Case 17

47 year old male who presented to our office complaining of multi-systemic symptoms. These symptoms include a history of a tick bite followed by a raised, circular rash on his body, headaches, jaw pain, difficulty swallowing and speaking, double vision, decreased hearing, sound sensitivity, joint pain, neck stiffness, shifting joint pain, drooping shoulders, poor muscle coordination, loss of muscle tone, shortness of breath, night sweats, fevers of 104.2F, heart palpitations, tremors brought on by fine motor movement, numbness in extremities, feeling as if bugs are crawling on his skin, poor balance, lightheadedness, extreme fatigue, poor stamina, and disturbed sleep. In addition, he is experiencing extensive cognitive compromise including disorientation, decreased short term memory, easy distractibility, confusion, difficulty thinking, dyslexia –type reversals, word retrieval problems, and forgetting how to perform simple tasks. He is a horticulturist as well as an avid hiker and walker. He has a history of multiple tick bites.

PMH:

He had a tick bite in 7/14/03. On 7/26/03 he came down with a “flu-like illness” quickly followed by delirious, high fevers, floaters in his vision, shortness of breath, and soaking night sweats. At this time he was treated with Rocephin 2g daily for 1 month followed by Amoxicillin. He has suffered from hypertension since age 18 which he is being treated with Lisinopril.

MEDS:

Lisinopril 5mg, ASA 81mg, Elavil 20mg, Gabitril 4mg

ALLERGIES:

NKDA

LABS:

Igenex – Western blot shows exposure in the following bands: IgG 18, 23-25, 30, 31, 39, 41, 45, 58, and 66. IgM 18, 23-25, 28, 30, 31, 34, 39, 41, 45, 58, 66, and 93. Babesia and Bartonella titers are negative.

Immunosciences – Showing severa IgG and IgM Lyme Antibodies (peptides) positive in addition to positive IgG Babesia. Ehrlichia is negative.

MDL – The following tests were negative: Mycoplasm Fermentans, hominis, Penetrans and pneumoniae by PCR.

MRI of brain – Few punctuate foci of T2 prolongation present within the right cerebral hemisphere white matter.

SPECT Scan – Mild symmetric bilateral decrease in temporal lobe cerebral cortical perfusion, more prominent laterally.

PE:

BP- 128/86

General: WNWD, NAD, A&Ox3

HEENT: PERRLA, EOMI, no TMJ tenderness. Pharynx without exudates.

Neck: No thyromegaly or lymphadenopathy

Resp: No respiratory distress, CTA, costochondral tenderness with palpation

CVS: RRR, NSR

Abd: Non-tender, no organomegaly, normal bowel sounds

Extrem: non-tender, full ROM, no pedal edema

Neuro: CNs II-XII intact, no motor or sensory deficit. Cerebellum intact. DTRs 2+ bilaterally

Cognitive: Cognitive impairment. Refer to Neuropsychological Report.

ASSESMENT:

Based on his multi-systemic picture (musculoskeletal, cognitive, neurological), his history of working in an endemic occupation for tick bites, and his Western Blot showing exposure in bands IgG 23-25, 31, 39, 41, and 93; IgM 23-25, 31, 34, 39, and 41(which have shown to be very specific for the Borrelia Burgdorferi bacteria), his poor SPECT scan and MRI, and cognitive impairment, he appears to be suffering from Neuroborreliosis (Lyme disease).

TREATMENT:

Started patient on a course of oral Zithromax 500mg daily, Mepron 750 mg daily and Tinnidazole 500mg bid. Patient started having psychotic episodes with the Tinnidazole and it had to be discontinued. Not much improvement with symptoms on the oral medications and decided to move to the next step.

Doxycycline IV 100 mg bid x’s 2 week, if tolerated well, then Doxycycline IV 200 mg bid x’s 10 weeks, for a total of 12 weeks of treatment. Mepron 750 mg suspension po bid. Zithromax 500mg qd po. Armour thyroid 1 grain po daily.

March 18, 2005

Patient returned to office for a follow-up visit after 5 weeks of Doxy IV. Patient reports continued progress. Cognitively much clearer, no musculoskeletal pain. Energy and stamina seem to be continually improving. Continues to do acupuncture 2x’s/ wk. Considering starting to drive again near home (has not been able to drive for almost 1 year because of movement perception difficulties). Sleeping better than he has in a year. Not even taking anything for sleep. Occasional drenching night sweats.

A/P:

  1. Continue IV Doxy for another 8 weeks
  2. Continue all oral antibiotics