Case 5

January 11, 2005

26 year old female presents with a history of mono-like symptoms for the past year and a half. A year ago May, she developed a sore throat, swollen glands and fatigue. After a few weeks, everything disappeared except the fatigue remained. That summer she was working at an outdoor camp in Maine and felt completely drained, unable to do anything. Then she started having body aches, burning sensations in her legs which continue to be bad enough to keep her awake at night. Currently, she experiences persistent low grade fevers and night sweats, neck and joint pain migrating from wrists to ankles and up all of her extremities. Any sort of physical exercise completely exhausts her. She reports no change in cognitive functioning, memory or confusion.

PMH:

She reports being more ill over that last 4-5 years starting after a long hiking trip when she came down with a horrible flu. Since that time she seems to be very susceptible to colds and has waves of fatigue and soreness.

Meds:

Effexor, Maxalt, Yasmin, Flonase, Clariton

Allergies:

Tylenol – hives

SH:

Currently live back home with her parents. Graduated from college and was a 9th grade English teacher as well as a ski instructor in Colorado. Always worked out doors at camps all of the country. Recently has become so ill that she is unable to live on her own, had to move home and quit her job.

PE:

BP – 124/80, P – 88bpm

WNWD, NAD No facial abnormalities. PERRLA, EOMI. TMJ tenderness. No thyromegaly or lymphadenopathy. No respiratory distress. RRR, no murmur, costochondral and costosternal tenderness to palpation. Full ROM of extremeities, tenderness to palpation of the left knee, no edema. CNII-XII intact, DTRs 2+ bilaterally. no motor or sensory deficits. No gross memory or cognitive deficits.

Labs:

Igenex: Western blot shows exposure in bands IgG 31, 34, 39, 41, 45, 85, and 66; IgM18, 23-25, 31, 39, 41, 45, 58, 66, and 93 (CDC positive). Babesia and Bartonella titers are negative. Human Monocytic IgG 1:40 (elevated), IgM <1:40. Human Granulocytic IgG 1:80 (elevated), IgM <1:40.

Treatment:

  1. Zithromax 250mg bid
  2. Mepron 750mg suspension bid
  3. Continue treatment for 4 weeks

Feb 21, 2005

Patient returned to the office complaining of debilitating fatigue and exhaustion which was worse for the first 1-2 weeks of antibiotics and has improved slightly since then, continued burning sensation, neck pain and stiffness, headaches more frequent. No significant improvement with the oral antibiotics.

Treatment:

  1. Insertion of PICC line
  2. IV Rocephin 2g daily x 8 weeks
  3. Followed by IV Doxycyline x 8 weeks