Case 1

HPI: 34 year old male presents to the office complaining of headaches, weakness, stiff neck and fatigue. In the fall of 2003 he had increasing difficulty staying focused and became very fatigued. He never felt rested, always feeling depressed with little or no energy. March 2004 he developed severe dizziness and lightheadedness. April 2004 he became so sound sensitive and dizzy that he passed out and went into a seizure which put him in the hospital and was dismissed as an anxiety attack. June 2004 migraines became unbearable, total body weakness, stiff neck, oval rash developed on his leg as well as hives covering his entire body. He has had an EEG, MRI, CT Scan, ECG, Spinal Tap, and CXR which all came back negative. He received a positive Lyme confirmation at 4.7. He was treated with 5 days of IV Rocephin, 2g daily and Doxycyline 100mg po bid which he stated made some improvement in his general symptoms.

Labs:

Igenex: WB shows exposure in the following bands: IgG 18, 23-25, 31, 34, 39, 41, 45, 58, 66; IgM 18, 23-25, 31, 34, 39, 41, 45, 58, 66, and 93. Babesia and Ehrlichia titers are negative.

MDL: Bartonella PCR, Mycoplasma Fermentans PCR, Mycoplasma hominis PCR, Mycoplasma Penetrans PCR and Mycoplasma pneumoniae PCR all negative.

Spect Scan: Subtle hypoperfusion involving the right posterior parietal cortex and basal ganglia which is highly suggestive, in an appropriate clinical context, to be compatible with mild Lyme encephalopathy.

Assessment:

Chronic Persistent Borreliosis (Lyme disease) with neurocognitive involvement.

Treatment Plan:

  1. PICC line insertion with IV Rocephin 2g daily for 12 week minimum
  2. Doxycycline 100 mg po bid
  3. Effexor 225 mg
  4. Provigil 200 mg po bid
  5. Carbatrol XR 200 mg bid
  6. Nutruient Program

January 7, 2005

Phone consult with patient. He reported feeling great — the best he has felt for years, almost no symptoms. He is now able to put in a good full day of work and is expanding his business. He had some difficulty with the Rocephin the first 4-5 weeks. His symptoms seemed exaggerated and his fatigue was debilitating, however after those initial weeks he started feeling much better and has steadily improved since that time. He will continue with the course of Rocephin and touch base again at the end of his 12 week course.