Age: 54.0
Sex: F
Vaccine: LYME
Symptoms: Blindness, Fatigue, Hypokinesia, Laboratory test abnormal, Muscle atrophy
Clinical narrative: This report describes multifocal motor neuropathy in a 54 year old female who received LYMErix. This report was received as part of litigation proceedings, with forwarding of medical records. The medical history included migraine headaches, alopecia, and Sjogren's syndrome. There were no known drug allergies. Family history was significant for rheumatoid arthritis and scleroderma. Concurrent medications included spironolactone for the teatment of alopecia, and unspecified 'female hormones." The vaccinee was evaluated by a hand therapist on 05/17/2000. She was referred by a rheumatologist who was reportedly "Lyme disease specialist" with chief complaints of muscle weakness, atrophy, and crampin in both hands. In a note to the hand therapist, the rheumatologist indicated that an unspecified test for HLA-DRA was negative, as was an antinuclear antibody titer. Lyme Western blot demonstrated a 31kd band. The rheumatologist recommended that the vaccinee not receive the third dose of LYMErix. The vaccinee was "a 54 year old right dominant female who reports that symptoms began with cramping in middle finger of right hand about one year ago. Symptoms worsened progressing to weakness and loss of hand motion. Pt underwent multiple tests including neurological testing. She was seen by an infectious disease specialist and had a Lyme's disease test. She received two vaccinations for Lyme's disease. EMG revealed multiple neuropathies, etiology unclear. Medical history includes family history of rheumatoid arthritis and scleroderma. She performs frequent use of computer and writing. Both hands have normal color and temperature. No edema was observed upon exam. Range of motion measurements indicate limitations in right wrist and finger extension in thumb abduction and opposition. Finger flexion is within normal limits in both hands. pt reports aching with fatigue during use of hand. tinels and phalens testing were negative. Fasciculations are present in left theoar muscle. Strength is decreased. functionally, the pt has difficulty typing and writing secondary to EDC and wrist weakness on right. She has difficulties with manipulation of small objects and buttening in left secondary to inability to oppose secondary to loss of thumb abduction." On 07/17/2000, the hand therapist wrote," the vaccinee has been followe din hand therapy two times weekly since 05/17/2000. She presents with no joint contractures no limitationns in passive joint range of motion. Active limitations in motion in hands and wrists in both right and left upper extremities are due t muscular weakenss and muscle imbalances in right and left hands. Significant muscular atrophy is noted in right and left upper extremities, particularly in intrinsic hand strengthening. There has been no worsening of symptoms since starting therapy and overall grip strengths have improved. Significant muscle atrophy remains with an unclear atiology." On 10/10/2000, the hand therapist noted, "ulnar muscle atrophy in right and left. More significant in left. Pt herself has noted that she has increasing difficulty with coordination and dexterity. Pt notes that although her atrophy has increased she finds that she feels better with therapy and has improved gross grasp strength." The vaccinee was examined by an ophthalmlogist on 07/11/2001 for a chief complaint of intermittent visual blurring. She reported that she had "multifocal motor neuropathy with nerve conduction block-an autoimmune disorder triggered by LYMErix vaccine." She also reported that she had "Sjogren's-no eye symptoms" and migraine headaches. In a letter to one of her physicians, the ophthalmologist wrote," As you know, she is being treated by you for multifocal motor neuropathy wit intravenous immunoglobulin. She states that she was first treated in November 2000 with five days of IVIG. She states that on each day after a few hours of the intravenous treatment she would notice blurred peripheral vision. This lasted on to two hours. She was not certain whether this was in one eye or both eyes, because she did not cover each eye separately. She states that she has been getting treatments once a month. More recently, she has noted more persistence of this peripheral blurring. Her past medical history is significant for multifocal motor neuropathy as noted above and possibly migraine headaches. her only current medications are Spironolactone for alopecia and hormone replacement