Case #1 (JD):

JD, a 55 yo healthy female presents to her physician:  She pulled 3 ticks off her legs after walking her dog 10 days prior to this encounter.  C/C: fatigue, soreness in her joints, and rash (not the typical “bull’s eye” that is present in approximately 9% of cases) at the site of the tick bite.   Her pain was constant/dull and only relieved minimally with 800mg Motrin PO TID.  Her pain was rated as 6-7 on a 0-10 pain scale (0= no pain, 10= worse pain ever).  She denied F/C/N/V/D. 

·         Physical exam revealed rash and joint tenderness

·         Pert Negatives:  Subjective absence of fever

·         Pert Positives: H/O tick bites, fatigue, joint tenderness, rash

Her physician’s immediate diagnosis was Lyme disease.  He drew Lyme titers and empirically treated her with Doxycycline 500mg PO QD x 2 weeks.   Titers came back positive.  The physician had a high index of suspicion for Lyme disease based on her clinical presentation and the fact that she reported tick bites with associated rash.  JD reports no long-term sequalae from the disease.  Her titers came back positive for Lyme disease antibodies.

Case #2 (DJ):

DJ, a 28 yo healthy female marathon runner presents to her physician:  DJ noticed her knee was swollen a month prior but blamed it on her marathon-training program.  CC: Fatigue.  Of late, she has intractable fatigue and has had to take a 2-week sabbatical from work because she “is just unable to function.”   By this time one month had lapsed since onset of initial s/s (swollen knee). 

·         Physical exam was unremarkable

·         Pert Negatives: No rash, no history of tick bite

·         Pert Positives: Intractable fatigue

During my interview with DJ, she couldn’t explain why, but her physician immediately chose to draw a Lyme titer.  Once the diagnosis was confirmed she was treated with 3 differing courses of antibiotics over a 6-month period.  Initially she was treated with daily IV Rocephin via PICC line x 1 month then transitioned to PO Rocephin.  Her symptoms returned when she completed her abx course.  DJ reported that she was compliant with the prescribed regimen.  Subsequently, she was placed on Rocephin + Doxy.  She developed sensitivity to Rocephin.  Her third course of treatment was Doxy + Azithromycin + Plaquenil x 1 month.  After this course her s/s abated and she was able to return to work and her daily activities.    She was diagnosed in July 2008 and did not fully recover until March 2010.  She reports no long-term sequelae since March 2010.

A bit about Lyme Disease:

Lyme Disease can be difficult to diagnose.  Less than 30% of victims recalled having been bit by a tick and less than 9% present with the classic “bull’s eye rash.” Lyme disease is caused by bacteria called Borrelia burgdorferi (B. burgdorferi).  Ticks pick up the bacteria when they bite mice or deer that are infected with Lyme disease Lyme disease was first reported in the United States in the town of Old Lyme, Connecticut, in 1975. Cases have now been reported in most parts of the United States. Lyme disease is usually seen during the late spring, summer, and early fall.

There are 3 stages of Lyme disease.

•         Stage 1 is called primary Lyme disease.

•         Stage 2 is called secondary Lyme disease and early-disseminated Lyme disease.

•         Stage 3 is called tertiary Lyme disease and chronic persistent Lyme disease.

Risk factors for Lyme disease include:

•         Doing activities that increase tick exposure (for example, gardening, hunting, or hiking)

•         Having a pet that may carry ticks home

•         Walking in high grasses

Case created by Julie Darling, 2011