Case 14

39 year old male presents to the office complaining of generalized weakness and numbness with an onset about 6 months ago. He reports numbness in both of his lower extremities up to his umbilicus and describes his hands as “always feeling asleep”. He has been experiencing repeat migraines with photosensitivity and increasing problems with memory and confusion. He also reports a general feeling of not being confident in his surroundings. He is a hunter and usually feels very secure in the woods, however lately he has noticed increasing uneasiness. In addition, he has been waking up with nightmares, causing him to not be sleeping well or getting enough rest.

SH:

Married. Highest education is grade 12. He is a self employed construction / carpentry contractor. Deer hunter.

PMH:

He had a prior MRI which revealed a severe neurodegenerative pattern consistent with MS (9-12-03). Neurological consultation supported the diagnosis. Visual evoked potential 9-24-03 was abnormal, consistent with a demyelinating process.

PE:

BP 145/88 P 90

HEENT- neg

COR- NSR, no rubs, gallops, murmurs

RESP – lungs CTA

NEURO – decreased sensation in lower extremities, memory impairment

Labs:

MDL – B. Burgdorferi PCR – neg, Bartonella PCR – neg, Babesia PCR – neg,

Anaplasma PCR – neg

Immunosciences – IL-1 Alpha -1 (0-40), IL-1 Beta – 1.5 (1.5-10.0), IL-2 Receptor 727 (223-710), TNF-Alpha 5.1 (1.7-20.0)

Igenex – Western Blot revealed exposure in the following significant bands IgM 31, 39, and 41. Positive Babesia RNA as well as IgG.

Impression:

This is a complicated and controversial neurological picture and there is no question that much of the Neuro-radiological work-up points strongly to a demyelinating disorder of the MS category. However, his lab results do show an underlying untreated Borreliosis and Babesiosis.

Tx:

  1. Zithromax 500mg qd po
  2. Ceftin 500 mg bid po
  3. Minocycline 100 mg bid po
  4. Neurontin 800 mg tid po
  5. B12 injections 25mg / cc x 3 weekly
  6. Nutrients

January 2004

Patient reports having some days when he feels clearer. He is now able to stand up to go to the bathroom, which was a problem because of weakness prior. However, generally he has made only minimal progress and still remains incapacitated.

  1. Mepron 750mg suspension bid
  2. IV infusion therapy with Rocephin 2g daily
  3. Following Rocephin, IV Zithromax 500mg daily

October 2004

Patient has had Rocephin 2g daily for three months followed by Zithromax 500mg daily for two months. Patient reports thinking much clearer, vision has significantly improved, he is no longer sound sensitive. Pain is still his main problem especially in his back along his spine. However, he has been swimming and able to stay awake in the evenings. He is taking Ambien to sleep which has helped immensely.

  1. IV infusion therapy with Rocephin 2g daily

November 2004

Patient has been on IV Rocephin for one month. Physically he is feeling significant improvement, however he is still experiencing joint pain and spinal tenderness after the Rocephin infusion. Unfortunately, during the last month, his wife has reported some bizarre behavior and awkward social interaction including having moments of confusion going to the wrong house. In addition, he reports only getting approximately 4 hours of sleep per night. He had a repeat MRI which has shown significant improvement.

  1. Pulse IV Rocephin 4 days of 2g bid then 3 days off
  2. Tramel cream for spinal tenderness
  3. Pain gel for joints
  4. Trazadone 50mg qhs
  5. Remeron 15mg qhs