Case 3

March 22, 2005

43 year old female who presented to our office with the following symptoms: migrating joint pain, fatigue, and memory problems. She reported word retrieval problems, poor concentration, forgetting conversations with people, change in mood, easy irritability, depressed, feeling suddenly overwhelmed, drenching night sweats and short tempered. These symptoms have been significant enough to affect her work. She can remember these symptoms starting approximately two years ago, but they have recently worsened enough for her to seek treatment.

Meds:

She has a history of being on Plaquenil and Prednisone for 3 months.

Allergies:

NKDA

PE:

BP — 122/78, P — 68bpm

WNWD, NAD

HEENT: normal inspection, PERRLA, EOMI

Neck: no thyromegaly, no lymphadenopathy

Resp: no respiratory distress, CTA. + costochondral tenderness and sternal tenderness

CVS: RRR, no murmur or gallops

EXT: non-tender, full ROM, no edema

Neuro: CN II-XII intact, no motor or sensory deficit

Labs:

Igenex – Western blot shows exposure in the following bands (IgG 30, 31, 39, 41, 45, 58, and 66; IgM18, 23-25, 28, 30, 31, 34, 39, 41, 45, 58, 66, and 93. Babesia and Bartonella titers are negative.

Immunosciences — Positive IgG and IgM Babesia peptides, positive IgM Ehrlichia peptide. Elevated NK Cell activity.

Spect Scan — Slightly diminished perfusion to the frontal lobes, left > right.

She has been diagnosed with Borreliosis and Babesiosis by Dr. Raxlen. She was initially treated with Biaxin and Plaquenil for 5 weeks without much improvement in symptoms. Therefore, she had a PICC line inserted and has now been on one month of IV Rocephin 2g daily.

March 10, 2005

She reported an increase in energy and cognitively feeling slightly “sharper” and “more with it”. She is not noticing the word retrieval problems as much and she is able to function with more ease at work. At this visit, we also added Mepron to treat the Babesiosis.

Unfortunately, despite her continued improvement, her insurance company is now refusing to pay for any more intravenous antibiotics and stopping the Rocephin at this point would be premature. She was referred to a neurologist for a second opinion and the neurologist recommended continuation of intravenous antibiotics for another 3 months.