Case 18

38 year old male with a history of symptoms starting in 2003. At our visit, he reported the following symptoms: pain in his left toes and burning sensation, headaches, pain in knees, tenderness in joints, spots, floaters and black lines across his vision, plantar fascitis, neck stiffness, decrease in energy, intense episodes of nausea and sharp stomach pains, and heart palpitations. In addition, he reports having some cognitive difficulties including word searching, not able to think clearly, feeling like he is in a “brain fog”.

PMH:

History of a positive RF and ANA which has led him to be treated for Rheumatoid Arthritis. He also has a history of a positive Ehrlichia titer and was treated with 2 weeks of Doxycycline at which time he noticed improvement in his vision for the first time. He has had two previous MRIs looking for any demyelinating lesions which may be typical of MS, but both MRIs were negative.

Exposure:

He is a self-employed builder and enjoys the outdoors. He has found several engorged ticks on himself as well as his dog.

Meds:

Prednisone, Celebrex, Plaquenil, Oscal, Arava, ASA 81mg

Allergies:

NKDA

PE:

BP – 110/78, P – 80

This is a well nourished, well developed male in no acute distress. PERRLA, EOMI, no gross facial abnormalities. Neck without masses, no lymphadenopathy or thyromegaly. No respiratory distress, breath sounds normal, chest non-tender. Heart is RRR, no murmurs or gallops, pulses are 2+ bilaterally. Skin is normal color without any rashes or lesions. Extremities have full ROM, no edema, normal strength, tenderness with palpation of left elbow and wrist. DTR’s 1+ bilaterally. CN II-XII intact, no motor or sensory deficit. He was unable to subtract from 100 by 7’s and was unable to name the previous four presidents.

Labs:

Igenex – Western blot shows exposure in the following bands IgG 18, 23-25, 28, 30, 39, 41, 45, 58, 66, and 93; IgM 18, 23-25, 31, 39, 41, 45, 58, 66, and 93. Both Babesia IgM and IgG titers were elevated. IgM Human Ehrlichia titer is elevated. Bartonella IgG and IgM titers are negative.

Assessment:

Based on his clinical picture (multi-systemic symptoms) and his laboratory results which shows a CDC positive IgG Western Blot and exposure in the IgM significant bands (23- 25, 31, 39, and 41), he appears to be suffering from Chronic Persistent Borreliosis in addition to Babesiosis and Ehrlichiosis.

Recommendations:

On February 7, 2005, Mr. Zuccaro was re-evaluated by Dr. Raxlen. At this time he had the following recommendations:

  1. Zithromax 250 mg po tid
  2. Mepron 750 mg suspension po bid
  3. Minocycline 100mg po bid
  4. Plaquenil 200 mg po bid
  5. Nutrients