therapy. She is also getting the IVIG once a month as mentioned above. She is not allergic to any medications. On examination her visual acuity corrects to 20/20 in either eye. On color vision testing she identifies all the affereot pupillary defect. Motility was full. Amsler grid was normal bilaterally. Visual fields were full to confrontation techniques. Mumphrey visual fields were performed with a 30-2 threebold test and these were essentially normal bilaterally. Slit lamb examination showed a papilloma of the right lower lid, but was other wise normal. Tension by applanation techniques were 14 OU. Dilated fundus examination showed congenifally anomalous discs with no cup in either eye, her fundus was otherwise normal. Impression: The vaccinee complains of transient visual loss iwth an essentially normal ophthalmologic examination today. She does have congenitally anomalous discs and possibly buried dursen and this may predispose her to having episodes of transient blurring. The episodes also may be a migraine equivalent." The ophthalmologist recommended that the vaccinee take one aspirin daily to improve blood flow to the optic nerves. As of 02/25/2002, the outcome of the events were unknown. Reported on 03/04/2003: "This report describes the occurence of multifocal motor neuropathy in a 53-year-old female who was vaccinated with Lyme disease vaccine recombinant OspA (LYMErix).  This report was recieved as part of litigation proceedings with forwarding of medical records.  The subject's medical history included allergies to horse serum, codeone, penicillin, and erythromycin; "mile" osteoarthritis of the right knee (1998); chronic degenerative joint disease; possible knee bursitis; carpal tunnel syndrome; migraine headaches; alopecia; Sjogren's syndrome; uterine fibroid; hand cramping; sinusitis; pharyngitis; pneumonia; nose bleeds; elevated platelet count; abnormal uterine bleeding (1996); senile urethritis changes; groin herniation; hypertension; fatigue; tick bites (1993, 1995); and chronic constipation.  Family history was significant for rheumatoid arthritis and scleroderma.  Surgical history included carpal tunnel release, tubal ligation, hysterectomy, and appendectomy.   Concurrent medications included spironolactone, conjugated estrogens (Premarin), meroxyprogesterone acetate (Provera), Lactulose, felodipine (Plendil), loratadine (Claritin), fluoxatine (Proxac), folic acid, glucosamine, a multivitamin, and asprin.  The subject received injections of LYMErix on 05/28/1999 (lotLY104A2) and 06/28/1999 (lot LY130B9).  In a Statement of Injuries, the subject's attorney alleged that the subject "has been diagnosed with multi-focal motor neuropathy with nerve conduction block as well as sjogren's.  (She) has suffered from cramping, muscle weakness and atrophy fasiculations in her hands and forearms, as well as poor circulation in both hands.  (She) has suffered from dry eyes, mouth and mucous membranes."  The following information was recieved from medical records.  On 08/18/1999, the subject was seen by the physician.  She experienced cramping in the right middle finger and was "still having trouble with both knees." On 11/02/1999, the subject was seen by the physician.  She had been having hand cramping for 1.5 months.  Her knees had "min. swelling", full range of motion and negative laxity.  The medical record noted "muscle thinning hands/fingers =/-boggy joints.  Rule out rheumatoid arthritis."  On 11/09/1999, "Lyme + 2.25, but W.B. (Western Blot) negative."  the physician wrote that the patient "has clinical symptons of Lyme".  He prescribed cefuroxime (Ceftin).  On 12/23/1999, the subject was seen by the rheumatologist.  The patient compalined predominantly of spasm in both thenar eminances occuring at any time.  She could be working or at reast and although it is not painful she finds it somewhat annoying because she has to manually pull the thumb back into position to be able to function properly.  She denies any pain.  She has no numbness or tingling.  She does admit to a slight cold sensation in the middle finger of the left hand and has no other complaints referable to the hand apart from the right middle finger she does notice tends to lock at times.  She denied any other problems apart from pain in her knees particularly more in the summer when gardening and she notices that one part of her knee medially swells.  The patient has no other complaints in the shoulders, elbows, wrists, feet, back or hips.  She denied morning stiffness, numbness, tingling, or other problems.  