headaches were 2-3 times a month for 1-3 days that resolved with IMITREX or EXCEDRIN and sleep. On 2/28/2012 a neurology evaluation stated "headaches began in 2003 after hit in head by tent pole during a windstorm with no loss of consciousness." Headaches are always to left side of head behind left eye and in parietal region, have an aura of black spots and blurry vision, and are worse with stress and insufficient sleep. He was a former football player and had had 2 concussions in 2001 and 2003 with loss of consciousness. He also had severe PTSD with nightly flashbacks, has weekly panic attacks at home and in public with palpitations and chest pain. He reported using THC daily for headaches, joint pain and irritable bowel syndrome, drinks 2-3 alcoholic drinks on weekend and just quit smoking (2/2012). He has 8 headaches a month. Current medications as of 2012 include Tramadol, hydrocodone, nortriptyline and sumatriptan. He stated based on his internet research he "thinks AVA vaccines with squalene caused all of his problems". Patient reported he rarely leaves home other than to go to multiple medical appointments and is not active due to poor health.