October 5, 2007
RE: Sandra Campbell
To Whom It May Concern:
Mrs. Campbell is a 28-year-old female with a history of chronic illness which became significantly worse in the fall of 2006. She presented to the Lyme Resource Center with symptoms including cognitive disorientation and memory difficulties, unrelenting headaches, frequent urination, and extreme fatigue.
Test results from Immunosciences Lab (multi-peptide antigen assay) on May 1, 2007 reveal positive IgM antibodies for B.B Sensu Stricto (Lyme disease), indicating active infection, as well as positive IgG antibodies for the tick-borne co-infection, Ehrlichiosis. In addition, IgG for Bartonella, another co-infection, falls into the equivocal range. Her CD57 level is 24, representing suppressed immune function – a common finding among chronic Lyme patients. Please find attached copies of these results.
Based on her clinical presentation and laboratory results, it appears that Mrs.Campbell is suffering from Persistent Borreliosis, Ehrlichiosis and possible Bartonella co-infection. Treatment was initiated with oral medications. However, due to the severity of her illness, the length of time that she had been ill, and her significant gastrointestinal difficulties while on oral antibiotic therapy, it became medically necessary to pursue intravenous antibiotics. Although she had had some improvement with a course of intravenous Rocephin 2 g daily for 12 weeks, Mrs. Campbell continues to suffer unrelenting pain. She takes Tramadol 50 mg prn for pain. A recent trial of a Fentanyl patch for pain relief was unsuccessful. Currently Mrs. Campbell is starting an 8-week course of intravenous Zithromax 500 mg daily, in the hope that an intracellular antibiotic will be effective following the Rocephin. However, the patient’s overwhelming pain continues.
At this time Mrs. Campbell is medically unable to work regularly scheduled hours for at least 12 months, due to the above-mentioned pain. During this period of time, she would like to work for 5-15 hours per week, when her health permits. Her progress will be re-evaluated in a year’s time, and further recommendations made.
If you would like any further information, please feel free to contact our office.
Bernard D. Raxlen, MD Carolyn B. Welcome, PA-C