Past medical history was significant for diffuse alopecia, for which she is under the care of a dermatologist.  she takes lactulose for chronic constipation.  Other medications include conjugated estrogens (Premarin), multi-vitamin, glucosamine, and folic acid.  The rheumatologist wrote that "It is my impression at this time that the patient has bilateral spasm of the thenar eminences and in fact we did observe fasciculations during her visit.  She also has a thickened tendon which could be cousing a trigger finger on the right and a possible history of bursitis at the knee.  Degenerative joint disease was noted on the x-ray, we understand, on the right.  There is no evidence, in my opinion, at this time of scleroderma or rheumatoid arthritis.  I am not quite clear what is causing these hand spasms.  We understand the electrolytes were normal back in March prior to these symptoms so we would recommend repeating the sodium and calcium just to be sure these are not abnormal and could be contributing.  I have explained to the patient that we are not really clear what this is and that possibly neurology might be able to evaluate and give further suggestions....The only other possibility we thought of was whether her dermatologic medication for slopecia could be contributing to these hand spasms or possibly even the glucosamine.  She is on folic acid though her CBC is normal it is possible also that she could have a B12 deficiancy and that might be something to consider also.  If any of the above medications could be stopped for awhile to determine if these symptoms improve, that might be another option."  On 02/01/2000, the subject was seen by the orthopedist.  The medical record indicated that the subject "started to get a crampy sensation with the right long finger.  Around this time, she had multiple blood work done and they were all negative.  She had two vaccinations for Lyme disease following that.  She had a subsequent blood test that was positive for Lyme, even though the Western Blot was negative.  The value was 'quite' high and she was treated with antibiotics for a month.  None of these medications ever helped the cramping of her hands.  The cramping started to get worse, sometime around August of last year.  She was seen by a rheumatologist who ruled out rheumatological right wrist doesn't have the fingers, on the right hand oly the index finger, since she cannot extend the fingers.  On examination, there was a definite atrophy of her left forearm, especially on the ulnar side.  In both hands, she shows intrisnsic atrophy.  The physician wrote that the  patient had classic drop fingers, suggesting radial nerve paralysis on the right side.  She cannot make a full "O" between the index and thumb on the left side, due to marked abduction weakness, suggesting medial nerve involvement.  Her reflexes were normal on all four extremities.  There was no clonus noted, plantars showed a slight withdrawal pattern but it was not a real Babinski.  "Coming to the negative values, she definitely has involvement of radial nerve and ulnar nerve on the right upper extremity starting from the elbow level.  On the left hand, it is ulnar nerve and the median nerve; the radial nerve seems to be functioning."  The physician was "quite concerned" as to the diagnosis.  "She doesn't have a simple problem.  It could be a form of muscular dystrophy.  I think we can rule out multiple sclerosis since her reflexes seem quite normal, but amyotrophic lateral sclerosis cannot be ruled out and a syringlomyelia is also another possibility, since the upper extremities are involved and not the lower extremities."  The physician ordered MRI of the brain and cervical spine and complete electromyographic studies.  he kept the "provisional diagnosis" of myopathy.  On 02/08/2000 the subject underwent nerve conduction and electromyograph testing.  She had new onset weakness of both upper extremities and also had fasciculations of the intrisnsic hand muscles.  Conclusions; normal nerve conduction velocity testing.  Abnormal electromyograph studies...The diagnosis of amyotrophic lateral sclerosis (ALS) can be considered but was unlikely in the face of normal lower extremity findings.  No lower motor neuron lesions such as faeiculopathy were evident.  On 02/09/2000, the subject underwent an MRI of the cervial spine to rule out syringomyelia or demyelinating disease.  Impression; accentuated cervical lordosis.  Otherwise negative exam.  An MRI of the brain performed on 02/09/2000 showed 1.  Tiny focus in the deep right parietal white matter of uncertain significance.  