Saturday, July 7, 2012

Fatigue in a complicated patient

After a long struggle, the patient is doing fairly well. The cognitive improvements have been superb. But the fatigue and lack of endurance have recently been unbearable. The fatigue has improved and worsened in fits and starts. Recently, she has pushed herself just a little too much;  rebound fatigue with no endurance became unbearable. No reserves.

Long term intravenous antibiotics, 7 months and counting, have worked great. For three months, IV Flagyl as mono-therapy has been effective.

Despite normal lab studies, I clinically diagnosed adrenal fatigue. I treated her with Cortef and Florinef with a very positive result. Fatigue and energy much improved.

She has a history of very clear cardiac Lyme and has a permanent pacemaker. Her cardiologist has been carefully adjusting the pacemaker, recently increasing the top heart rate. The increased heart rate allowed with exercise seems to have helped as well.

POTS cannot be easily diagnosed. Her heart rate, recent exam, decreased with standing rather than vice-versa expected with POTS.

Surprising, at our last visit she reported relief in other symptoms. Her face was oily for the first time in more than a year (under autonomic/sympathetic control). A sensation of incomplete bladder emptying resolved (under autonomic/parasympathetic control) control. The sensation of hot/cold temperature dysregulation improved. These are POTS symptoms, not generally considered  adrenal fatigue symptoms.

I prescribed Florinef, a mineralcorticoid analogue of aldosterone made by the adrenals for the treatment of Adrenal fatigue. This hormone is widely prescribed for POTS because it increases salt and water retention helping with postural dizziness. A strictly symptomatic therapy. In this case it was prescribed for adrenal fatigue, not POTS.

Adrenal fatigue patients describe salt cravings. Perhaps this is due to adrenal/aldosterone dysfunction.

My treatment of adrenal dysfunction seemed to improve dysautonomia. An unexpected outcome.

She also started taking Ritalin again which has been very helpful for fatigue. Many clinicians prescribe Provigil/Nuvigil for fatigue. Ritalin usually works the same but is much more affordable.

Stimulants like Ritalin/Adderall, augment the effects of dopamine and norepinephrine. Adrenal insufficiency is associated with decreased norepinephrine excretion - stress hormones.

Taking Ritalin hopefully does not make adrenal fatigue worse. Like cortisol, it may take pressure off a mis-firing adrenal system. Anyway, it helps.

Improvements of symptoms and function hopefully help the overall healing process.

Too much stimulant may have a negative effect causing dependence -  decreased endogenous neuro-transmitter function.

It is all complicated and outside the box, but working for this heretofore desperate and hopeless patient.

3 comments:

sharparrow85 said...

Hello LymeMD,

I am curious about the cognitive improvements of lyme patients after IV abx. After IV treatment, do patients become on par with the "normal" population when it comes to cognition/memory..? Or are these treated patients still below average in cognition even after treatment?

I dream of going back to school someday (had to drop out due to cognitive dysfunction) but wonder, even after treatment, will I be able to handle it like a "normal" person that's never been infected before.

Unknown said...

I've had Lyme, or was initially infected, 35 years ago. My family (we're all in different states now) have been diagnosed and we all began symptoms after moving to Connecticut in '77. I was only recently diagnosed after a new subset of symptoms made me realize something was terribly wrong. I also have mycoplasma pneumonea.

My fatique has gotten so bad, the only way I can begin to move upon waking, with body in pain and feeling like lead, is after taking that 30 mg adderal ER kept on my nightstand. It doesn't always cut through herxing-type paralization, but what a miracle. The instant-type ritalyn doesn't work well for me. It's too up and down and drug-like. The extended release is so much smoother and seems like less side effects. I will test going off of it when I can but appreciate being able to function better because of it.

Precious said...

@sharparrow

I believe that the cognitive issues can dramatically improve in most cases, it really depends on the damage that the infections has produced in someone's CNS.

Lyme Disease