Case 6

HPI: 46 year old wheelchair bound female presents with an extensive history of Multiple Sclerosis. Ten years ago (1995), her knees started becoming weak and had increasing problems moving her feet. In 1998, she was diagnosed with primary progressive MS. Her spinal tap, and MRI were negative. Since that time she has become progressively worse to the point of no longer being able to ambulate. In 2003, she had a Baclofen pump inserted which she feels is not helping very much. She has been several courses of steroids over the last year which she feel had made her much worse.

Currently she is complaining of daily headaches behind her eyes, weakness in her arms which started earlier this year causing her difficulty holding her arms over her head and is now unable to write and complete fine motor tasks. She has significant neck pain, cracking and stiffness. She has continuous nausea and constipation, and she needs to urinate every two hours. Her leg pain is a constant aching and stiffness, at times she is completely unable to bend her knees and her muscle go in to spasm. She experiences drenching night sweats and significant fatigue during the day. She is unable to sleep well at night due to the night sweats and her urinary frequency. Cognitively she is having trouble with word retrieval, clarity of thinking, and memory.

Meds:

Detrol, Baclofen, Provigil, Prozac, Percocet

Allergies:

NKDA

PE:

BP – 120/68, P – 70 General – WNWD, anemic in appearance, wheelchair bound HEENT: PERRLA, EOMI, pale conjunctivae NECK: + tenderness to palpation over SCM bilaterally RESP: CTA CVS: RRR EXT: Non-tender. LE very spastic. Patient has almost no ROM. UE weakness bilaterally, unable to hold arms above head. NEURO: CN II-XII intact. LE DTR absent, UE DTR 1+ bilaterally

Labs: Igenex – IgG, IgM positive, showing exposure in the following bands: IgG 23-25, 30, 31, 34, 39, 41, 45, 58, 66, and 93; IgM 18, 23-25, 30, 34, 39, 41, 45, 58, 66, and 93. Babesia titers are IgM <1:20, IgG 1:40 (<1:20). Human Monocytic (Echrlichia) titers are IgM 1:160 (<1:40), IgG 1:80 (<1:40). Bartonella titers are IgM <1:20, and IgG <1:40.

Assessment:

Borreliosis, Babesiosis, Ehrlichiosis.

Tx:

  1. Minocycline 100mg bid
  2. Insert PICC line and start IV Rocephin 2g daily ASAP
  3. Detrol LA 4mg, qhs
  4. Ambien 10mg qhs
  5. B12 1g/ml injections twice weekly
  6. Magnesium Sulfate 1g/2ml IM injections weekly

12/30/04

On IV Rocephin for 2 weeks. Mentally thinking clearer and memory improved. More energy, getting up everyday around 7am instead of 11am. Sleeping much better. Out of wheel chair and walking with a walker every day for exercise. Headaches less frequent. Neck pain gone, nausea gone, constipation gone, not taking any pain medications, no night sweats. Able to make dinner for her family a few nights per week.

Labs:

WBC 2.9, RBC 3.09, Hg/Hct 7.6/24.1

A/P:

Progressing well. Will stop Rocephin until lab results return to normal and restart with IV Zithromax.