Solve the Medical Riddle: She Has a Fever, Nausea, Neck Pain, and a Headache, Fourth Week

Editor’s note: Welcome to our thirdAGE feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

The first week of this riddle, the patient reported her symptoms to her PCP. The doctor proceeded with the examination using the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendation

Last week, we let you know what some people had suggested as possible diagnoses. This week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Alexandra B. is correct. Irene does indeed have Lyme disease. Not every one has memory of a recent tick bite or the classic “bull’s eye rash” (and the rash can be subtle and sometimes missed). Blood tests for Lyme are usually positive a few weeks after the tick bite and resulting infection. Yet when erythema migrans — the so-called “bull’s eye rash” — isn’t present, there may not have been enough time for antibodies to become positive. In Irene’s case, weeks into the infection, the blood tests proved to be positive. Also, the enzyme-linked immunosorbent assay (ELISA) test was positive and the Western blot test was also positive, confirming that the positive ELISA test was not a false positive because of some other illness “cross reacting”.


Treatment for Lyme disease is with antibiotics. Irene has no antibiotic allergies so the doctor prescribed doxycycline 100 mg twice daily for 14 to 21 days. Because doxycycline can cause sun sensitivity, Irene was advised to avoid the sun. The doctor told Irene about one patient who got severe sunburn while taking doxycycline to prevent diarrhea while traveling in Mexico. The doctor instructed Irene to use sunscreen when she goes outdoors.

Doxycycline can also cause esophagitis, an inflammation that may damage tissues of the tube that carries food from the mouth to the stomach. The doctor advised Irene to take the pills with plenty of water to wash them down. He also told her not to take a pill the last thing before going to bed in order to avoid reflux of stomach acid and further esophageal irritation from the medication.

Here is Irene’s take on what happened:

“I found out that the laboratory has a mandatory reporting requirement for Lyme disease. I got a call from a local public health facility questioning me in order to find the potential source of infection. I said it was probably a tick in my own backyard, and I detailed where I live. The Centers for Disease Control is tracking the incidence of Lyme disease state by state.