Patient Information: Posted by request and with permission
25 year old formerly healthy and active, white, married F. Lives on farm with horses, dogs, chickens, cats.
Currently diagnosed conditions:
Hashimoto's Thyroiditis: Under control
Degenerative Joint Disease (knees)
Abnormal Lab Results:
-Abnormal ANA panel
-High neuron-specific enolase (9, high range @ 8.1)
-Low vitamin D
-All organ function tests came back within range
-Negative: limes titer, porphyria, all forms of STI, HIV/AIDS, negative for all forms of hepatitis, double-strand anti-DNA test
Daily Mediation/ Dietary Supplements:
Pre-Natal Vitamins (for therapeutic purposes only.)
-Extreme joint, muscle, and bone pain: P reports that it feels as if someone is ripping her bones apart from the inside out. Joints randomly give out, inflame and become hot, and/or hurt.
-Intermittent and unexplained fevers
-Extreme sun sensitivity: 20 minutes in direct sun without protection results in vomiting, fever, extreme fatigue
-Fatigue: P states that she used to be active up to 18 hrs a day. Since becoming sick, she has become unable to care for herself and is now sleeping up to 18 hours a day.
-Flash migraines: On and off for up to a week at a time
-Tingly/numb sensations throughout body: P reports that sometimes it feels like her spine is completely numb or that it feels like "jello," that other times it feels like it's on fire and the pain extends to the rest of her extremities. Also reports that hands and fingers go numb when she must respond quickly to threatening situations (ex: a car cutting her off in heavy, fast-moving traffic).
- Periods of lack of appetite/anorexia followed by over-active appetite/weight gain
-Chest pain/shortness of breath
-Brain fog/memory loss
-Dramatically increased clumsiness/lack of coordination
Patient has been diagnosed with fibromyalgia and is on Tramadol daily to manage pain as well as Lyrica (75mg TID). Lyrica has helped some of the fatigue symptoms but is not providing enough relief. Recently experienced significantly inflamed, hard and painful femoral lymph nodes - started on Bactrim and experienced no relief. Returned and was prescribed z-pack. Since starting on antibiotics, P states that she has experienced a dramatic change in pain and energy level and no longer has to take tramadol for joint pain.
Wondering if this is still possible Lupus, Lymes, or even a chronic unidentified systematic infection?