Patient with positive serology for 4 tick borne infections and surprising presentation

A 50 something year old male patient joined my general family practice about 3 and 1/2 years ago. He was fairly healthy but described an unusual history. Some months before he suffered a rib fracture. His orthopedic surgeon prescribed miacalcin, the hormone calcitonin, to speed up the healing of his fracture. He developed acute psychiatric symptoms. He became depressed and then manic. He was diagnosed with bipolar disease and anxiety precipitated by calcitonin. Over the next two years his psychiatric disorder worsened and he was placed on an increasing number of psychotropic agents by various psychiatrists, who were somewhat miffed by the odd atypical presentation in this man.

A little over one year ago he came to me office complaining of skin discoloration. He had two rashes. One was a classic EM rash on the right thigh.

A little more history. He was an avid deer hunter. He did have some fatigue and neck pain. He did recall a brief, minor episode of fever and chills three months preceding the rash. Besides the psychiatric symptoms he was generally robust and felt quite well.

Blood samples were sent to Quest Diagnostics: The CBC was normal. B12 and folate were normal. His vitamin D levels were normal. Babesia microti- elevated IgM titer. Bartonella Quintant- elevated IgM titer. Anaplasmosis phagoctytophilum- very high IgM titer. Borrelia burdorferi- Western Blot- 9/10 IgG bands and 3/3 IgM bands. Lyme C6 antibody index- over 6.0.
At this point his psychiatrist had him on Depakote- a mood stabilizer 1750mg per day (a very high dose), Seroquel- an anti-psycotic used for severe mania and Klonopin, a tranquilizer used for anxiety and the anti-depressant Lexapro.

He came to my office to review the lab results. He looked remarkably well. I felt like I needed some of his Klonopin to figure out how to treat him.(Humor- if the board is reading this). I stared with Zitromax and Mepron for 3 weeks only. At that point his neck pain was gone. He had no chills or flu like symptoms. He had only mimimal fatigue and nominal joint pains- mostly knees. His mood swings were perhaps a little better. He was treated with a month of Amoxil one gram twice daily and Cipro 500 mg twice daily. No Herx- feeling well. He was treated with Amoxil- same dose and Doxycycline 400 mg per day for 6 weeks. Blood to Labcorp: CD57 120, CBC- WBC count 5.2 (normal) but new right shift. This means there were more lymphocytes and fewer neutrophils than usually seen. The Lyme WB showed IgG bands 10/10, IgM 2/3
bands. Bartonella, Babesia and Ehrlichia were negative. The C6 titer was 5.5. The folic acid level had increased from 18 to greater than 24. He was not taking vitamins. After 12 weeks Flagyl was added. He was now taking Amoxil- same dose, Doxyclycine- same dose and Flagyl 500 mg daily. His energy level was normal. He had not medical symptoms. His psychiatric symptoms were improving quickly and his pychiatrist was quickly weaning him from psychotropic medicines. After an additional 8 weeks his Doxycycline was changed to Biaxin. He had no symptoms related to tick borne illness, except mild anxiety and mood swings.

Six months after his first presentation, still on the same antibiotics, his psychiatrist had stopped Depakote and Seroquel. The dose of Klonopin was in a process of being tapered off. He was still on Lexapro. Two months later he was off Klonopin. His prior antibiotics were discontinued. He was changed to Minocin 100 mg twice daily. Most recent labs: Lyme WB IgG 9/10, IgM 1/3. CBC- no change- persistent right shift, C6 index- 5.2. Routine labs including autoimmune and markers for inflammation are normal.

His "Bipolar" disorder is in remission.

He is convinced it all started with that darn Miacalcin. The PDR states that Miacalcin is synthetic calcitonin, a hormone secreted by the parathyroid glands. It's primary effect is to strenthen bone by inhibiting the activity of osteoclasts, the cells which remove bone matrix. It is rarely reported to cause depression and anxiety: reasons unknown. It has not been linked to bipolar disease. Does it have a feedback effect on vitamin D or cell mediated immune functions? This has not been reported.

The psychiatric symptoms preceeding the acute typical presentation of Lyme and tick borne illness by some years.

I suspect he had chronic Lyme causing an atypical psychiatric disorder with superimposed acute re-infection. Miacalcin? A red herring?

He is in his mid 50s. He is the picture of health. He has no physical or cognitive limitations. He mountain bikes miles. And by the way, he still hunts deer.