2. Mucosal thickening within the left maxillary antrum, left side of the sphenoid and deviation of the nasal septal structures towards the right.  On 02/15/2000, an orthopedist wrote that "the brain looks normal and the cervical spine shows an extreme (cannot read) C6-7 level, but there is no true neurological involvement."  Her reflexes were normal.  She still exhibited right-sided radial and nerve involvement, left-sided median and ulnar nerve involvement.  "She either has a rare muscular diease of a neurological disease."  At the moment, stated the physician, diagnosis remains unknown; probably myopathy.  On 02/15/2000, the subject was seen by the physician.  he had reviewed the patient's magnetic resonance imaging (MRI).  He stated that "the brain looks normal and the cervical spine shows an extreme lordosis at C6-7 level, but there is no true neurological involvement.  She has a normal nerve conduction sutdy, but an abnormal electromyelogram.  I examined her once more.  Her reflexes are normal  She still exhibits right sided radial and ulnar nerve involvement, left sided median and ulnar nerve involvment.  I checked her for thoracic outlet syndrome.  I do not find any positive Adson test.  I took a regular x-ray of her cervical spine and I don't see any cervical rib either.  She either has a rare muscular disease or a neurological disease....At the moment, diagnosis remains unknown, probably mypathy."  On 02/18/2000, the Lyme antibodies/total immunoglobulins ratio were elevated, the Lyme antibodies interpretation by enzyme immunoessay was positive, and the rheumatoid factor was negative.  On 07/21/2000, a Lyme western Blot was performed.  The IgC antibodies were positive and the IgM antibodies were equivocal.  On 02/26/2001, the patient was seen by the rheumatologist.  "in follow-up for her rheumatic problems.  Her carpal tunnel syndrome continues to do well using splints at night.  She had an intra-articular injection in the past in her left first carpometacarpal phalengeal joint which was rather successful and relieved a lot of the difficulty there.  She is complaining today about pain and locking at the right first carpometacarpal phalangeal joint.  She brought x-rays which were taken which show a fair degree of degenerative changes at the first carpometacarpal phalangeal joint bilaterally with associated hydroxyapatite deposition.  She is taking just tylenol (paracetamol) or occasional aspirin for her discomfort.  I injected the first right carpometacarpal phalangeal joint with a small dose of steroid which will hopefully relieve a fair amount of her inflammation and also help it from continuously locking on her...." In 03/01/2000, the patient was seen by the neurologist.  An electromyograph (EMG) and nerve conduction studies were performed in both upper extremities.  "There appears to be a significantly prolonged left median response selectively across the left carpal tunnel.  Radial responses are diffusely slow, with left ulnar, radial, right median, and ulnar responses being normal.  EMG examination demonstrates fibrillations, positive waves, and polyphasic units in the right radial and left median distributions, with the remainder of the needle EMG examination being normal.  The physician's impression was that "there is a polyneuropathy, and, therefore, etiological causes, including Lyme disease and rheumatological disease, need to be excluded.  In addition blood studies....At this point, she may require a spinal tap, as well as a muscle nerve biopsy, but that will be withhelf for a period of approximately one month...."  On 03/13/2000, the subject underwent magnetic resonance imaging of the brain.  The history was Lyme disease.  The physician's impression was "1. Timy nonspecific white matter focus in the right peritrigonal white matter which is unchaged in comparison to a 02/09/2000 exam.  Otherwise, negative examination of the brain. 2. Mucosal thickening in the left maxillary antrum and the left side of the sphenoid." On 03/21/2000, the rheumatoid factor was negative, the total T4 was elevated, the T7 was elevated, the Lyme disease IgG/IgM by EIA was negative, and the antinuclear antibodies were negative.  On 04/04/2000, the subject was seen by the neurophysiologist.  "She had an MRI, showing again no change, but there is some sphenoid sinusitis....She describes continued cramping and aching.  Lifting heavy objects and stretching make the pain worse.  Advil (ibuprofen) relieves some of the paing but actually makes her eye twitch.  