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Health Report

by K.B. Liegner
[additions in square brackets by J. Gruber]
(submitted in February 1998 to Deutsche Krankenversicherung, Köln, Germany - without [additions])

Anamnese / History

Patient has a home north of Berlin, next to Müritz National Park, much wildlife, with a large piece of land which is totally overgrown, waist high grass, having been there at the end of August 1997; the area is highly endemic for ticks.
Insect bite below the right knee, very inflamed, swollen. This lasted for a least 6 weeks and evolved into a lesion with central clearing and a brownish ring.  Subsequent to this she developed multi-system symptoms and prominently neurologic symptoms with severe headaches, sinus infection, optic neuritis on the left, vision reduced. She was given Clyndamycin for Sinus Infection. Within 3 days her eye problems resolved, vision returned.  Following weeks she developed a facial palsy on the left side, which resolved in about 10 days on its own.

Beschwerden / Chief Complaints

Symptoms have included at one time or another:

severe headaches, eye pain, light sensitivity, dizziness, paresthesias, muscle twitching, ear pain, pain in head, respiratory problems, mental fogginess,  lightheadedness, dizziness, tingling in different areas of body, cognitive difficulties. She observed four week cycles of light sensitivity. [more, added to version 26.3.04 by J. Gruber]

Laborergebnisse / Befunde

MRI  showed multiple lesions, spinal tap fluid  and blood were tested for a variety  of diseases with no laboratory evidence for autoimmune diseases, MS, syphilis, AIDS, and Lyme disease.

Vorbehandlungen / Previous Treatment

In November [1997], she was treated for the possibility of Lyme Disease with 4 weeks of Ceftriaxone infusions. Three days after starting Ceftriaxone her respiratory symptoms resolved.  About 10 days into the treatment she had a diffuse rash, as well as fever, chills, swollen glands, and multiple swollen joints.  She continued the treatment and those symptoms resolved.  After one month she had very marked resolution of symptoms , very clear-cut, as was the resolution of the optic neuritis to Clyndamycin.  Also, it is noteworthy that she had persistent respiratory problems which also resolved very promptly with institution of Ceftriaxone.(graphical display of diary of symptoms)


It is noteworthy that this patient has had very very extensive epidemiologic exposure risk for ticks. In my experience it is somewhat unusual to have brain leasions so soon after occurrence of erythema migrans. One wonders whether or not the erythema migrans lesion that she had August 1997 was in fact her first exposure to Lyme disease. It is conceivable to me that she may have been exposed and harbored a latent or inapparent central nervous system infection with Borrelia long prior to manifest symptoms. On the other hand, she was absolutely and totally without any symptoms whatsoever prior to August 1997 raising the possibility that all of her symptomatology including the development of central nervous system lesions might have been due to a fulminant central nervous system involvement by Lyme disease.

Marianne suffers from chronic neuroborreliosis based on her clinical history, MRI findings -and favourable changes on repeat MRI following intensive antibiotic therapy-, CSF findings, Lyme Western blots (34 and 39 KiloDalton bands)  and clinical response to antibiotics.

In my opinion, the diagnosis of Lyme disease is quite clear on clinical grounds regardless of what serologic tests show. It is my opinion, in my experience, seronegativity is not rare and that immune response can be very desultory and may take months or even years to become apparent.

Since the patient is not asymptomatic and since there is at this point abundant evidence in the worldwide medical literature that treatment for Lyme Disease may be suppressive and not curative, I feel that it is appropriate to offer the patient further antibiotic therapy. She was given a prescription for Ceftin for a dosage range between 500 mg up to 2.000 mg po q12h depending on impact and tolerance. We may opt to change therapy depending upon response. Also, it was discussed that it may prove necessary for the patient to have further parenteral antibiotic therapy. At the time in January [1998] it was not clear whether that would be necessary.

More recently, Lyme urine antigen test was performed which was positive for detection of shed proteins specific for Lyme Disease.

Since she does report cyclic symptomatology [for a statistical analysis of the symptomlog see Figs. 2, 3, 4, 5] suggestive of persistent active borreliosis [background], continued intensive treatment is warranted [a tentative rationale for the determination of end of treatment]. Considering the serious neurologic involvement she has manifested, treatment of maximal intensity is appropriate.

Past Medical History / Familiy History

Usual childhood illnesses and immunizations. No hospitalizations or surgery. She does not smoke. No alcohol use. No illicit drugs. No blood transfusions. No family history of neurologic disorders or joint or connective tissue disorders.

Physical Examination (Neurological)

Cranial nerves II-XII intact. Motor/sensory/DTR normoactive and symmetric. Tinel's sign negative. Plantar reflexes downgoing. Finger to nose, heel to shin intact. Vibratory and position sense intact in lower extremities. Romberg negative. Gait, heel, toe and tandem intact. Higher mental function grossly intact. Affect appropriate.

version: 28.3.04
Address of this page
Joachim Gruber