I have so many great cases. I can't write about as many as I would like. This case is very alarming to me. I will summarize its salient features. Her treatment for purposes of this discussion started at age 15. She had knee pain since age 11 which was getting worse. She had not sought care for the knee pain. At age 11 she came to the office with mono-articular arthritis of one knee. A Lyme test was CDC positive. She was treated with two weeks of Ceftin- and then lost to follow up.(She was treated based on guidelines as they were understood at that time.) Shortly before the first visit now, she noted a bulls eye rash on her leg. It was noted that she had years of fatigue and neuropathy symptoms. An associate in my office had diagnosed "ADHD" two years prior to this visit and prescribed Adderall with a positive result.
Her standard Lyme WB showed 13/13 positive bands. Her C6 peptide antibody was through the roof. She was treated with 4 months of oral antibiotics without improvement; in fact she got worse. She developed a syndrome of numbness of both legs below the knees. (I have seen this exact syndrome on several other occasions.) She was started on IV Rocephin. She stayed on this for only 30 days. It was stopped when I was out of town because of suspected PIC line infection. The numbness resolved quickly. Her memory improved. It only became clear- after the Rocephin, that she had memory problems. Sometimes you only notice something when it is no longer present. The "ADHD" was better as well. She continued to improve, dramatically on oral antibiotics- but then stopped taking everything. She went off antibiotics for about 5 months and was lost to follow up.
When she returned, finally- two months ago, Her forgetfulness had become "terrible." She had lost all of her cognitive gains. A SPECT scan showed hypoperfusion of the left frontal lobe of the cerebral cortex. She now complained of hot flashes- suggesting a possible Babesia co-infection. She was treated for Babesia and Lyme over the ensuing two months. The joint pain was better. The fatigue was a little better. The memory loss- inattention- brain fog were no better. She was/is having academic difficulties.
My plan is oral antibiotics for another month- if the cognitive deficits are not improved IV therapy will be re-instituted.
I would like to comment on the SPECT scan. It shows changes in regional blood flow patterns in the brain. Blood flow may be decreased in areas of the brain which are metabolically inactive due to toxins or other injury. The areas of the brain which show poor perfusion are diseased in a way which causes them to function poorly.
Classically, neuroborreliosis is associated with poor functioning in the frontal lobes. There may also be diffuse involvement of the temporal or parietal lobes.
The abnormality here is seen in her dominant hemisphere. So of course it would cause cognitive difficulties.
What is the finding in ADD? Frontal lobe dysfunction: the same thing. With straight ADD the abnormal scan corrects with the administration of Ritalin or a similar drug. The problem has to do with a lack of dopamine activation of neuronal pathways to the frontal lobes.
It should not be surprising that what is diagnosed as ADD may in fact be neuroborreliosis. Lyme induced "ADD" may also improve with Ritalin. It just doesn't work as well as with traditional ADD. Many "ADD" patients may be able to stop stimulant medications after successful antimicrobial therapy of their Lyme disease.
She should get better. I lectured her and parents about compliance. Aggressive therapy is critical. The consequences of ineffective therapy, long term, would be grave.