March 7, 2005
36 year old female who presented to our office complaining of fatigue, muscle aches, neck pain, vertigo, fevers, photosensitivity, tinnitus, a 40lb weight gain, nausea, joint pain in the wrists, knees, elbows and ankles, plantar fascitis, and chest pain. In addition, she been experiencing several cognitive difficulties including word searching, concentration problems, easy distractibility, increasing memory problems, and disorientation in familiar places.
She has a fairly extensive treatment history. In 1999 she presented with many of the above symptoms to and infection disease specialist who diagnosed her with meningitis and placed her on a two month course of Rocephin. Then she saw Dr. Dante who diagnosed her with Lyme disease and treated her with oral antibiotics some of which include Tetracycline, Biaxin, and Plaquenil. Following Dr. Dante’s protocol, she reported only being 30-40% improved and ventured to get a second opinion. She then saw Dr. Burrascono who diagnosed her with not only Borreliosis, but Babesiosis and treated her with oral Mepron and Zithromax followed by IV Rocephin 4g daily for 4/7 days per week for 6 months. However, she then developed cholecysitis and was switched to IM Bicillin in addition to oral Levaquin. At that point, she recalls feeling the best that she has felt since she became sick in 1999.
Since November of 2004 she has been off all antibiotics. She is currently feeling 50-75% well, but not as good as she had felt following the IV antibiotics.
Protonix, Klonopin, Atenolol
Sulfa drugs, Morphine
BP – 110/88, Resp – 12, P- 78bpm
Physical exam is essentially normal. She did have some difficulty with naming the past four presidents and had dyslexic-type reversals with short-term memory of numbers.
Spect Scan – Abnormal perfusion pattern with small multifocal perfusion defects, a non specific pattern
MRI – Two small punctuate foci of flair hyperintensity in the subcortical white matter of the right and left frontal lobes consistent with Lyme disease, vasculitis or migraines. These patterns were not present on her previous MRI.
Igenex – Western Blot showing exposure in the following bands IgG 30, 31, 34, 39, 41, 45, 58, and 66; IgM (CDC positive)18, 30, 39, 41, 45, 58, and 66. Bartonella and Babesia by PCR are negative.
Based on her multi-systemic picture (musculoskeletal, gastrointestinal, neurological and cognitive), her history of Lyme disease, and her Western Blot which continues to be IgM CDC positive, she appears to be suffering from Chronic Persistent Borreliosis (Lyme disease) and Babesiosis (based on her clinical history).
- Zithromax 250mg po bid
- Mepron 750mg suspension po bid
- Insertion of a PICC line for intravenous antibiotics
- IV Doxycycline 100mg bid x 12 weeks
- Weekly dressing change
- Weekly blood work including General Chemistries (CBC with diff, electrolytes, LFT’s, Kidney functions)