Wednesday, April 1, 2009

ER diagnosis

A 43 year old woman came into my office with just two days of prickly, burning sensations on the skin of her arms and legs. Her hands were a bit swollen. She had no other complaints. She spends no time outdoors and has not been exposed to typical tick habitats. She had no history of insect bite or rash. Her past medical history revealed a prior parathyroid resection. Her exam showed some mild peripheral nerve changes. My "Lyme brain" came to attention. Still, I reasoned to myself: "Everything is not Lyme." I thought of various reasons for an acute sensory neuropathy. Lyme causes neuropathy in the chronic form, not the acute form, therefore it should not be at the top of the list. There was a long list of other potential diagnoses to be considered. I considered metabolic causes: thyroid disease- especially given her history, electrolyte imbalances- perhaps calcium in this case, B12 deficiency, autoimmune cause, post infection autoimmune syndrome- usually after a viral infection and even celiac disease. Of course I couldn't remove Lyme from the differential diagnosis. I ordered the appropriate screening labs including a Lyme Western Blot. Somehow the Lyme serologies were inadvertently omitted by the lab. Her labs showed an elevated Mycoplasma titer and high sed rate. A week later the neuropathy symptoms were a tad improved. Now she complained of palpitations. Non- specific I thought. Everything is not Lyme I told myself once more. I diagnosed a Mycoplasma induced autoimmune syndrome and prescribed a medrol dose pack. I have recently seen a case of autoimmune neuropathy with joint pain as a post infection syndrome following a respiratory infection. I thought this might be the same sort of case. 10 days later she was back in my office. She been to the ER. She had experienced a sudden episode of weakness and back pain and couldn't get out of bed. Xrays there showed arthritis in the spine. That was the cause of her difficulties the ER docs suggested. The ER took blood for "tests." I saw her for follow up the other day. She continued to feel poorly- all over. She was almost in tears. The numbness and tingling was now diffuse; and now she had joint pains affecting the feet, ankles and knees. She had a headache and she was tired. She continued to have a few palpitations. She had no sweats or cognitive changes. Her physical exam showed normal heart and joints and mild distal peripheral neuropathy- decreased ability to feel pin pricks and vibrations, but minimal.

Then she asked me if I had received the lab report from the hospital. They had called her and informed her she had LYME DISEASE. Then I found the faxed lab report. The ILISA index was 1.57. A positive is over 1.1. Her "confirmatory" Lyme WB showed 2/3 IgM bands 23 and 41. The IgG showed only a 41 band.

I think without the ER visit I would have arrived at the Lyme diagnosis sooner rather than later. The surprising aspect of this case is that the ER ordered the blood test. Physicians in my community only think of Lyme if there is: an EM rash, acute arthritis with effusion, acute meningitis, acute heart block, acute Bell's palsy and perhaps a few other syndromes. Putting together back pain with numbness and tingling and other atypical symptoms and considering Lyme disease(from their perspective)- I am impressed. On the other hand they probably thought: "Here is another one of Dr. J's patients- must have Lyme like all the others."

1 comment:

btrflynana... said...

Your post today brings hope to me that some of the doctors out there are finally starting to listen!!!

Hopefully this is not a fluke situation and in that particular hospital/area the medical professionals are realizing more and more just how serious and real this disease is!

It would be great if other ER's would react and think along the same lines, instead of throwing their hands up in total perplexity when confronting how to treat us when we show up!

Thanks for sharing this glimmer of hope for us!!!