Rarely Such a Thing as a Text Book Case

by Ginger Savely, RN, FNP-C

Sandra looked thin, pale, and hunched over in obvious pain when I first met her in my office in June of 2004. The 37-year-old was at the end of her rope. She had been to several doctors, a gastroenterologist among them, and had submitted herself to numerous tests to find out what was causing her extreme abdominal distress. For two months she had been unable to eat solids and had survived on a liquid diet.

The moment that food of any kind entered her stomach, she suffered excruciating stomach pains and nausea. She had lost her appetite and had actually become fearful of eating. At 5’3”, she weighed in at 109 pounds and reported having lost 30 pounds over the previous two months. She had gone on temporary disability leave from her job as a hospital respiratory therapist. Sandra and her family were understandably very worried.

Gastrointestinal scopes and imaging studies, stool cultures, and extensive blood work including work-up for H. pylori (the causative agent of stomach ulcers) had revealed nothing. The gastroenterologist, having explored all of the standard possibilities, had suggested that her symptoms might have a psychosomatic origin and suggested psychotherapy as a way to get to the bottom of the problem.

Sandra intuitively felt that this was not right and that something else was going on. She had a happy life with a good marriage and job that she loved. Besides, she had started to notice other new symptoms including fatigue, joint pain, muscle aches, and weakness. Her gastroenterologist had assumed these symptoms to be either related to the same presumed psychosomatic process or to poor nutritional status after two months of solid food avoidance.

Sandra came to me desperate for help. There was nothing unusual about her exam except for her obvious distress. I asked about her family’s health. Although there wasn’t anything out of the ordinary, something very interesting came up. Her sister had been diagnosed with Lyme disease the year before.

Sandra explained that she and her sister had lived in a rural setting six years before and had sustained many tick bites. In fact, as it turns out, Sandra had suffered a prolonged febrile illness in 1998, which resolved spontaneously and had always remained a mystery.

I had read several articles about gastrointestinal manifestations of disseminated Lyme disease. What if this was at the root of her problem? Sandra certainly had the exposure potential and had other signs of the illness including fatigue and joint pain. The fact that she did not recall an erythema migrans, the classic “bull’s eye” rash that is diagnostic of Lyme, did not concern me since only about half of Lyme patients have this.

It certainly didn’t hurt to look. I ordered Lyme Western Blots and other tick-borne infection tests through IGeneX Labs in Palo Alto, California. Sure enough, she was positive on both the Lyme IgG and IgM. Her other tick-borne disease tests – Ehrlichia, Bartonella, Babesia and Anaplasma – were negative. I started treatment with both intramuscular and oral antibiotics. I also encouraged her to take numerous nutritional supplements including probiotics to replenish the natural gut flora, and milk thistle and alpha lipoic acid to protect the liver from damage due to processing of the antibiotics.

The transformation was almost miraculous. Even one week after initiation of treatment, Sandra reported significant reduction of her symptoms. Per the ILADS (International Lyme and Associated Diseases Society) published treatment guidelines, I continued treatment, changing the antibiotic protocol every few months, until complete resolution of symptoms, which turned out to be 7 months. Sandra went back to work, took a trip to Italy a month later, and went happily on with her life.

Sometimes clinicians need to look beyond the obvious when the cause of a patient’s distress seems elusive. Sir William Osler, the most famous physician, teacher and philanthropist of the 19th century, couldn’t stress enough the importance of a thorough history in diagnosing a patient. Apparently, the other important requirement is an open-mind and a willingness to realize the myriad of atypical presentations that can be seen for various illnesses.

After all, in the real world there’s rarely such a thing as a “textbook case”.