A 22 year old female had a tick bite with at rash at age 5 (recalled by mother). Her pediatrician treated her for 3 weeks. No symptoms recalled. At age 10 she had another bite, treated the same way, no problems. At age 12 she found herself not feeling quite right. It started with vague aches and pains, loss of energy. Her pediatrician diagnosed growing pains. She still did not feel well. Her concentration at school lessened, straight As were replaced with Bs. Her pediatrician diagnosed pre-teen hormones and prescribed reassurance. An avid athlete and enthusiastic basketball player, she collapsed on the court at age 13. The cardiologist and neurologist gave her a clean bill of health.
Her state of well being fluctuated. She had good and bad days, good and bad months. High school was a struggle. She had little time for friends or extracurricular activities. She started going to sleep at 7:30 and having a hard time waking up. She maintained her grades, B+: memory, concentration and focus were poor.
At 16 her pediatrician referred her to a psychiatrist. A diagnosed of depression made she was started on Zoloft. Maybe it helped; maybe not.
She finished one year of college but had to drop out. She had more memory problems, fatigue, joint pains, headaches and other symptoms.
Her mother asked her doctor to do a Lyme test. The test showed a negative ELISA and a positive Western Blot with a 41 IgG band and 41 and 23 IgM bands. The ah ha moment. She was treated with doxy for a month. Didn't help. The infectious disease specialist had nothing to offer. A friend referred her to me.
A repeat Lyme Western Blot 6 months later showed now only a 41 IgG band. The co-infection panel was negative.(I later noted that the B duncani test had not been done).
Her symptoms were typical in my experience for chronic Lyme: fatigue, brain fog, cognitive problems, numbness and tingling in the extremities, headaches, neck pain, muscle pains, migratory joint pain of both large and small joints and prominent depression.
She was treated with an aggressive anti-Lyme regimen. She felt worse over the next two months. Two months later a new symptoms emerged: profound night sweats, air hunger, flu-like symptoms with low grade fevers. A repeat round of lab tests showed a positive titer to B. duncani at the lowest cut-off point. Anti-babesia therapy was started. She had prominent nausea and Mepron intolerance. Zofran was needed to manage the nausea. Over time she began to feel better.
A new Lyme Western Blot from a different laboratory showed 58 and 41 IgG bands and a 41 IgM band. There was a partial reaction at the 23 band.
She continued to improve over the next six months. However cognitive problems were slow to respond. Intravenous treatment was discussed. There was an insurance snag. PICC never placed. Two months later she seemed to be better nonetheless.
A year into treatment she is doing pretty well. After a year at home she is back in college doing fairly well. Symptoms, especially night sweats quickly relapse off Malarone. Still a problem.
Follow up LabCorp testing, including B. ducani was negative. We were specifically looking for a positive Lyme test for insurance, not clinical reasons.
An additional Lyme Western Blot was sent to Stony Brook. This test showed: 41 and 60IgG bands and 18,35,41,72 and 93 IgM bands. I thought this was a definite positive.
Clinical note: The odd Babesia scenario has been relatively common in my practice. Initially the patient denies any symptoms suggestive of Babesia. Babesia symptoms only become prominent after Lyme therapy has been started, as if the Lyme Herx somehow awakens the sleeping dog of asymptomatic chronic babesiosis. The two players seem to act together.
Lab comments:
My confidence in Western Blots is waning. Different laboratories frequently come up with divergent results - not even close.
I am sure this patient has a form of babesiosis. Still, one laboratory I use frequently turns up positive results for B dunani at the lowest cut off point, frequently in patients who would otherwise show a negative Lyme/co-infection panel.
Could the reported "WA1" IgG antibody actually cross react with a different organism. Or, are there a lot of false positives? Dr. Fry suggested this may be a cross-reaction to a non-Babesia protozoan which he has identified.
In truth, sometimes I order a lot of Lyme related tests searching for the positive that might justify IV therapy if anyone is looking.
Another lab's Western Blots would have undoubtedly showed different results. Maybe its best to look at Lyme Western Blots from several labs if it doesn't break the bank.
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