Case 4

March 22, 2005

27 year old female who has been experiencing multi-systemic symptoms since October. These symptoms include: headaches, neck stiffness and tightness, joint pain, nausea, hot flashes, night sweats, photosensitivity, muscle weakness and soreness, decreased exercise tolerance, decreased energy, significant fatigue during the day, tremors in her hands, numbness and tingling in her back, and balance difficulties. In addition to these physical symptoms, she reports trouble with her memory, difficulty thinking clearly, feeling confused, and easily distracted.

PMH:

She was placed on a 10day course of Amitriptyline and Prednisone for her headaches by a neurologist. She reports feeling great the first two days and then feeling worse than before. In December her PCP started her on Ceftin 500mg bid. After her Ceftin, she continued getting worse and her PCP gave her Rocephin IM, 3 weeks of Doxycyline. Following the IM Rocephin, she had a spinal tap that was negative.

Meds:

Lexapro, Xanax, Ovcon, Percocet, Vicodin, Phenergan

Allergies:

NKDA

PE:

BP – 110/68, P- 80 bpm General, WNWD female, NAD. No gross abnormalities. PERRLA EOMI No thyromegaly or lymphadenopathy. + TMJ tenderness. No respiratory distress. CTA, + costochondral tenderness to palpation. RRR. No murmurs, gallops, rubs. Several trigger points in upper back area. Abdomen non-tender. No organomegaly. Extremities nontender, full ROM, no pedal edema. CNII-XII intact. DTR’s 1+ bilaterally. Cognitive exam reveal difficulties naming the previous 4 presidents of the US. She was able to subtract from 100 by 7s for me.

Labs:

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

March 22, 2005

Based on her clinical picture and laboratory results, she appears to be suffering from Borreliosis (Lyme disease) and possible Babesiosis. Although her blood work did not show evidence of Babesiosis, her clinical picture is very suspicious. Babesia, a red blood cell parasite, causes extreme fatigue which is worse with exercise, neck pain, shortness of breath, and night sweats. Unfortunately, she reports all of these symptoms; therefore we are unwilling to rule out Babesia as a diagnosis regardless of her serology at this time.

Since our last meeting, she has been on 5-6 weeks of oral Zithromax and Mepron. After not seeing much improvement with these oral preparations, her PCP placed her on IV Rocephin for a period of 6 weeks, which was an excellent choice. Today, she reported some improvement in her symptoms including decreased fatigue (not need to nap during the day), headaches greatly improved, neck pain improved, hot flashes have subsided and hand tremors have disappeared. However, she is still experiencing intense joint and bone pain, shoulder stiffness, spinal tenderness, shortness of breath, night sweats and rapid mood swings.

Based on her clinical picture, laboratory results and her clinical trial of both oral and intravenous antibiotics, it is clear that she is suffering from Borreliosis (Lyme disease) and possible Babesiosis. While she has had some improvement with the Rocephin, it would be premature to stop the antibiotics at this time. In general in a case as severe as this one, we recommend continuing the intravenous antibiotics at least one month after the majority of symptoms have resolved. If the antibiotics are not continued for an appropriate amount of time, then the patients seem to quickly relapse.

Recommendations:

  1. Continue IV Rocephin 2 g daily for a total of 12 weeks
  2. Zithromax 250 mg po bid
  3. Mepron 750 mg po bid
  4. Nutritional supplements