She said she has inability to flex her muscles, with weakness in her hands and arms."  On 04/11/2000, the patient was evaluated by an infectious disease specialist for possible Lyme disease.  "(The subject) was generally well up until December of 1998.  At that time, she developed onset of swellings and arthralgias in both knees for which she was evaluated and treated with anti-inflammatory agents.  At that time, she apparently had Lym serologies and arthritis serologies which....came back negative.  in march of 1999, she developed a sinus infection for which she was treated with Augmentin (amoxicillin clavulanate) for three to four weeks and then in may of 1999 because of her potential exposure to Lyme disease in an endemic area she received the first dose of the Lyme vaccine.  In august of 1999 she began to develop symptoms of what she described as predominantly cramping and wekness in both hands and wwrists for which she began to be evaluated.  At that time, she apparently again had a Lyme serology done which was indeterminant and she received a one-month course of Ceftin (cefuroxime).  She states that at the time she did not feel she had much improvement on the Ceftin but in retrospect she feels she may have had some benefit as she felt worse shortly after discontinuing it.  In December of 1999 she was een by a rheumatologist and at that time her examination revealed in addition to the hand weakess evidence of atrophy and fasciculations.  She apparently had an extensive rheumatologic evaluation at that time which showed no diagnostic rheumatologic serologic tests and she did undergo further testing subsequent to that including head MRI, spinal MRI, EMG's and nerve conduction studies.  The results of which have revealed evidence of a single tiny patch of demyelination on the head MRI and EMG nerve conduction studies that show evidence of some possible demyslinating or motor neuron problem in the hands.  She also had a repeat MRI and MRA (magnetic resonance angiography) done...which showed no abnormalities.  She has had some additional work up including an echocardiogram which has shown nild aortic insufficiency and mitral valve prolapse and some equivocal thyroid studies.  She has had no fevers, chills, night sweats or other constitutional symptoms and no longer has significant arthritis symptoms in her knees and is predominantly trouble by the progressive weakness in both hands and wrists.  The only other remarkable laboratory abnormalities that she reports is a positive Sjogren's antibody...she does not recall any flu-like illness consistent with an early Lym prior to the onset of rashes....Family is remarkable for one sister who died of complication of scleroderma.  There is a grandmother with rheumatoid arthritis...Examination of the upper extremities revealed some muscle atrophy in both hands with some fasiculations.  Of note, handgrip and strength were weak...of note, in terms of Lyme serologies, there was a Lyme antibody screen from march 1999 that was negative with an ELISA titer of 0.17, a Lyme antibody test in November 1999 that revealed a positive Lyme total antibody of 2.25 which was positive but a IgG and IgM Western blot both of which were interpreted as showing no bands....I discusse the situation in detail with (the subject) and her husband.  Their major questions are whether or not the objective neurological abnormalities that she has could be tierh attributable to Lyme disease or complications from the Lyme vaccine.  i explained to them that although peripheral neuropathy can be seen in association with Lyme disease that this pattern of (cannot read) with significant muscle atrophy would be extrememly unusual in the absence of other Lyme related symptoms.  She also appears to have had negative Lyme serologies at several points along the way although of note she has received courses of oral antibiotics for sinus infections and is further compounded by her having recieved two doese of the Lym vaccine.  Based on her symptoms of primarily peripheral or motor neuron type nuropathy in the absence of any central nervous system symptoms it is unlikely that a spinal tap would be very useful for the diagnosis of Lyme although it may be useful for excluding other neurologic conditions.  I told her that I thought it would be worth repeating her Lyme ELISA and Wester blot studies at a reputable lab....I am unaware of any documentation of polyneuropathy-like syndromes being riggered by the (Lyme) vaccine but....Lyme disease could certainly not be absolutely excluded with the testing that was done and we discussed the risks versus benefits of an empiric trial of...doxycycline for the possibility that her symptoms may be Lyme related."  