I am a 37-year-old male, employed as a computer systems consultant in Pennsylvania. Besides a few minor sicknesses, I have been in excellent physical and mental condition.
I have been suffering for the past four months with overwhelming fatigue, confusion, inability to concentrate, memory problems, altered mental/emotional status, slurred speech, dizziness, and sensory abnormalities. A full description of these symptoms follows below.
These symptoms have forced me to take a leave of absence from work, disengage from almost all social interactions, and stop any physical activity.
A Lymes disease ELISA test showed no evidence of Lyme. As far as I know, I never developed a migrans rash; since I live alone I would have noted a rash only in an easily visible area. A full description of relatively recent test results follows below.
CSF IEP and other testing showed no evidence of MS.
An MRI revealed a single hyperintensity lesion in the periventricular region in the left occipital area. The lesion did not react to dye.
Symptoms In Last Four Months:
Symptom Description Severity Frequency
Physical Fatigue · Overall sense of weakness.· Become exhausted very easily with any physical activity. Severe Constant
Confusion/Memory · Difficulty concentrating.· Difficultly remembering. · Sense of “brain fog”, with “zoned out” feeling.· Trouble “finding” words when speaking.· Slur words when speaking. Severe Near Constant
Altered Mental Status · Much more easily agitated and irritable.· Situational feeling of information overload.· Heightened noise awareness with even small noises (e.g. dropped fork in floor) hurting ears. Medium Frequent
Dizziness/Vertigo · Constant unsteady spinning feeling. This feeling varies from “acceptable” to severe and incapacitating Severe Constant
Sensory Abnormalities · Involuntary twitching in arms and legs (frequent).· Left hand grip weakness (occasional)· Heavy, numb (like Novocain), pins/needle, tingle, painful forearms/hands (occasional lasting for ~ 1-2 days)· Clumsiness, especially dropping items.· Foot drag when walking.· Occasional tight, numb (like Novocain), vibrating/buzzing feeling on top of skull (6 in X 6 inch area) (lasting 5-10) minutes).· Occasional high-pitched sounds in ears (usually right ear) Medium (ranked as Medium since less effect on Job/Life performance) Frequent
Fainting · Early September fainting episode requiring trip to ER. I did not lose consciousness but could not speak and did not have awareness for 10 minutes. No evidence of stroke. Normal EKG.· Two other subsequent incidents of near fainting; severe weakness/dizziness, rapid shallow breathing, feeling of not enough air, moist cold skin. Severe Infrequent
Back Pain · Lower back/hip joint pain. This started before this grouping of episodes but is now worse. Medium Constant
Recent Test History: (September-October 2007)
CBC Panel (with Glucose) Normal Blood Chemistry
Thyroid Function Normal (one Calcium test high; calcium high because of heavy use of antacid (calcium) before blood sample)
VERS/BAERS (Evoked Potential) Normal
BPV (Benign Positional Vertigo) Negative
Spinal Tap with CSF IEP Normal in relation to serum levels (normal protein, normal pressure, no cells, no IgG/IgM abnormalities observed).
Lyme (ELISA): Blood Sample taken September 21st, 2007. Negative. Note: I was taking Cefuroxime 500mg X 2 per day, starting September 5th, 2007 ending October 5th, 2007 for a presumed sinus infection. Could this influence the result?
MRI Single hyperintensity lesion in the periventricular region in the left occipital area. The lesion did not react to dye
Other Relevant Information:
I travel frequently to Puerto Rico for work. Although I stay in higher-end hotels, I have been exposed to the outdoors and the local food. Since May of this year, I have been to Puerto Rico twice and stayed in San Juan and Guayama, on the south side of the island.
I traveled to Ireland (near Dublin) for work Sept 23-25, 2007.
I also lived in Brazil for two months, returning to the States January 2005.
I have had chronic rhinitus for five years, apparently associated with reflux.
I have had life-long depression and see a psychiatrist at regular intervals. Endogenous depression is in the family; maternal grandfather, undiagnosed depression, suicide at age 42; mother, lifelong depression on aniti-depressant medication since 1994.
I have had migraines for my whole life but these have diminished in frequency and intensity in my thirties.
Pulse: 80 bpm
Weight: 175 lbs.
Current Daily Medication:
Effexor ER 150mg/Daily. I was taking 225mg daily for five years. My neurologist requested that I drop the does to 150mg to see, if by off chance, an SSRI reduction would improve the vertigo/dizziness symptoms. I reduced the dose on October 25th, 2007.