Thursday, June 12, 2008

Bad luck?

When I was in medical school there were many witty aphorisms tossed about. The eager students voraciously snapped up these nuggets of wisdom. As a third year medical student your introduction to clinical medicine is immersion in a world of critically ill and dieing patients. But we were told that 15% of the population got 85% of the disease. This helped us feel secure that we would not suffer the fate of the unfortunate patients, because we were in the 85%. There were a lot of questions asking for statistics. It was called "pimping." Overtired, anxious students asked questions from our elders the answers to which we had no way of knowing. I think the theory was that anxiety produced by this method would compensate for the inability of a sleep deprived brain to learn well. A sagacious second year resident said the right answer was always 15% or 85%. I met one of those "unlucky" patients in July 2006. She must have been in the mythical 15%.

She was 24 years old. She already had a history of polyneuropathy, pleurisy, pericarditis, tranverse myelitis, migraines, possible seizure disorder, mysterious movement disorder, gallbladder disease requiring surgical removal and a host of other mysterious complaints. When I first met her she complained of vertigo, numbness of hands, face and the lower one half of her body, headaches and joint pain. Subsequently other complaints emerged including profound fatigue and cognitive deficits. She experienced "brain fog" as well as memory loss and slow cognitive processing. Her initial labs showed positive exposure to Babesia microti, but a negative standard Lyme Western Blot.
Her movement disorder seemed typical of Parkinson's. She had rigidity and tremor. Two neurologist felt it was not Parkinson's disease, but a third agreed with my diagnosis. She responded to drugs used to treat Parkinson's. After treatment for Babesiosis she was treated for chronic Lyme disease with a cocktail of antibiotics. She quickly experienced improvement in memory and concentration, joint pain and numbness and tingling. She became pregnant at the beginning of 2007 causing a disruption in her treatment. During the pregnancy she did well. Even the Parkinson's improved somewhat. After delivery everything quickly got worse. The arthritis, forgetfulness, Parkinson's and fatigue were all worse. Repeat lab testing finally confirmed exposure to Lyme by IgeneX criteria. IV Rocephin was given. She had an allergic reaction to the first dose. It was switched to IV Zithromax. It didn't make a dramatic difference, but over time she showed gradual improvement. She has been continued on cocktails of oral antibiotics over this time. I saw her today and she is moving to Washington state in one month. She continues to have fatigue, which comes and goes. Her Joint pain is better, but it also comes and goes. Her memory and cognitive processes are much better. She doesn't remember how bad it was before. Her husbands states that she is almost back to normal. The Parkinson's is stable and controlled on medicine. She feels well enough to go back to work for the first time in years. The most effective antibiotics for her have been: Ceftin, Zithromax, Flagyl and Rifampin along with Plaquenil. Her Babesia has been treated with Mepron. She has Vitamin D dysregulation and was tried on a low dose of Benicar which was discontinued due to excessive "Herxing." In summary she is slowly getting better in every way except the Parkinsons which is static. All of her problems are related to chronic Lyme infection. I have one other patient who developed Parkinson's disease at a young age along with Lyme disease. Unfortunately, this has not responded when the Lyme was treated. I believe the brain damage is permanent in this regard. She has been unfortunate but is much improved since our first meeting. She will need much continued care in Washington state, for how lonng I do not know. Good luck.

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