To report a new association of rheumatoid arthritis (RA) following anthrax vaccination.

A 42 year old Caucasian Avionics Master Sergeant with history of arrhythmia after ASD repair developed stiffness followed by pain of his knees and all proximal interphalangeal (PIP) joints starting day 5 after the first anthrax vaccine dose. Chills, fever, joint and neck pain with nodule at injection site occurred with Dose 2. Dose 3 associated with fever, chills, nausea, vomiting, neck, hand, and shoulder pain. Doses 2 and 3 were coupled with Typhoid Vi and Yellow Fever respectively with no known prior adverse reaction to either vaccine. Symptoms of pain and stiffness persisted for 9 months with anorexia and 6.8 kg weight loss. Vaccination was terminated after the third dose.

Physical exam revealed swelling of bilateral PIP joints with presence of Bouchard's nodules. CBC was normal, Rheumatoid Factor 198, ESR 53, ANA negative, CRP 2.7, anti CCP antibody 168 (detected by ELISA, indicates recent onset of RA). X Rays reveal mild degenerative changes of hands and knees bilaterally.

Anthrax Vaccine was licensed in 1970 and is currently used to protect against biological warfare. No prior association with RA has been documented. Predictable reactions include skin redness, swelling at the injection site with rare malaise, arthralgia, and myalgia. Anti Squalene antibodies (ASA), an experimental vaccine adjuvant found in some anthrax vaccines has been implicated in Gulf War Syndrome characterized by multisystemic symptoms, and autoimmune diseases in experimental animals. Further studies are required to implicate ASA with RA.