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

By Marie Savard MD

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”.

Plan/Treatment

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.

“I was diagnosed early and had treatment early so that may mean there is no residual evidence of infection in my blood. Two weeks of antibiotics did the trick and I am now mercifully symptom free. I’m really glad my husband urged me to go to the doctor. I’m the type who will put off getting checked out in the hopes that whatever I have will just go away! That would not have been a good choice in this case as I understand lyme disease may become chronic and cause more serious problems.

“One positive result of all this is that I’m now much better about wearing sunscreen even though I’m finished with the course of antibiotics. I always knew I should use sun protection, both to prevent skin cancer and to stave off wrinkles, but I was kind of lax about that. No more. I slather on the stuff and wear a wide-brimmed hat. I’m also more vigilant about bites. I definitely don’t want to go through another bout of Lyme disease! As prevention, my husband and I do careful tick checks when we come in from outside and I throw our clothes in the dryer on high heat. If you live in or travel to an area where there are ticks, I strongly suggest doing the same!”

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.