36 year old female presented with a 4 year history of Lyme disease. Starting four years prior horrible arthritic pain and swelling in hands. Treated with Amoxicillin x 3 wks then Doxycycline for 3 wks. Two months later no significant improvement. Then treated with Biaxin and Doxycyline and experienced a sever Herx reaction. For the better part of the following year she reports being bed ridden and unable to walk in addition to increasing problems with memory and disorientation. Patient reports a 50-60 lb weight gain.
SH: Patient is a veterinarian and is constantly around animals, especially horses.
PE: 214lbs, BP 100/60, RR 16, HR 64 Physical exam essentially negative except: Trigger points at clavicles 9/10, costochondral area 8/10
Igenex: Babesiosis PCR — neg, Borrelia PCR — neg, Babesia IgM and IgM titers <1:20, Urine Lyme Multiple PCR — neg,
Immunosciences: Babesia PCR — neg, Bartonella PCR — neg
Quest: CBC with diff — wnl, Electrolytes — wnl, BUN/Creatinine — wnl, LFT — wnl
SPECT Scan:7/1999 non-specific diffuse regions of decreased perfusion within the cerebral hemispheres bilaterally, especially within the temporal lobes bilaterally. Non-specific findings which can be seen in Lyme disease.
Doxycyline 200mg bid, Biaxin 500mg bid, and Plaquenil 200mg bid Patient was unable to tolerate the Plaquenil because of dizziness Recommended IV Claforan 2gm tid and weekly nutritional IV
After two months of IV Claforan, the patient started developing a rash with infusion which was originally controlled by pre-medicating with Benedryl, however, rash became too overwhelming. Patient was switched to Primaxin 500mg IV tid for four weeks. After a total of 3 months of IV therapy, patient reported symptoms almost completely gone. No neurological symptoms, great improvement with cognitive symptoms, and joint pain was completely gone. Her PICC line was then pulled.
SPECT Scan: 7/2000 Previously noted abnormalities resolved. Study is now normal.
June 2002 Patient started experiencing joint pain symptoms again. Patient was prescribed Zithromax 250mg bid and Plaquenil 200mg bid for two months which she was able to tolerate at this time and had complete resolution of symptoms