Clinical Case 1
Daniel Sebastian Medina, D.O.
The Case
HPI: Patient is a 17-year-old male presenting to the emergency department for evaluation of a decreased appetite, headache, fatigue, malaise, back pain, and tactile fevers. Per the patient, he has been having the symptoms for about a month. They come and go in episodes. This current episode began a week ago. Mother at bedside states his temperature never got above 100.2 at home. Patient has lost 10 pounds in the last 6 months despite trying to gain weight. He denies any night sweats, nausea, vomiting, diarrhea, abdominal pain, chest pain, shortness of breath, palpitations.
Allergies: Cat Dander, Dog Dander
Home meds: Montelukast, Fluticasone, albuterol
No surgical history, family history, denies drug, tobacco or alcohol use.
Review of Systems
Constitutional: Positive for appetite change (decreased), fatigue and fever. Negative for chills.
HENT: Negative for congestion and sore throat.
Eyes: Negative for itching and visual disturbance.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.
Endocrine: Negative for polydipsia and polyuria.
Genitourinary: Negative for difficulty urinating and hematuria.
Musculoskeletal: Positive for back pain. Negative for arthralgias and myalgias.
Skin: Negative for wound, Negative for color change
Neurological: Positive for headaches. Negative for dizziness and numbness.
Vital Signs & Physical Exam
Temp: 98.8 HR: 105 Resp: 18 BP 106/70 SpO2: 98% Weight: 127 lb (57.9 kg)
Physical:
Constitutional: Normal appearance.
HENT: Head: Normocephalic and atraumatic, Nose normal. No rhinorrhea.
Eyes: No scleral icterus. Conjunctivae normal.
Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Normal pulses Normal heart sounds. Capillary refill takes less than 2 seconds.
Pulmonary: Pulmonary effort is normal, Normal breath sounds.
Abdominal: General: Bowel sounds are normal. Abdomen is soft.
Musculoskeletal: General: No swelling or deformity.
Skin: General: Skin is warm and dry. +Rash
Neurological: He is alert and oriented to person, place, and time. No weakness.
Work Up
CMP
Na: 134 (L)
K:3.8
CO2: 31
Anion gap: 7
Glucose 110 (H)
Creatinine: 0.91
GFR:13
Ca: 9.2
Tbili: 0.8
Ast:23
ALT: 24
Alkaline phosphatase: 96
Albumin: 3.2 (L)
CBC
WBC: 15 (H)
RBC: 4.37
HGB: 13.1
HCT: 37.3 (L)
MCH: 30.0
MCHC: 35.1
TSH: 6.131 (H)
Free T4: 1.2
ESR: 53 (H)
CRP: 14 (H)
HPI: Missing elements
Patient is a 17-year-old male presenting to the emergency department for evaluation of a decreased appetite, headache, fatigue, malaise, back pain, and tactile fevers. Per the patient, he has been having the symptoms for about a month. They come and go in episodes. This current episode began a week ago. Mother at bedside states his temperature never got above 100.2 at home. Patient also went camping in Michigan 3 weeks ago, and developed a rash on his trunk and upper extremities which was diagnosed to be ringworm and for which he is currently taking ketoconazole and Diflucan. Patient has lost 10 pounds in the last 6 months despite trying to gain weight. He denies any night sweats, nausea, vomiting, diarrhea, abdominal pain, chest pain, shortness of breath, palpitations
Rash
+ Multiple circular rashes with central clearing to the trunk and bilateral upper extremities.
What happened next?
Positive Lyme IgG and IgM antibody screen
Confirmed with Lyme IgG and IgM Western blots: both were also positive.
Patient was found to be seropositive for lyme and was started on a 14 day dose of doxycycline due to neck pain with flexion concerning for indolent meningitis. Spent 2 days in the hospital. Ultimately discharged after 24 hours without fever, return of appetite and resolving inflammation after 2 days of doxycycline treatment.
Lyme Disease
Incidence is about 40 per 100,000 people. The infection occurs during late spring, summer, and early fall.
Stages
Stage 1: Early Localized disease presenting with erythema migrans (70% of infections) and low grade fevers. Can sometimes be associated with neck stiffness and headache. Usually 1-28 days following the tick bite.
Stage 2: 3-12 weeks after initial infection. Similar sx to Stage 1 with addition of dizziness, cardiac symptoms such as chest pain, dyspnea and palpitations. Diplopia, eye pain and Keratitis have also been reported. Bell’s palsy is seen in 5% of patients, while 20% of patients will have encephalopathy, meningitis or cranial nerve neuropathy.
Stage 3: Months to years after infection, typically one which did not show erythema migrans. Presents with aseptic meningitis, Bell’s palsy, arthritis specifically in the knees, fibromyalgia and radicular pain. Hearing loss.
Cardiac Considerations
Lyme disease can cause arrhythmias or transient heart blocks. Rarely do patients actually need permanent pacing.
Patient should remain hospitalized until all signs of conduction abnormalities resolve.
Treatment
Children under 8 y.o.: Amoxicillin for 14 days
Children over 8 y.o.: Doxycycline for 10 days
Pregnant patients: Ceftrixone IV for 14 days is preferred. Can do Amoxicillin for 14 days.
Ocular symptoms also respond to topical steroids.
Monitor for Jarisch-Herxheimer reaction.
References
Maraspin V, Strle F. How do I manage tick bites and Lyme borreliosis in pregnant women? Curr Probl Dermatol. 2009;37:183-190. doi: 10.1159/000213076. Epub 2009 Apr 8. PMID: 19367103.
Skar GL, Simonsen KA. Lyme Disease. [Updated 2023 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431066/