Clinical Case 1

Daniel Sebastian Medina, D.O.

The Case

Review of Systems

Vital Signs & Physical Exam

Temp: 98.8 HR: 105 Resp: 18 BP 106/70 SpO2: 98% Weight: 127 lb (57.9 kg)


Work Up



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


+ 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. 


Cardiac Considerations



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: