Lyme disease is the most common vector-borne disease in the United States, caused by the bacterium Borrelia burgdorferi. There are many co-infections, including Bartonella, Babesia, Anaplasma, Ehrlichia, and more. Symptoms may include headaches, joint pain, fatigue, muscle pain, anxiety, depression, neuropathy, palpitations, shortness of breath, etc. Only 30% of people exhibit a "bulls-eye" rash. According to the CDC, approximately 476,000 Americans are diagnosed and treated each year.
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CC: Joint Pain, Fatigue, Muscle Pain & Brain Fog
Lori was a 55-year-old female experiencing significant joint pain, muscle pain, brain fog, and fatigue. She would have random episodes of palpitations and would experience numbing/tingling in her hands that was happening at least a few times per week. She had tried physical therapy, massage, and several anti-inflammatory supplements/medications but was not getting any long-term relief. No history of major or recent accidents/trauma. Her primary care doctor had ordered imaging, but Lori had not gotten them done yet. Otherwise, Lori felt she was healthy. She had cut out gluten a few years ago, which did not help her pain, but did help her digestion. Ever since starting menopause three years ago, she felt that she was still getting hot flashes multiple times a day.
Lori's children were grown and out of the house, leaving just her husband and cats. She worked full-time and loved her job. She slept great, and stress was minimal. She had felt that she had no reason to be this fatigued.
Additional History
- Lori was drinking a gallon of cow's milk every single day.
- Her diet was filled with many carbohydrates.
Initial Lab Work
Medical Diagnostic Laboratories L.L.C (MDL)
- Positive Bartonella henselae IgG by ELISA
- Positive Lyme disease C6 Peptide by ELISA
- Positive IgM Lyme disease Western blot (IgM / IgG)
Lab Analysis
Lori's lab work had some pertinent findings that pointed to Lyme disease and inflammation as potential contributors to her symptoms.
Medical Diagnostic Laboratories L.L.C panel showed positive bands/markers for Lyme disease. MDL also showed positive for IgG Bartonella. In some cases, Bartonella is considered for further evaluation, regardless of IgG/IgM.
Tests showed negative markers for rheumatoid arthritis and had a normal thyroid panel indicating that her symptoms were not thyroid or RA related.
Evidence of inflammation was found. The patient had an elevated glycA which may be high with systemic inflammation. She also showed sensitivity to casein, which is found in dairy products.
Markers signifying an overactive immune system were tested. Lori's C3a was normal but did have an elevated C4a, which indicates an overactive immune system. These markers do not mark a clear diagnosis, but elevated markers can be due to Lyme disease, mold, ulcerative colitis, cancer, chronic inflammatory disorders, etc.
Markers indicating nutritional deficiencies were found. Omegas and vitamin D were low, most likely due to a lack of dietary intake.
Interventions
The following interventions were suggested:
Dietary Changes
The patient was encouraged to start an anti-inflammatory diet to decrease inflammatory foods. As the patient was already gluten-free, her main goal was to eliminate dairy from her diet completely.
Elimination Pathway Support
As soon as the patient was informed about her Lyme disease, she was provided with lymphatic drainage exercises, liver support, gut support, and a mold questionnaire. Manual Lymphatic Drainage (MLD) is a technique that supports the natural drainage of lymph. The lymphatic system is important as it serves as the "sewage system of the body" by helping to manage toxins. When this system is not efficient, the body may move toxins into the body fat away from vital organs, which can affect health.
Lymphatic work is considered important before, during, and after Lyme management to help avoid a potential Herx reaction (flu-like symptoms often felt during a detox). In addition, she was given a supplement called Clean Sweep (Mechanism Wellness) which contains NAC (1,200 mg), silymarin (200 mg), artichoke leaf extract (200 mg), and dandelion root (50 mg). This supports the detoxification process.
The patient was given gut support to promote a healthy immune system and to continue to enable her to have healthy bowel movements. This included probiotics (Orthomolecular) and GI Core (OrthoMolecular) which contains L-glutamine, zinc, Vitamin A, aloe vera, and DGL.
As mold testing can be controversial, a mold questionnaire was given to the patient as mold and Lyme symptoms may overlap and be involved in a cycle of immune dysregulation. The patient scored low, so mold testing was done.
Fish Oil, B Complex & Vitamin D
The patient had very low levels of omegas, B vitamins, and vitamin D. Supplementation was suggested to help support symptoms such as joint pain, brain fog, and fatigue.
Adrenal Rest
The patient was given adrenal support to help manage the hot flashes. She was given Adrenal Reset (Orthomolecular) that contained Bacopa (300 mg), Ashwagandha Root (250 mg), Rhodiola rosea Root (200 mg), Eleuthero Root (200 mg), L-theanine (100 mg), and Phosphatidylserine (100 mg). Many women who are peri/menopausal can sometimes benefit from adrenal support. As ovarian function diminishes, the adrenals have to not only do their normal job but also "take over" for the ovaries. If the adrenal function is sub-optimal, menopausal symptoms may worsen. Supporting healthy cortisol production is also considered important for Lyme management.
One Month Later Follow Up
The following were added to the management plan:
Antibiotics
Although pharmaceutical antibiotics and herbal antibiotics are both potential options for Lyme, it was mutually decided to start with pharmaceutical antibiotics. The patient was prescribed Azithromycin (500 mg) once per day and Cefuroxime Axetil (500 mg) twice daily for two months, with liver enzymes checked after four weeks of starting the antibiotics (that were normal). She continued all other supplements.
Biofilm Disruptor
Biocidin LSF (herbal blend) was given to the patient to take twice daily, away from foods and medications, to help manage the biofilm that Lyme + co-infections may reside in.
Follow-Up 3 Months Later
At our 3-month follow-up, the patient was feeling significantly better. Joint pain/muscle pain was 80% better, palpitations were 100% gone, brain fog was 100% gone, and energy was rated 9/10 (10=best). The patient reported feeling like her old self again. Since the patient's joint pain/muscle pain was not 100% better, the patient was taken off antibiotics and was given herbal agents to continue support. She started to take Phytocidal (Orthomolecular), which contains Andrographis (600 mg), Cat's Claw (400 mg), Japanese Knotweed (200 mg), and Sweet Wormwood (100 mg), taking two capsules twice daily and continuing the biofilm disruptor. The patient also reported that hot flashes were 100% gone. However, if she missed a dose of the adrenal supplement, the hot flashes would return during the day. She continued other supplements and was told to get labs retested with a follow-up in 1 month.
Medical Diagnostic Laboratories L.L.C (MDL)
- Positive Bartonella henselae IgG by ELISA
- IgGAlt Pos Lyme disease C6 Peptide by ELISA
- Positive IgG Lyme disease Western blot (IgM / IgG)
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Follow-Up 4 Months Later
Labs were reviewed with the patient, which showed much improvement. All symptoms that improved at the 3-month appointment remained significantly better. Because joint/muscle pain was still only 80% better, the patient was told to come in person for manual lymphatic drainage. The patient reported after 1-2 treatments, pain levels were almost 100% gone. At this point, the patient was off of her Lyme supplements completely, taking nutritional and adrenal support only. She also continued her probiotic for another three months.
Summary
This case demonstrates a detailed evaluation of looking at the potential contributors to an individual's joint/muscle pain, brain fog, and fatigue. By addressing gut health and liver health, making dietary changes, and managing Lyme, the patient was able to regain function back, and after years of discomfort, she was able to feel like her old self again.
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