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Wednesday, July 8, 2009

Ambien and a bump to the head with surprising consequences

A 42 year old female was in good health until she took an Ambien one night to help with some insomnia. Apparently she got up during sleep (sleep walking), went into the kitchen, and began to cook a meal. She then proceeded to fall down and bang her head. She presented to my office with a headache, some dizziness and severe pain and swelling in her lower extremities. Her calf muscles were extremely swollen and tender. I was concerned that she might have a subdural hematoma ( a clot in the skull) or rhabdomyolysis, a condition of muscle breakdown after injury which can lead to kidney failure. I sent her to the ER for a work up. The results were negative.

She came back in a day later. Her calf muscles were increasingly tight, swollen and painful. I was worried about a DVT (a blood clot). I sent her for a duplex (ultrasound) study to exclude this. It was negative. The pain was increasing in intensity. Narcotics, at a fairly high dose were needed to control the pain. The Percocet was not working; she returned with tears streaming down her face. She did not have myositis--inflammation of the muscles because the muscle enzyme CPK or CK was normal. Did she has some sort of myopathy? I ran some blood tests for an autoimmune disease. Oddly, her rheumatoid factor was elevated at 285. New symptoms appeared: there was now a tremor of her arms. I started a tapering dose of steroids. It was of no help.

A neurological exam was performed. Deep tendon reflexes were absent across the board. Pin prick sensation was decreased in a stocking/glove pattern affecting all limbs. Vibratory sensation was minimal in the feet. A tick borne disease panel was ordered.

The results: Lyme ELISA IgM 0.91--equivocal range, Lyme WB 41 IgM and IgG bands, Babesia WA1 antibody elevated 1:256, C6 peptide 0.2, CD57 63. Did she in fact have tick borne illness? Had trauma activated a latent tick borne infection leading to an autoimmune syndrome with progressive symptoms in a previously well individual? That was my thinking.

And her symptoms were progressive--rapidly. She developed uncontrolled rhythmic seizure like jerking of her arms. This was associated with uncontrolled vocalizations typical of Tourettes syndrome. The pain and muscle swelling continued to be severe and difficult to manage. She developed night sweats. None of these symptoms existed prior to her traumatic injury.

Treatment for Lyme and Babesia with typical antimicrobials over a 2 month period has been successful. The neuro symptoms--the seizures and Tourettes resolved. The pain and swelling has lessened. She is now returning to work half time, a feat which would have been unimaginable a few weeks ago.

This is the clinical vingette.

These are my thoughts--conjectures.

There are a large number of patients who harbor Lyme (Bb) and its associated co-infections without clinical illness. These parasitic entities are contained by the host and its immune system.
The healthy state can be quite tenuous. Many things can unleash the ticking bomb: intercurrent infection, stress or even physical trauma.

The percent of individuals in endemic areas who are assymptomatic carriers of TBD may be much higher than suspected, given my suspicion that the vast majority of infected individuals exhibit no symptoms of disease.

A positive Lyme ELISA test should not be discounted when the second tier--the Western Blot is negative. Any positive result for Lyme: ELISA, Western Blot or C6 peptide should be considered as potential evidence of the disease.

Positive tests for Babesia WA1 or Babesia duncani have become extremely common, much more so than B. microti. There has to date been no acknowledgement of this change in distribution of this parasite from the west coast to the east coast by health departments.

There are better sleeping medications than Ambien.


monkey girl said...

Definitely an unusual way to find out you with Lyme w/co-infections.

Ambien can be dangerous. I had taken it before and no problems. Two years later (last December) I took an Ambien, fell asleep, woke up went on the internet, ordered books from B & N, wandered around the house till my husband woke up and guided me back to bed.
Next morning, I didn't remember a thing.

Mark said...

Have you factored Cytochrome P450 into the equation as opposed to "a bump on the head"?

Unknown said...

Good grief! Lyme is showing up everywhere.
Would you say duncani is now showing up more often than microti? What is the difference in your mind between the two, symptom and treatment wise?

loz said...

What is a standard "tick borne disease panel"?

My son was diagnosed with LD, now after 3 weeks antibiotics (cefuroxim(allergy to penicillen), he still has an intermittent low grade fever, tiredness, night sweating, nausea. I suspect co-infection.

My doctor (I´m in Germany) doesn´t know what lab tests to order or what type of samples to send.

Please help!What do you ask the lab for?

nora said...

loz, there are at least two good laboratories in Germany, one in Köln, and one BCA Augsburg. Here amongst the pdf's is a list of tests.

Anonymous said...

The highly popular sleep medication ambien is used for short term sleep treatment only, i.e. for 7 to 10 days and it is known that Ambien is a prescription-based drug and hence should be used only after getting hold of a doctor’s prescription. Use Ambien as per the instructions of the doctor to cure your sleep problems and bear in mind that this medicine is likely to become ineffective if used for a long term and hence the use of this drug should be strictly supervised by a physician.

Adi said...

renolds: sounds to me like you're a rep for drug companies.

Ramesh said...

I have used ambien for a few months with no dire affects. It's not great though. I was given 5mg and after about a week I was sleeping well. I then lowered it to 1/2 and seemed to work for a few weeks then the sleeplessness came back. What I find with it is it helps you fall asleep fast, but you wake in a few hours. I doze and then keep waking up. I don't know if a stronger dose would work, but I don't like taking pills, but I couldn't function with no sleep. I was thinking a sleep clinic, but that seems to be for sleep apnea not for insomnia. Give it a try. Some people swear by it.