Case 9

HPI:

23 year old female presents complaining of an extensive history of symptoms. In August 2002 she developed a Bell’s Palsy and tested for Lyme disease. She was started on Doxycyline for one month during which time the Bell’s Palsy improved. She was then placed on Tetracycline for 3 months followed by three months of Erythromycin and Plaquenil. During this time she was also being treated for bipolar and anxiety disorder. When she presented to our office, she had the following symptoms: increased depression and anxiety despite multiple medications, difficulties with memory and concentration, trouble thinking clearly and processing thoughts, irritable bowel symptoms, bad back and neck pain, tremors, muscle twitching, headaches lasting for days at a time, extreme joint pain and at times swelling, and feeling extremely exhausted with all of her symptoms increasing around her menstrual cycle.

Meds:

Wellbutrin, Klonopin, Zyrtec, Straterra

Allergies:

PCN

Labs:

Igenex – Western blot IgG and IgM CDC positive with exposure in the following bands: IgG 18, 23-25, 28, 30, 34, 39, 41, 45, 58, 66, and 93; IgM 18, 23-25, 28, 30, 31, 34, 39, 41, 45, 58, 66, and 93. (Number IgM 31 is four starred) Babesia and Bartonella titers are negative. Immunosciences – Positive results include: IgG and IgM M. Fermentans; IgG, IgM and IgA M. Penetrans; IgG, IgM B. Burgdorferi Lysate, IgM Outer surface protein A, IgM Outer surface protein E, IgM LFA Antigen, IgM Immunodominant protein, IgM Variable major protein, IgG and IgM Borrelia Sensu Strict; IgG and IgM B. Garinii Decorin ; IgM B. Afzeli Decorin; IgG and IgM Babesia; IgM Ehrlichia peptide

Spect Scan – negative

MRI – negative

A/P:

In light of her clinical picture and laboratory results, this patient appears to be suffering from chronic persistent Borreliosis complicated with Babesiosis, Bartonella, Ehrlichiosis and Mycoplasm.

  1. IV Rocephin 2g daily x 12 weeks

March 3, 2005

Patient presented for follow-up appointment after 3 months of Rocephin. She reported some overall improvement in her symptoms including feeling less run down, more energy, starting to experiences more frequent “good days” and less depression. However, she is still experiencing extreme joint pain, sleeping during the day, problems with concentration and thought processing, hands and feet swelling, shortness of breath, sharp pain across her abdomen, nausea and vomiting.

  1. Stop IV Rocephin
  2. Start IV Zithromax 500mg daily x 12 weeks
  3. Mepron 750mg suspension twice daily po x 12 weeks