A 38-year-old male had a 3-week history of fatigue and lethargy with intermittent complaints of headache, fever, chills, myalgia, and arthralgia. According to the history, the patient’s symptoms began shortly after a camping vacation. He recalled a bug bite and rash on his thigh immediately after the trip. The following studies were ordered:
Lyme disease test, Elevated IgM antibody titers against Borrelia burgdorferi (normal: low)
Erythrocyte sedimentation rate (ESR), 30 mm/hour (normal: ≤15 mm/hour)
Aspartate aminotransferase (AST), 32 units/L (normal: 8-20 units/L)
Hemoglobin (Hgb), 12 g/dL (normal: 14-18 g/dL)
Hematocrit (Hct), 36% (normal: 42%-52%)
Rheumatoid factor (RF), Negative (normal: negative)
Antinuclear antibodies (ANA), Negative (normal: negative)
Based on the patient’s history of camping in the woods and an insect bite and rash on the thigh, Lyme disease was suspected. Early in the course of this disease, testing for specific immunoglobulin (Ig) M antibodies against B. burgdorferi is the most helpful in diagnosing Lyme disease. An elevated ESR, increased AST levels, and mild anemia are frequently seen early in this disease. RF and ANA abnormalities are usually absent.
Critical Thinking Questions
1. What is the cardinal sign of Lyme disease? (always on the boards)
2. At what stages of Lyme disease are the IgG and IgM antibodies elevated?
3. Why was the ESR elevated?
4. What is the Therapeutic goal for Lyme Disease and what is the recommended treatment
Peripheral Vascular Disease
A 52-year-old man complained of pain and cramping in his right calf caused by walking two blocks. The pain was relieved with cessation of activity. The pain had been increasing in frequency and intensity. Physical examination findings were essentially normal except for decreased hair on the right leg. The patient’s popliteal, dorsalis pedis, and posterior tibial pulses were markedly decreased compared with those of his left leg.
Routine laboratory work Within normal limits (WNL)
Doppler ultrasound systolic pressures Femoral: 130 mm Hg; popliteal: 90 mm Hg; posterior tibial: 88 mm Hg; dorsalis pedis: 88 mm Hg (normal: same as brachial systolic blood pressure)
Arterial plethysmography Decreased amplitude of distal femoral, popliteal, dorsalis pedis, and posterior tibial pulse waves
Femoral arteriography of right leg Obstruction of the femoral artery at the midthigh level
Arterial duplex scan Apparent arterial obstruction in the superficial femoral artery
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