On 04/26/2000, a Lyme Western Blot was performed.  The IgG antibodies were positive; the IgM antibodies were not reported.  The subject was evaluated by a hand therapist on 05/17/2000.  She was referred by a rheumatologist who was reportedly a "Lyme disease specialist" with chief complaints of muscle weakeness, atrophy, and cramping in both hands.  In a note to the hand therapist, the rheumatologist indicated that an unspecified test for HLA-DR4 was negative, an was an antinuclear antibody titer.  Lyme Western blot (NOS) demonstrated a 31 kD band.  The rheumatologist recommended that the subject not receive the third injection of the LYMErix.  The subject was "a54-year-old right dominant female who reports that symptoms began with cramping in the middle finger of right hand about one year ago.  Symptoms worsened progressing to weakness and loss of hand motion.  Patient underwent multiple tests uncluding neurological testing.  She was een by an infectious disease specialist and had a Lyme's Disease (sic) test.  She received two vaccinations for Lyme's Disease (sic).  EMG (electromyelography) revealed multiple neuropathies, teiology unclear.  medical history includes family history of rheumatoid arthritis and scleroderma....She performs frequent use of computer and writing.  both hands have normal color and temperature.  No edema was observed upon exam.  Range of motion measurements indicate limitations in right wrist and finger extension in thumb abduction and opposition.  Finger flexion is within normal limits in both hands....Patient reports aching with fatigue during nuse of hand.  Tinele and phalens testing were negative.  Fasciculations are present in left thenar muscle.  Strength is decreased: grip right 47.5 pounds, left 50.0 pounds; lateral pinch right 14.5 pounds, left 12 pounds, three point pinch right 7 pounds, left 7.5 pounds.  Sensation as tested by the Semmes Weinstein Monofilaments indicates normal sensation (2.83)....Functionally, the patient has difficulty typing and riting secondary to EDC (extensor digitorum communis) and wrist weakness on right.  She has difficulties with manipulation of small objects and buttoning in left secondary to inability to oppose secondary to loss of thumb abduction."  On 06/05/2001 the medical record noted that the subject was receiving intravenous immunoglobulin therapy for focal neuropathy "which may be secondary to Lyme disease or vaccine."  On 06/07/2000, the subject was seen by the neuromuscular specialist.  The patient was referred because of a progressive neuromusculoar disorder of unknown diagnosis.  In August 1999, the patient developed intermittent flexion cramps of the right third finger.  Over the subsequent months, there were cramps in both hands.  This lasted for 6 months and has gradually improved.  The cramps were "mildly annoying", lasted for seconds, and occurred about five times per day, and increased with certain hand positions.  In September 1999, there was muscle twitching of the left thumb and in the right forearm.  In November 1999, the patient was treated for presumptive Lyme disease with Ceftin; there was no improvement in her hand problems.  About that time, her physician noticed muscle wasting in the right intrinsic hand muscles.  There was some hand and wrist weakness bilaterally and a right wrist drop.  There was difficulty holding objects, buttoning and typing.  for the last two months, there has been fatigue and achiness in both arms.  The legs have been strong wiithout strophy or cramps.  For the last two months, there has been some choking with solids; she has to clear her throat frequently, but her cough was strong.  There has never been any significant numbness, tingling or pain.  The patient had a positive Sjogren's blood test, but had no history of dry eyes, or dry mouth.  A complete rheumatologic work-up showed no rheumatoid arthritis or scleroderma.  The patient was also concerned about mild cognitive problems, dyslexia, and imbalance.  The patient was being follwoed by a nuerologist.  In march 2000, his diagnosis was polyneuropathy.  An electromyograph (EMG) showed abnormalities of the right radial nerve and left median nerve.  magnetic resonance imaging (MRI) of the cervical spine was normal.  MRI of the brain, both in February 2000 and March 2000 were normal except for a tiny focus in the right parietal white matter.  One of the Sjogren's antibodies (SS-B) was abnormally high; however SS-A antibody was normal.  