Monday, November 17, 2008
Three Legged Monster
I have been treating this critically ill 45 year old man for 2 1/2 months. He had previously been treated by ID specialists with 21 days of Doxycycine. He had been critically ill for 18 months with a rapid downhill spiraling course. He had 3 spinal taps, (I would have said no thank you after the first). Two were negative. The third time he was diagnosed with viral meningitis. He was given a second course of Doxy- thank you. His body is racked with pain. He has unremitting shooting pains and burning of his entire body. Every joint and muscle hurts. His body is weak and he is unable to function. His cognitive deficits have progressed to the point of global dementia. He has restless legs, fevers and chills and soaking sweats. I started him on oral anti Bb meds. He herxed severely. A break in therapy was needed. Low dose malarone was added and his chills and fevers became unbearable. This was put on hold. Despite my concerns, the family was desperate for a more aggressive approach. I was leery, but agreed to give it a try. One month in I started Rocephin. The neuro and musculoskeletal Herx was severe. The decision was made to tough it out. Mepron was added. The Herx was worse: the patient developed a delirium. This abated with a lowering of narcotic analgesics and a reduction in dose of Rocephin. When the Rocephin was ramped up again the Herx returned and was intolerable.The dose of Rocephin was lowered once more and his symptoms settled down. His mental status was at least back to baseline. The soaking sweats of the Babesia Herx persisted. The Mepron was stopped. Malarone one tablet daily was re instituted. The sweats and chills abated. Two legs of the monster were at least being held at bay: Borrelia and Babesia. His blood smear is swarming with the mystery bacteria. It was a stalemate, The patient was circling the tarmac. His pain was minimally improved. His mentation was stable. The drenching sweats were gone. He was also encouraged that the restless leg syndrome had quieted down with Mirapex. His wife was certainly grateful since he had belted her in the face during sleep. I know the Lyme and Babesia were only being tamped down. Every time I upped the ante things got worse. Is it better to treat only one thing at a time as is oft stated? That approach so far had failed. Perhaps it is better to hack away at all three legs at once. Today I set out a trap for the third leg of this dreadful monster. I don't know what the mystery germ is, nonetheless, I cautiously added Zithromax and Rifampin in an effort to throw it off balance. Hopefully the monster will fall. I know if it does I will have to return to the work of chopping away at the other legs.