Case 11

10 year old male presents complaining of “bugs crawling all over my body”. He has developed an increasing fear of separating on death. He had a sudden onset in February when he became more and more afraid. As the week progressed, he felt that he was going to disappear, his room was going to catch fire, and he felt the ground was going to fall beneath him. He refused to be touched and kept describing the sensation of bugs crawling all over him. He saw a psychopharmacologist who put him on Risperidal. He was also hospitalized because of the sudden changes and had a series of EEG, Spinal Tap, MRI and blood work. Everything came back normal.

PE:

Wt: 67.5 lbs, RR: 20, P: 92bpm

HEENT: PERRL, eyes unable to focus in one direction. Tenderness at tip of nose. No sinus tenderness or nasal congestion.

NECK: Supple. No lymphadenopathy. Normal ROM. + Trigger points.

RESP: CTA

COR: RRR, no murmur or gallops

ABD: soft, normal bowel sounds, no tenderness, distention or hepatosplenomegaly.

EXT: 4/4 upper and lower extremity. No clubbing or cyanosis. No edema

NEURO: A&Ox’s 3. CN II-XII intact. Responds to light touch stimuli but feels bugs are crawling on him when touched. DTR 0-1+UE, 1+LE. Normal cerebelluar function. Romberg and Pronator negative. Normal gait.

Labs:

Igenex: WB showed exposure in the following bands IgM 45, 58. IgG 41, 66. No ova or parasites found. Strep negative.

Assessment:

Borreliosis (Lyme disease)

Treatment Plan:

  1. Biaxin 250mg / 5ml po tid
  2. Ceftin 250mg / 5ml po qd
  3. Nutrients

June 6, 2000

Going back to first grade. No anxiety attacks, no paraesthesias, not getting lost in familiar places anymore. Still significant difficultly falling asleep and staying asleep. Stays up until morning hours and can not get out of bed in the morning. Continue antibiotics and Ambien 5mg qhs prn.

May 24, 2001

Doing much better. Back to 90% of normal self. He reports not feeling anxiety. He is sleeping well through the night and continues to be improving. Trouble with auditory processing. Continue antibiotics.

October 30, 2001

Started a program to help with auditory processing and doing well. He is finally on a normal sleep schedule 9:30pm – 7 am. No headaches. Allergies are more under control and able to do more physical activity. Continue Biaxin 250 XL.

February 18, 2004

Sleeping great still. Not anxious at all anymore. Able to go sledding and play with friends. Now taking a Karate class and loving it. No trouble in school, doing well with grades and homework. Went to camp over the summer and was involved in all kinds of activities. Feeling as good as ever. Continue Biaxin on a maintenance protocol. Biaxin 250mg bid, two times weekly.