Lyme Disease

Case Study

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:

Studies Results

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)

Diagnostic Analysis

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

Case Studies

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.

Studies Results

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

Diagnostic Analysis

With the clinical picture of classic intermittent claudication, the noninvasive Doppler and

plethysmographic arterial vascular study merely documented the presence and location of the

arterial occlusion in the proximal femoral artery. Most vascular surgeons prefer arteriography

to document the location of the vascular occlusion. The patient underwent a bypass from the

proximal femoral artery to the popliteal artery. After surgery he was asymptomatic.

Critical Thinking Questions

1. What was the cause of this patient's pain and cramping? 2. Why was there decreased hair on the patient's right leg? 3. What would be the strategic physical assessments after surgery to determine the

adequacy of the patient's circulation?

4. What would be the treatment of intermittent Claudication for non-occlusion?