Case Study 13.

November 2003

Patient presented with history of an atypical Lyme rash. Patient complains of severe aching throughout his entire body, especially his legs and lower back. He has been experiencing increasing exhaustion and decreased energy. In addition he reports feeling “less sharp” with memory and cognitive functioning. Patient has also been having significant seizure activity which is suddenly new. Patient has been taking Depakote to control seizure activity.

Labs:

Greenwich – WBC, RBC, Hgb, Hct, Plt ct, electrolytes, Bun/Creat, Bilirubin, Alk phos, AST, Albumin, Anti-Tpo, Thyroglobulin Ab all wnl. Glucose 68 (70-110), ALT 84 (5-65). HLA-DR4 – not detected.

Immunosciences –Western blot shows positive exposure in the following bands: IgM 31; IgG 41 and 58. IgG, IgM, IgA of Mycoplasma Fermentans <100. IgG M. Penetrans 10 (0-20), IgM 108 (0-20), IgA 10 (0-20). IgG Candida 4325 (0-3200) B. Burgdorferi PCR – neg, Lyme Recombinant Antigen – neg, Bartonella PCR – neg, Babesia PCR – neg, Ehrlichia PCR – neg, Babesia Elisa – neg

Igenex – Western blot shows exposure in the following bands: IgG 43, 39, 41, 45, 58, and 88; IgM 18, 23-25, 30, 31, 39, 41, 58, and 66. Babesia Fish (RNA) – neg, Bartonella titers IgM <1:20 and IgG <1:40; Babesia titers IgM <1:20 and IgG <1:20.

Tx:

  1. Zithromax 500mg po bid
  2. Ceftin 500mg po tid
  3. Plaquenil 200 mg bid
  4. Diflucan 100 mg bid
  5. B12 injections 1mg three times weekly x 1 month
  6. Magnesium Chloride injections 1cc twice weekly for 1 month
  7. Nutrients – CoQ10, ENADA, DHA, Alpha-Lipoic Acid, Brain Wave

December 2003

PICC line placement with Rocephin IV 2g qd.

January 2004

Patient reports symptoms much more under control. He reports thinking much clearer and memory improvement. His exhaustion comes more in waves and not as constant as before. His pain in his legs is mostly in the evening now and less severe.

  1. Rocephin increased to 2g bid for 6 weeks
  2. Continue Zithromax 500 mg po bid
  3. Mepron 750 mg suspension po qid
  4. Minocycline 100 mg po bid
  5. B12 injections

March 2004

Patient is now completely off Depakote. He has not experienced any myoclonic seizures. He stopped his Mepron earlier in the month and started having “wake-up jerks”. He has tremors when waking up and falling asleep. These “jerks” previously were repetitive, but now are random. His aching and exhaustion has disappeared. His cognitive continues to be clearer.

  1. IV Doxycycline 100 mg bid
  2. Continue Mepron 1500 mg daily
  3. Zithromax 500mg daily
  4. Gabatril 4mg qhs
  5. Diflucan 100 mg daily

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