Case 15

March 23, 2005

54 year old female, a registered nurse, was first seen in our practice on July 2, 2004. In the winter of 2001 and 2002, she began to experience persistent pain and weakness in her arms. Later, it included back pain, sore hips all the time, muscle tremors, hypophonia, micrographia and fatigue. On February 2004, she had a neurological consultation with Dr. Macinsky, who diagnosed early Parkinson’s disease, affecting the right hand. He suggested the medicine Sinemet. She declined the medication at that time.

In May of 2004, she saw Dr. Sinatra, a cardiologist, who suggested an alternative diagnosis, neurological Lyme disease. Dr. Sinatra recommended that she make an appointment with Dr. Perlmutter, a neurologist in Florida. The patient traveled to Florida to see Dr. Perlmutter, who confirmed the diagnosis and recommended antibiotic treatment preferably intravenous therapy.

Physical Exam:

HEENT: head and neck with slight rigidity; SCM muscles in spasm; Fundi normal; no Nystagmus

Neurological exam:

Slight shuffle in patient’s gait; slight cogwheel rigidity in right arm; some evidence of mild Parkinson facies; negative Romberg sign; finger-to-nose slightly erratic and slower than normal, reflexes 2+ arm, 1+knees, 0 ankles.

Cardiovascular exam:

Normal rate and rhythm; possible grade 1 murmur with tricuspid valve; no pericardial rub, BP 140/88

Musculoskeletal:

Muscle generally sore to palpation, costochondral pain on palpation.

Serology for Western Blot IgG and IgM was sent to Igenex Laboratory in California. Positive IgG (23-25, 28m 30m 31m 34m 39m 41m 45m 66) and IgM (18, 23-25, 30, 31, 34, 39, 41, 45, 58, 66). Brain Spect scan revealed decreased perfusion in the high posteroparietal region.

She was originally placed on oral antibiotics: Biaxin 500mg bid, Plaquenil 200mg bid, and Minocycline 100mg bid. Confirmation of “atypical, neurological Borrelia” presenting as Parkinson’s disease, confirmed by serology and Spect scan as well as the previous recommendation by Dr. Sinatra and Dr. Perlmutter. Intravenous Claforan 3 g bid was initiated as her first phase of treatment followed by Zithromax 500mg daily, Clindamycin 900mg daily.

She continues to improve clinically and has made a definite progress toward regaining her health. This included her gait, some of the cogwheel rigidity and relaxation of her Parkinson mask. However, despite several letters and phone calls her insurance has become increasingly difficult to cover payment. Therefore, we have referred Ms. Rowean to Dr. Jemsek for evaluation and treatment as a second opinion.

Discussion:

There is evidence in the current literature of neurological disease presenting as atypical Parkinson disease. The etiology has been shown to be an underlying infection / inflammatory condition triggered by the Borrelia bacteria. In these special instances, it is imperative to maximize the highest possible concentration of antibiotics to the brain in order to breach the blood brain barrier. Claforan 3 grams bid has been an excellent CNS antibiotic proven to be effective in these difficult hybrid cases.