Tuesday, October 14, 2008

Quick post- promised a patient.

I had a hellacious day. Lyme patients out the wazoo. I apologized to a patient who had been waiting for over an hour. I told him the previous patient was "famous."
He said: "Hey, don't I rate?" I thought about it for a minute and told him I would write about his interesting case.

This 66 year old gentleman came to me first on September 5, 2008. He had just come back from New Jersey. He complained of an acute flu like syndrome with muscle pain, headache, neck pain,weakness, fever, chills and drenching sweats. The symptoms were occurring in 3 day cycles. His physical exam showed no obvious focus of infection. Of course I thought "ah ha" Babesia.
I started him right on Mepron and Biaxin. He saw me again on September 23. The sweats and chills were 100% gone. Now he had red cutaneous nodules and heel pain. "Ah ha." Bartonella.
I switched him to Cipro and Doxycyline.

Today I saw him again. The heel pain and nodules were gone. Now he felt tired and achy. "Now," I thought: "Typical Lyme." I looked at his labs. Standard co-infection panel negative. Lyme WB by IgeneX: IgM IND 41 band only, IgG 41 band ++, 31,34 and 39 bands-all IND.

"Looks like old Lyme." I scratched my head. Many patients have new infections which seem to activate old disease. In this case I suspect he had a fresh Ixodes bite injecting him with new Lyme and new co-infections. Now he was experiencing symptoms of typical chronic Lyme. The expression "let sleeping dogs lay" csmr to mind. It looks like the new exposure had kicked him into chronic Lyme mode. I prescribed Amoxil, Biaxin and Plaquenil and asked him to return in one month. This is an interesting presentation.

Every case is different.

Yes: it is Lyme disease. Not :Lymes disease. Many make this mistake. So what?
From high school lit: "A rose by any other name would smell as sweet."

7 comments:

dogdoc said...

They really are all different. How do you approach it when all the signs run together say in a patient with chronic lyme disease , bart, and babs? You start treating the borrelia and the tired, foggy goes away (until night when the babs kicks in) but the morning foot pain and parathesias get worse. Do you flip a coin and decide to get off a winning horse for one to treat the other? Here is where the art kicks in I guess.

aokinski said...

Hello,

Someone on a lyme disease discussion forum gave me the link to your blog. I recently found out I have lyme disease and am looking for a doctor like you who really knows what they are doing! (I'm in the montgomery county area)

I live in Montgomery County (very close to Germantown). I originally went to my endocrinologist because I was tired, had flu like symptoms, and just did not feel well in general - I thought it had to do with my thyroid since both my parents have thyroid problems. Luckily, he suggested that I get tested for lyme. The bloodwork came back positive and he referred me to an infectious disease specialist.

I did not get good information from the ID. I asked him if there was anything I should know about the antibiotic treatment (doxy 100mg 2x a day) and he said 'stay out of the sun'. Over the past three weeks I have been way more sick than I was before. Over the last couple days I've been throwing up and it got very bad last night - I was having hot flashes, stomach cramps, and throwing up. I called the ID this morning and he said to stop taking the medicine immediately and scheduled an appointment for the end of this week. I didnt really get good information from him the first time so I am just desperate now to see a doctor who can really listen to me and look at my case (instead of just treating me like my concerns aren't important).

If there is any way that I can set up an appointment with your office I would be so greatful. My email address is annacosinski@gmail.com and my phone number is 301-633-6274. I would really like to get an appointment with someone who can work with me and explain what is happening. Thank you so much for your consideration!

Anna

dogdoc said...

Anna- you can get docs info from Barbara at ILADS also 301-263-1080. Don't know if ok to give it out directly to your email if asked. Doc, what are the rules?

aokinski said...

Thank you, dogdoc. I actually sent an email to Barbara but I received an Out of Office reply that she is away til the 22nd. If the information can be emailed to me that would be GREAT! Thank you so much,

Lyme report: Montgomery County, MD said...

This blog printed twice. Erased the other. The question was about Unasyn. This med is like an IV form of Augmentin. It is based on Ampicillin. This is short acting and needs to be given 4x per day. This not practical for Lymies. I heard Dr. Burasccano claim that Lyme can make beta lactamase (become resistant to penicillin): Is there any data to support this? There is evidence that Bicillin. plain old penicillin is effective.
Based on current info there is no reason to recommend that Unasyn be used in Lyme therapy.

dogdoc said...

Good morning doc! I remember one study that showed beta-lactamase found in Borrelia. Was a long time ago that I read it- I believe it was from Europe. I can find it if you want. I haven't seen any clinical studies or in-vivo work on patients.

Joe said...

Hi,

I just found your blog today. Lots of nice write ups. Thanks for sharing all this information.

I was bit by a tick, had very obvious bulls eye rash, in July 2007. Got on short course of doxy, then short course of amox, prescribed by a non-literate GP.

Within 3 weeks of being bit, I was already losing the ability to function - very acute neuro issues. Rage, hypersensitivity to light, sound, smell, motion. Confusion. The list could go on and on.

It's been 17 months now, and I'm under the care of a good LLMD (Dr. Phillips!). I've seen some improvement, but am not well yet by any means.

I've always been puzzled that I could get "late stage chronic lyme" so quickly after being infected.

This post is the first time I've heard anyone else speculate on an infection "waking up" dormant lyme from an earlier infection. I think my LLMD has considered this, and knows he can't prove it, and he'd treat me the same regardless, so doesn't pursue figuring this out.

I agree with that, but it's still a puzzle that would be nice to solve. I had a LOT of lyme exposure in 2005 - I hiked the whole Appalachian Trail, sleeping on the ground (just on a ground sheet, no tent) for 120 nights. I pulled deer ticks off me a few times.

But I had zero symptoms. Then, six months after I finished the hike, I got "shingles". In quotes, because it was like everything I'd heard about shingles, and my GP diagnosed as shingles. But apparently with shingles the pain NEVER crosses the mid-line. It's on one side of your head only. Mine was mostly on the right, but there was definite spreading painful nodes on the left as well.

My GP dismissed it as impossible (funny how they do that). I forget what treatment I received - is it typical to treat with abx? Anyway, I got better after a few weeks. Never considered it might be lyme.

Looking back now, I can see there were several times after the shingles incident, and before I got bit, where I had unexplained, varying symptoms. A couple of times I went on doxy for 3 weeks, as I always have possible tick exposure, and I seemed to get better.

But I never considered chronic lyme.

Is it reasonable to suspect that I had lyme all along, though asymptomatic at the outset, and this is the reason I got so bad, so fast after getting bit in 2007?

Regards.
-joe