Case 16

24 year old female presents complaining of being very ill over the last year including several hospitalizations. In August of 2004, she reported an onset of abdominal pain which was later diagnosed as pancreatitis. She followed up with a gastroenterologist who diagnosed her with Babesiosis and placed her on Mepron for two weeks. Since that time, she has experienced the following symptoms: urinary urgency problems, twitching in her legs, continual headaches, drenching night sweats and fevers, pain and stiffness in the back of her neck, jaw pain, burning sensations in her legs and feet, increasing problems with coordination, difficulty sleeping, and extreme fatigue which has prevented her from working and doing daily activities. Cognitively, she reports trouble with word retrieval, increasing memory and reading comprehension problems, stuttering, and dyslexia-type reversals with words and numbers. A recent MRI shows white matter in the frontal lobes.

Exposure History:

She has vacationed several times in Nantucket (which has shown to be a very Lyme endemic area) with her family. After one such visit to Nantucket, she recalls having an unusual “flu-like illness” followed by diffuse body aches.

PMH:

Prior to the 2004, she has been healthy and reports no significant past medical history.

PE:

BP – 100/64, P – 70bpm

HEENT: PERRLA, EOMI, + TMJ tenderness, + pharyngeal erythema without exudates

NECK: + bilateral lymphadenopathy, no thyromegaly

RESP: CTA, + costochondral and sternal tenderness

CVS: RRR, pulses 2+ bilaterally

EXT: + knee joint tenderness, full ROM and strength

NEURO: A&O, unable to recall previous 4 presidents, unable to repeat a series of numbers, DTRs 2+ bilaterally.

LABS:

Immunosciences: Food allergy panel. See enclosed.

Igenex: Western blots shows exposure in the following bands: IgG 31, 39, 41, 45, 58, and 66; IgM 18, 28, 30, 31, 34, 39, 41, 45, 58, 66, and 93. Babesia titers are both elevated at IgM 1:20 and IgG 1:80. Human Monocytic IgG titer 1:40, Bartonella titers are negative.

Impression:

Based on her multi-systemic picture (musculoskeletal, cognitive, neurological), her history of vacationing in tick endemic areas, her Western Blot showing exposure in bands IgG 31, 39, and 41; IgM 31, 34, 39, and 41(which have shown to be very specific for the Borrelia Burgdorferi bacteria), elevated Babesia and Ehrlichia titers, poor MRA results, and cognitive impairment, she appears to be suffering from Neuroborreliosis (Lyme disease) as well as Babesiosis and Ehrlichiosis.

A/P:

She was placed on a three week course of oral antibiotics including Zithromax 250mg twice daily, Mepron 750mg twice daily, and Doxycyline 100mg twice daily. She was then re-evaluated. At that visit she reported some improvements in her condition; however, she was having significant difficultly tolerating the oral medications. Insertion of a Port for intravenous antibiotics and Initiation of intravenous Rocephin 1g bid for 12 weeks.