Steven E. Phillips, MD
Specialist
in Internal Medicine and Lyme Disease
R. James Martin
01/22/98
HISTORY OF PRESENT ILLNESS: This is a 51-year-old white male who comes with a chief complaint of cognitive dysfunction. He has a history of multiple tick bites, no rashes and a long history of migratory polyarthralgias, malaise, cognitive changes manifested by depression and rage disorder and memory problems. He has also experienced waxing and waning fatigue, tinnitus in his right ear, no vertigo or hearing loss.
Lyme serology demonstrates both a positive IgG and positive IgM Western blots. Of note, his blood culture was also positive for B. burgdorferi. Over the past couple of years, he has had increasing sleep disturbances associated with night sweats.
He was treated with Rocephin IM at 3 g per week with Zithromax 250 mg per day with marked improvement followed by relapse. Of note, his serology is also positive for Babesia microti IgG.
PAST MEDICAL HISTORY:
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MEDICATIONS:
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SOCIAL HISTORY: He is a 60-pack-year smoker. Denies alcohol. He grew up in New Jersey, Connecticut in Lyme hyperendemic areas.
FAMILY HISTORY: Lymphoma in mother at age 42. She died.
PHYSICAL EVALUATION: He appeared well. His blood pressure was 150/86, otherwise afebrile. Vital signs stable. He was alert and oriented with fluent speech. No cranial neuropathies. No frank arthritis. Gait normal.
ASSESSMENT PLAN:
1. INFECTIOUS DISEASE - This is a 51-year-old man who grew up in a hyperendemic area for Lyme disease in New Jersey and Connecticut. He has a history of multiple engorge tick bites. In his History of Present Illness, not only does he have a constitutional syndrome consisting of musculoskeletal, neurologic and cardiac symptomatology, but also he has positive Lyme Western blot, both IgM and IgG, as well as a positive culture for B. burgdorferi. He also has a positive antibody for Babesia microti. Since this man had substantial, but relapsing improvement on Rocephin in combination with Zithromax, I would recommend a high-dose Doxycycline/Biaxin regimen as he has not tried this regimen yet.
However first, I would recommend treating with a combination of Zithromax and Mepron for a period of three weeks to treat for possible babeosis after which I would treat with Doxy 200 mg twice a day with appropriate esophageal care and sunburn prophylaxis as well as Biaxin 1000 mg b.i.d. Caution the patient regarding possibility of C. dif colitis. To be followed up with IM Penicillin 1.2 million units q. week x no less than 12 weeks and follow up prn. While on high-dose p.o. antibiotics, LFTs to be drawn q.o. week.
Yours truly,
Steven Phillips, M.D.
Medical Advisor for the Lyme Disease Foundation
Medical Advisor to the Lyme Alliance
Peer Reviewer to Infection, the international journal of infectious diseases.
Featured presenter at the Tenth Annual LDF International Conference on Lyme borreliosis at the National Institutes of Health
SP:T+343
