A patient I saw today:
This was one of my early cases. I was just learning. The daughter saw me first. She was diagnosed with some form of reactive arthritis by a rheumatologist. She had a borderline rheumatoid factor, borderline ANA and a high CRP and sed rate. She was placed on Methotrexate, a commonly used immune/disease modifying drug. Around that time she began seeing me. I demonstrated evidence of chronic infection, either old or active, with Lyme as well as other bacteria. Ongoing infection could be an explanation for her problems. This could imply an alternative approach to her problems might be helpful. The rheumatologist became aware of this. A cough led to a chest X-ray. Surprise. It showed enlargement of hilar lymph nodes in her thorax. The rheumatologist was alarmed. He knew that Methotrexate(MTX) could be associated with Lymphoma- a type of cancer. He also knew that MTX induced lymphoma could regress when the MTX was stopped. The MTX was stopped. A repeat Chest film was normal. He was relieved: another one pulled out of the fire. The ball was in my court. I treated her for Lyme and chronic Salmonella- something I considered more important at that time. She responded poorly. Antibiotics didn't help. I sent her to another LLMD/rheumatologist. The other physician tried her on everything under the sun, including many alternative medical therapies. She also struck out. The new rheumatologist, as a last resort, suggested the patient try Enbrel, another immune modulating drug. After the close call with MTX my patient said no thank you and returned to me.
The father is another story. The same (first rheumatologist) diagnosed him with rheumatoid arthritis. It was atypical. He was in his 60s and it occurred after an acute viral infection. He had high titers against EBV and a dramatic positive WB for Lyme. He was upset when he realized the rheumatologist made the "wrong" diagnosis. Unlike his daughter, he responded beautifully to anti-Lyme treatment and went into a complete remission. He too had a positive rheumatoid factor test and other markers for autoimmune disease.
My impression is that both father and daughter have the same genetic profile. They share an HLA genetic type which put them at risk for infection-activated autoimmune disease. One had responded well to anti-microbial treatment, the other had not.
Let's get back to the daughter. She has a very high CRP, about 45. Her sed rate is in the same range, about 45. She has persistent joint pain and fatigue. She also has radicular pain of the left upper extremity (pinched nerve pain in the neck), but this could be due to a mechanical problem such as a disc, not Lyme disease.
She has no other neurological symptoms or cognitive symptoms, and no other symptoms of note. She had been on three years of antibiotics and other therapies, with no change in her complaints. She has some other low grade, nagging lab abnormalities: low carnitine, low B12. low folate and vitamin D dysregulation. Her RA factor and ANA remain modestly elevated. If I were not a "Lyme doctor" I would say she has a variant of rheumatoid arthritis. The Enbrel seems appropriate- except that it might give her cancer, and she wasn't willing to risk it.
So what to do? I dazzled her with fancy foot work. I explained the molecular mechanisms of autoimmune disease- various theoretical constructs- Th1 and Th2- I was stalling. It was the end of the day.
Sometimes I just don't have a great answer. So I ended up prescribing a novel combination of antibiotics- maybe I'll (she'll) get lucky. Perhaps not. One out of two isn't bad, is it?
I don't get everyone better. But I never quit trying.