Case 7

11/8/04

45 year-old female with an extensive history of multiple episodes of pneumonia and Celiac Sprue presents to the office complaining of heart palpitations which caused both of her lungs to collapse, migrating pain in right eye, right ring finger and in back of next. Continual right sided headaches which have become increasingly worse since the summer. Few months ago had an episode of Bell’s Palsy causing drooling from her right side and her right eye became droopy. She has developed episode of horizontal diploplia, hearing can be either muffled or extremely sensitive. On any day she can have pain in any joint, burning in the bottom of her feet and lower legs which wakes her from sleep. She has developed tremors and weakness of her extremities and finds herself falling often when walking. Her sleep has become much worse, takes her 11/2 hours to fall asleep and then wakes with night sweats and nightmares. Cognitively she finds herself reversing tenses, word searching, increasing grammatically problems, forgetting names of people she works with, not able to understand written text, and dyslexia-type reversals with words and numbers.

PMH:

Patient recalls being bitten several times by ticks as a kid with multiple bull’s eye rashes. As a kid, she was never treated for Lyme disease. Over the last year, she was placed on Tetracycline several times which she recalled helped the fevers subside and helped her start thinking clearer. Currently she is on a course of Doxycycline. She also suffers from PTSD from abuse ages 0-30 and is currently in therapy.

Meds:

Doxycycline 200mg bid

Allergies:

PCN, codeine, epinephrine, Albuterol

PE:

BP: 100/70 P: 78bpm

GENERAL: WNWD, NAD, flushed appearance

HEENT: Nl inspection, decreased ROM in neck, difficulty tracking, no nystagmus, TMJ tenderness, bilateral non-specific lymphadenopathy

RESP: NAD, CTA, + chostochondral and chostosternal tenderness

ABD: +RLQ tenderness to deep palpation, nlw bowel sounds, no organomegaly

EXT: + tenderness to palpation of R knee and elbows (B), + calf tenderness, FROM, no pedal edema, equal strength

NEURO: difficulty with finger to nose, balance unsteady — drifts to the right, able to recall short term memory, difficulty with long term memory

Labs:

Igenex — Western blot shows exposure in the following bands IgG 18, 23-25, 28, 30, 31, 34, 39, 41, 45, 58, and 66; IgM 18, 23-25, 30, 31, 34, 39, 41, 45, 58, and 66. Human Monocytic IgM 1:40, IgG neg. Bartonella and Babesia titers are negative.

SPECT Scan — uniform and symmetric perfusion. Normal scan.

Assessment:

Chronic Persisent Neuroborreliosis

TX:

Zithromax IV 500mg daily x 12 weeks

12/14/04

On IV Zithromax for 4 weeks, had an episode of paralysis and ended up in the ER. All tests were negative and feeling / movement slowly returned to normal. Feeling much better. Dizziness gone, able to go to the gym, more energy, memory getting better, doing IMT/PT 2-3x’s per week, sleeping better, night sweats significantly improved, cognitive improvement able to read and understand the newspaper, decrease in headaches.

2/2/05

On IV Zithromax for 3 months. Sound discrimination has improved, but deafness has also increased. Definitely overall improvement. Great memory and cognitive improvement, pain, inflammation and motor problems much better. Endurance, fruatration, anger and depression comes in waves.

Tx:

Change Zithromax to IV Clindamycin 900mg bid

Tinnidazole 500mg daily

Oxygen therapy 2-4 litres for 20 minutes q2-3hours as needed