Case 2

42 year old female presents with persistent sinus and sleep problems starting 2-4 years ago. One year ago she experienced a locked jaw and TMJ symptoms. In February she was feeling lightheaded and dizzy which was not related to any activities. Recently started having increasing cognitive problems including difficulty concentrating, word retrieval problems and depression. She complains of frequent headaches and neck stiffness. During the night she has night sweats and chills, and extreme fatigue with poor stamina during the day.

SH: Married. She works as a secretary for her husband’s company.

Labs:

Igenex: Western Blot exposure in the following bands — IgM 18. 23-25, 31, 39, 41, 45, 58, and 66; IgG 18, 23-25, 30, 31, 34, 39, 41, 45, 58, and 66. Babesia titers IgM and IgG <1:20. Bartonella titers IgM <1:20, IgG <1:40.

Spect Scan: Patchy areas of decreased cortical uptake involving the temporal lobes and frontal parietal regions, consistent with Lyme disease. A single area of increased activity in the right frontal parietal junction is seen as well and this finding has also been described as an area of luxury perfusion in the patients who suffer from a Lyme disease type vasculitis.

Tx:

Biaxin 500mg bid, Plaquenil 200mg bid, Minocycline 100mg bid, Ambien 10mg qhs, Antivert 50mg qd.

July 2004

Patient reports that all of her symptoms are less severe and less frequent; she is experiencing more good days than bad. She has had neurocognitive improvements. No night sweats, decreased light-headedness, and neck stiffness.

November 2, 2004

Patient reports’ feeling much better, has had significant improvement since first visit. Neck stiffness, brain fog, headaches, night sweats, fatigue gone.

Tx:

Decrease Biaxin, Minocycline, Plaquenil to once daily for 1 week, then alternate day