Age: 56.0
Sex: F
Vaccine: LYME
Symptoms: Laboratory test abnormal, Musculoskeletal stiffness, Myalgia, Nausea, Neck pain
Clinical narrative: Fever, muscle aches, swollen joints, very elevated sed rate. She is a 52 year old woman who comes in for evaluation of joint symptomatology following vaccination for Lyme disease. In mid-June 1997 she removed an engorged, adult female tick. Soon thereafter, she developed a bright red skin lesion, 10 to 20 cm in diameter, in the pubic area at the site of the tick bite. The lesion was accompanied by high fever and nausea. She was treated with doxycycline for two weeks, with the complete resolution of symptoms. In July 1998, while vacationing, she developed pain in the right shoulder after carrying suitcases. This was diagnosed as a rotator cuff tendinitis. It was treated successfully with physical therapy. In April 1999 she received the first dose of the Lyme disease OspA vaccine. Soon after the first injection she developed pain in the right hip. On month later, after the second injection, the pain became considerably worse, and she also developed thigh and knee pain accompanied by headache and neck pain. An MRI scan of the hips showed marked swelling. Lyme disease tests showed IgM reactivity with the 23 and 39kD spirochetal proteins, but IgG testing was negative. An ESR was 111. She was treated with Arthrotec, but the pain did not improve. She then received prednisone up to 30mg a day, which helped the hip pain considerably. However, when the dose was reduced, her symptoms recurred. Starting in July of 1999 she also received antibiotic therapy for presumed Lyme disease. She was first given doxycycline for 3 weeks. She then received another course of doxycycline an then Flagyl. Next, she was given the combination of Flagyl and dirithromycin. Her joint symptoms became worse despite this therapy. In November she received Bicillin injections, and again, her knee symptoms worsened. Along with the combination antibiotic regimen, she had nausea, vomiting and diarrhea. She took a leave of absence from work. In January 2000 she tried a homeopathic approach. She also tried various NSAIDs including Celebrex, Vioxx and ibuprofen. She is currently taking ibuprofen 2400mg a day since this helped more than the other drugs. By January she began to have joint pain in other places, including both shoulders, the right second MCP joint, and the right ankle. She also describes radiating numbness and tingling from the right shoulder down the lateral side of the arm. She wakes in the middle of the night with pain. She has a hard time getting out of bed in the morning because of stiffness, and has a gelling phenomenon when sitting. Past medical history includes longstanding hypothyroidism, for which she takes synthroid. This developed along with an early menopause. In addition, she has had longstanding depression. In the fall of 1998 she went to a psychopharmacologist and was started on Zoloft. In April 1999 this was changed to Effexor. She now takes 300mg a day of this medication. She has a strong family history of heart disease, but no history of arthritis. On physical examination, she has pain and swelling of the second MCP joint, pain on motion of both shoulders, pain on palpation of the top and bottom of the neck, pain on motion of the neck. She has mild swelling and marked warmth of both knees, with marked pain on motion. There is also pain on compression and motion of both hips. Finally there is pain on palpation and eversion of the right ankle. The examination of the heart, lungs and abdomen is normal, as is the neurologic examination.