Case study: Lyme disease in patient with Long COVID

The authors cited the World Health Organizations definition of Long COVID as follows: definition of Post COVID-19 – “Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others which generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.”²

Lyme disease has similar characteristics. The definition of chronic manifestations of Lyme disease include: persistent symptoms for at least 6 months, fatigue and cognitive dysfunction that impact on everyday function. Chronic Lyme disease symptoms can fluctuate or relapse over time.

Symptoms appear 4 months after COVID-19

A previously healthy 26-year-old medical student contracted COVID-19 in March 2020 at the onset of the pandemic. Her symptoms resolved after two weeks.

Four months later, the medical student became ill. Her symptoms included “frontotemporal headaches, chest tightness with some dyspnea, palpitations and tachycardia with anxiety, dizziness with episodes of near-syncope on sitting or standing, and blurred vision,” wrote the authors.

The symptoms were “eventually coupled with significant fatigue, mild cognitive impairment or ‘brain fog’ with impaired focus and memory recall, loss of appetite, diarrhea, uncharacteristic heat intolerance, and diffuse myalgias.”

The woman was initially evaluated by an endocrinologist, given her history of hypothyroidism. She was euthyroid.

Lyme test is positive

Her IgM Western blot was positive on two bands consistent with early Lyme disease. Her IgG Western blot was negative. Because of social distance guidelines during the pandemic, she spent a lot of time outdoors in a wooded area. The tests for tick-borne co-infections were normal. Her infectious disease and primary care doctor prescribed two weeks of doxycycline.

The woman’s symptoms persisted despite treatment.

In fact, her symptoms increased, as she complained of “worsening blurred vision with the introduction of bilateral floaters, worsening of palpitations with tachycardia and/or anxiety, worsened heat intolerance, and an increased frequency of near-syncopal events, which all interfered with all physical activity.”

Her headaches remained near-constant and began alternating between tension-like and left-sided, migraine-like presentations with concurrent nausea and left-sided allodynia of the scalp.

In the weeks thereafter, “these symptoms were then coupled with new-onset sleep disturbances with insomnia and intermittent night terrors,” wrote the authors.

Ramp up in symptoms – Herxheimer reaction?

The authors did not discuss whether this flareup might have been a Herxheimer reaction described after initiating an antibiotic for Lyme disease.

The woman’s sense of smell changed. She had anosmia and ageusia for 4 or 5 days after the onset of her acute COVID.

Note: Anosmia is a partial or complete loss of smell. Ageusia refers to the loss of sense of taste.

She had strong phantosmia after her treatment for Lyme disease. “Per the patient, this caused the smells of otherwise benign foods, perfumes, or body odors to be swapped with foul smells of ‘burning rubber’ or ‘rotting meat,’” wrote the author.

She was referred for migraine-like headaches. Common abortive therapies, including triptans and calcitonin gene-related peptide (CGRP) antagonists failed.

She was presumed to suffer from “a novel “post-COVID headache,” according to the authors. There was some relief of her headaches with Excedrin and Fioricet and prochlorperazine for nausea.

She was subsequently diagnosed with polycystic ovarian syndrome. Metformin improved her period but led to hypoglycemic symptoms.

She continued extensive testing. Her pulmonary evaluation was normal. She had an incidental right bundle branch block that did not require an intervention.

She gradually improved with a trial-and-error program that included POTS rehabilitation, graded exercise and osteopathic manipulative treatment (OMT). OMT was offered through her faculty. “A variety of anxiety reduction techniques and sleep hygiene improvements were also employed with limited success in reducing her fatigue and brain fog,” wrote the authors.

“By November 2020, the patient’s symptoms began to gradually improve, with notable reductions in palpitations, anxiety, and fogginess, but with a compensatory increase in fatigue and new-onset constipation and hair loss.”

Incidentally, she contracted COVID a second and third time. She was treated with molnupiravir after her first COVID reinfection.

She was also vaccinated twice with Moderna mRNA COVID-19 vaccination. “She noted moderate improvements in her fatigue and brain fog in the first 24 hours following her first dose,” wrote the authors.

The authors suggest, “The influence of co-infections, such as the Lyme disease infection described here, or other accounts of Epstein-Barr virus or other herpes viruses infection or reactivation, should also be granted further consideration in the syndrome’s pathogenesis and management.”

The woman was treated successfully. However, she encountered some clinicians who were skeptical and dismissive.

“The patient presented here is health literate and has access to seemingly high-quality healthcare, yet endorsed several instances where her symptoms were ignored, misdiagnosed, or misattributed to perceived anxiety by several clinicians,” the authors wrote.