A 58-year-old man with a diagnosis of chronic lyme disease.

DR BURNS: Mr C is a 58-year-old man diagnosed as having chronic Lyme disease. He lives in a suburb of Boston and works as a consultant. He has managed care insurance. Mr C had an episode of Bell’s palsy on the left side of his face in August 1992 and reported that he spent a lot of time on Martha’s Vineyard, an endemic area for Lyme disease. Subsequently, he noticed that he became less competent mentally. He could not do simple math and he became depressed. In 1994, he was diagnosed as having Lyme disease. At that time, he complained of neck pain radiating to his left shoulder and hand, with numbness and tingling in his hand; back pain that radiated down his left leg; bilateral joint aches in both elbows and, to a lesser extent, his shoulders; bilateral tinnitus; periodic blurred vision (worse in the right eye than the left); difficulty concentrating and word finding; and periodic sweats. Results of his physical examination were normal with the exception of having difficulty spelling “world” backward and subtracting 7 serially. In October 1994, his Lyme (IgM/IgG) antibody titer was positive at 1:4. He was treated with tetracycline, 500 mg 3 times daily for 1 year. Following the initial course of tetracycline, his symptoms improved. However, in July 1996, Mr C restarted tetracycline 500 mg 3 times daily, for complaints of generalized aches and pains, hot flashes, nausea, sweats, dizziness, and a general uneasy feeling. Since then, persistent symptoms have included fatigue, sweats, slight memory loss, generalized aches and pains, headache, facial flushing, numbness of his left thumb, altered sensation on the left side of his face, and weight gain. Mr C was treated with repeated courses of tetracycline as well as several courses of clarithromycin, 500 mg twice daily, combined with hydroxychloroquine, 200 mg twice daily. His last course of tetracycline was in early 1999, at which time a Lyme Western blot assay showed an IgM reaction to the 83-kd protein and IgG reactions to the 41and 62-kd proteins. In the fall of 1999, due to a change in his insurance, Mr C transferred to a new primary care physician, Dr N. His new physician was not convinced of the benefit of recurrent courses of antibiotics. In the fall of 2001, Mr C returned with multiple concerns including difficulty sleeping, forgetfulness, cognitive difficulties especially with calculations, decreased libido, anxious feelings, facial stiffness, puffy eyes, and cracking in his neck and shoulder. Mr C was concerned that some of his symptoms may be related to Lyme disease. At that time, physical examination findings were normal. Dr N thought that Mr C might have a mild depression and prescribed paroxetine, 10 mg/d, which was later increased to 20 mg/d. With this regimen, Mr C reported that he noticed less anxiety, less joint pain, and improved cognition. He also was sleeping better. His current medications include paroxetine, 20 mg/d, quinapril, 10 mg/d, and atorvastatin, 10 mg/d. Mr C has no known drug allergies. He exercises regularly and rarely drinks. He previously smoked about 1 pack per day but quit smoking about 7 years ago. Mr C has a past medical history of hypertension, hyperlipidemia, seborrheic dermatitis, and chronic Lyme disease. His father died of “natural causes” and his mother of ovarian cancer. He has one brother who recently underwent coronary artery bypass graft surgery.