Case 10

HPI:

43 year old previously healthy male presenting with a history of a tick bite two years ago on his right thigh and again one year ago. Over the past year, he has developed difficulty with his speech (slurring) and weakness. He has an MRI which was negative. Since then he has had increasing symptoms including trouble swallowing, shoulder pain (which he had injected with cortisone), testicular pain, problems blowing his nose because he is unable to take in enough air, and a general onset of fatigue. He was evaluated by an ENT, a neurologist, had a stress test, echocardiogram, swallowing study, and dental exam which was all inconclusive. He denies any headaches or vision changes. He has been experiencing difficulty falling and staying asleep, and his has been having migrating joint pain.

PMH:

He has been diagnosed with hypercholestemia and had a short course of medications for Myasthenia Gravis, which have been discontinued. He has also been hospitalized two times in the past year due to aspiration pneumonia. Both times he was given IV antibiotics which he developed a rash.

Meds:

None

Allergies:

Cephalosporins – developed rash with previous administration

PE:

General: WNWD, NAD, PERRLA. Right eye unable to track laterally, but both eyes have difficulty tracking. Glossopharyngeal weakness without deviation. Equal facial sensation.

Neck: No lymphadenopathy or thyromegaly

Resp: CTA, no respiratory distress, chest non-tender

CVS: RRR. NSR. No murmurs, gallops or rubs

Ext: Non-tender. Right thumb and 1st finger weakness as compared with the left, otherwise strength equal bilaterally

Neuro: Cerebellum intact. Romberg and Pronator drift negative. DTR’s 2+ bilaterally.

Labs:

Igenex: Western Blot shows exposure in the following bands IgG 30, 31, 39, 41, 45, 58, 66; IgM 18, 23-25, 31, 34, 39, 41, 45, and 66. Babesia titer negative. Ehrlichia Granulocytic IgG 1:80.

SPECT Scan: Mild to moderate hypoperfusion in both parietal lobes and frontal lobes. Moderate hypoperfusion in both temporal lobes. Perfusion in the cerebellum and the basal ganglia and the visual cortex appears preserved.

MDL: Mycoplasma PCR – negative

Treatment:

  1. PICC line placement
  2. IV Doxycyline 100mg bid
  3. Zithromax 500 mg po qd 4. Nutrients

2/15/05

On Doxycyline for 2 months. Patient reports more energy and stamina. Speech had improved but recently plateaued. Last two weeks he has had enough stamina to get up at 5:30am to go to the gym. He has been working with a speech therapist who has been reteaching him how to swallow, working on taking smaller bites to prevent aspiration. His swallowing has significantly improved. His joint pain which was constant is now completely gone, breathing easier at night, less drooling. Not biting his tongue anymore, able to blow his nose. Diploplia gone. Still has episodes of uncontrollable laughing.  Night sweats have subsided. Right thumb is becoming atrophic.

  1. Finish course of IV Doxycyline 100mg bid
  2. Start Clindamycin 900mg bid
  3. Physicial therapy for right thumb
  4. Continue speech therapy