The following lab tests were normal: "GM1", antinuclear antibodies (ANA), complete blood cell count (CBC), blood chemistry profile, vitamin B12, thyroid function tests, and srum protein electrophoresis (SPEP).  There were slight abnormalities in the thyroid function tests.  A Lyme Elisa test was positive; however, the Western Blot was negative.  The physician's summary and impression was that the patient had a 10-month history of asymmetrical progressive weakness, wasting and fasciculations in the hands and forearms.  There have been no sensory symptoms or signs.  This appears to be a lower motor neuron syndrome, primarliy in the distribution of right radial and left median nerves.  this appears to be a multifocal motor neuropathy, a peripheral nerve disease which is often treatable with immunosuppressive agents.  The physician stated that "although amyotrophic lateral sclerosis (ALS) has to be considered, there are no significant upper motor neuron findings.  I am not sure of the significance of the single abnormal Sjogren's antibody test."  On 06/30/2000, the subject underwent an electromyograph.  The clinical history was weakness in both upper limbs and suspected motor neuropathy.  The physician's impression was "multi-focal motor neuropathy with conduction block.  The principal nerves involved are the right radial nerve and left median nerve, with evidence of conduction block in the forearm for both nerves."  On 07/14/2000, the hand therapist wrote,"(the subject) has been followed in hand therapy two times weekly since May 17, 2000.  (She) presents with no joint contractures nor limitations in passive joint range of motion.  Active limitations in motion in hands and wrists in both right and left upper extremitiesa re due to muscular weakness and muscle imbalances in right and left hands.  Initially, intrinsic muscles tested in the F to G range in right and left hands.  there has been gradually increasing gains in pinch and grip strengths in right and left hands.  Right grip strength has increased from 47.5 pounds to 60 pounds.  Left grip strength has increased from 50.5 pounds to 63 pounds.  Finch strength: lateral pinch: right 19.5 pounds (+5), left 13 pounds (+1)....Significant muscular atrophy is noted in right and left upper extremities, particularly in intrisnsic hand musculature.  (The subject) is on a therapy program of heat modalities, soft tissure massages and graded strengthening.  There has been no worsening of symptoms since starting therapy and overall grip strengths have improved.  Significant muscle atrophy remains with an unclear stiology."  On 09/19/2000, the patient underwent unspecified radiologic imaging of both hands.  The reason for the study was degenerative joint disease.  The physician's impression was "severe degenerative changes at the greater multangular-first metacarpal joints bilaterally, consistent with osteoarthritis.  Mildd degerative ....right theird metacarpal-phlangeal joint.  Tiny metallic foreign body in the soft tissues of the distal phalanx of the left second finger."  On 09/20/2000, the subject underwent a Dexa bone density study.  The reason for the study was screening post-menopausal.  The physician's impression was "osteopanic bone mineralization in the lumbar region."  Lyme urine antigen tests performed on samples collected on 08/28/2000, 08/29/2000, 08/30/2000 were negative.  On 10/10/2000, the hadn therapist noted, "ulnar muscle atrophy in right and left.  More significant in left.  Patient herself has noted that she has increasing difficulty with coordination and dexterity.  patient notes that although her atrophy has increased she finds that she feels better with therapy and has improved gross grasp strength."  On 11/08/2000, a Lyme Western Blot was performed.  The IgM antibodies were equivocal and the IgG antibodies were positive. On 03/27/2001, a Lyme Western Blot was performed.  IgG antibodies were equivocal with bands 75, 62, 41, 37, 31 present; IgM antibodies were equivocal with band 23 present.  On 06/18/2001, the suject was seen by the physician.  Her last treatment with intravenous immunoglobulins (IVIG)was 06/04/2001.  Within hours after treatment, she "sees improvement; better strength in hands, less cramps and twitch, less coolness in hands.  Last treatment given after five weeks.  Felt 'worse' but not as bad as initially (prior treatment).  Vision: some residual blurriness of peripheral vision-notices when reading; more prominent 1 day post IVIG.  Impression: mulifocal motor neuropathy with "CB"; IVIG holding her only approximately three wee