Lyme disease: case report of persistent Lyme disease from Pulaski County, Virginia
A 50-year-old Caucasian female presented to the urgent care clinic with extreme headaches, fever with intermittent shivering cold spells, 10/10 generalized joint pain, excessive thirst and fluid intake, and a progressing rash on her back. The patient described the headaches as tremendous pressure pushing inwards “as though she was wearing a heavy helmet,” such pressure that sneezing and coughing gave her the perception that her “head would explode.”\nThree days before her visit to the urgent care clinic (day one), the patient noticed an initial small, slightly raised lesion resembling an insect or spider bite. The patient did not examine her back, but described what she thought to be a scab covering the bite while she scratched. On day two, the patient’s fever reached 39.3°C (102.8°F), and she had an increasing burning sensation at the site of the bite. A family member examined the bite, and recognized that the bump had developed into a circular rash. The patient took over the counter ibuprofen and Benadryl, and was able to sleep through the night. On day three, the patient felt poorly, but completed a normal working day. By day four, the patient awoke feeling worse, with 10/10 joint pain, high fever, and excessive thirst and fluid intake; this led her to seek medical attention.\nOn exam, her temperature was 40.2°C (104.4°F). She had a large circular red rash on her back with bull’s-eye appearance, 16 × 18 cm in diameter ( and ). The rest of her physical examination was unremarkable. Her prior medical and surgical history is not significant to this case. The patient recalled a walk in the woods 3 weeks prior to her exam, but denied finding a tick on her body.\nInitial laboratory investigation results are shown in and . The patient’s white blood cell count and platelet count, hemoglobin, and hematocrit were within normal ranges. Her serum chemistry was unremarkable, except for elevated glucose, borderline low alkaline phosphatase, and slightly depressed osmolality.\nA serologic test for LD (antibody response to B. burgdorferi by enzyme-linked immunosorbent assay [ELISA]) was ordered and showed negative results (). A 10-day treatment of doxycycline (500 mg twice a day) was prescribed. The patient gradually began feeling better, and was able to return to work after 4 days of antibiotic medication. On day nine, her body temperature was within normal limits, the polydipsia and headaches had dissipated, and the rash had decreased to 11 × 14 cm. The patient expressed concern that a 10-day treatment was inadequate in proportion to her symptoms and to the size of her rash. Her doxycycline prescription was extended to 30 days by her primary care physician, continuing at 500 mg twice daily.\nA second set of serologic tests were ordered on day 28, which demonstrated the presence of immunoglobulin (Ig)-M without IgG antibodies to B. burgdorferi. The patient also sought a dermatology consultation, and the lesion was biopsied. The pathology report described microscopic changes consistent with lichenoid and spongiotic dermatitis. A Steiner stain failed to reveal spirochetes.\nOn day 48, 2 weeks after completing the antibiotics, the patient began experiencing lower-extremity neuralgia as well as tingling in her hands. She described her pain as “electrical currents running down her legs.” The patient visited her primary care provider, who started a second 30-day treatment of doxycycline (500 mg twice daily) and gabapentin (900 mg daily before bed).\nThe patient has been referred to a local physician who has extensive experience with LD for continued management of her medical therapy. At the time of this report, a year later, this patient reports that her symptoms include chronic fatigue and intermittent arthralgia that has required a cane to mobilize at times. Her only medication is methylphenidate (36 mg daily) for fatigue.