My 25 year old patient is a liberal arts major at a small, prestigious college. He has missed multiple semesters from college because of Lyme associated cognitive problems. He seems brilliant to me. We converse about a variety of topics in literature and philosophy in a way which seems fluid and cogent. He shares a problem with so many Lyme patients. On the outside he looks OK, but observers don't know what its like inside his brain. He complains of executive dysfunction, difficulty concentrating and difficulty connecting thoughts. Reading, comprehension, and writing can all be difficult. Invisible psychiatric symptoms, mood swings, irritability and anxiety co-exist when things are bad. But - he has been stable for the last 8 months except when I try to wean him off antibiotics. The only thing that works is quadruple antibiotics, two for Lyme and two for bartonella syndrome. If I take away any one of the 4 and symptoms return quickly. A recent cold set him back for a month. He seems he holds on only by a tenuous thread. But there is something else going on, a pattern I have seen repeated in many other patients.
I ask him question of life before Lyme. He has a history of chronic, recurrent, difficult to resolve sinus infections and bronchitis.
I ordered another test: an immunoglobulin profile. Total levels of IgG, IgM, IgA, IgD and IgG. IgG subclasses 1-4.
There are deficiencies of IgG, IgM and several IgG subclasses.
I ordered a pneumonia vaccine, 23 strains, measure immune responses in 3 weeks. There is minimal IgG antibody response in 13 strains within the vaccine.
The patient has CVID - common variable immune deficiency syndrome(s), a collection of genetically predisposed, acquired disorders. This may explain much of what has been going on with this patient.
Other patients have responded to IVIG or especially the newer subcutaneous form he is scheduled to start as soon as possible.
Hopefully this will be a game changer.