Neil Hirschenbein MD, PhD February 15, 2014
23 years old. GI problems all his life – gas, bloating, alternating diarrhea & constipation. Mental functioning problems – dx depression & ADD. Difficulties with social situations. Insomnia, chronic headaches, & chronic fatigue. Requires 12 hours of sleep to get by, but only does minimal things.
Stopped sports in 6th grade. Problems with memory all his life. College a great awakening, because now he had to take care of self. In college, multiple courses of anti- depressants without benefit & meds for ADD. 1 year ago started to avoid gluten, with decreased gas & diarrhea.
Past Medical History Surgery - none Hospitalizations – pneumonia as infant Medical – as above Meds – none Supplements – digestive enzymes, zinc, magnesium, B6, B12 Allergies - none
Family History – noncontributory Social History – 3 years of college, single, unemployed, has roommates but shortly will be moving back in with parents in central California
Additional food & environmental allergies Unable to gain weight despite hi cal diet Unable to exercise because of fatigue Lightheaded & dizzy Memory slightly better off gluten Always anxious, frequently depressed
No regular sleep schedule. Needs to sleep 12 hours, but requires more than 12 hours of being awake, before he’s ready to sleep again Currently goes to bed between 4 & 5 am, similar to family. Does not awaken refreshed Physical Exam – WNL, BP 90/50 Labs ◦ 25(OH)D – 41 ng/m ◦ 1,25(OH)2D – in 40’s, by history
Plan ◦ Inflammation protocol reviewed ◦ Olmesartan 40 mg q6h ◦ BP monitoring ◦ Herxheimer reactions reviewed
Difficulty getting meds thru insurance ◦ Eventually got generic thru Canadian Pharmacy Increased light sensitivity with olmesartan ◦ Slight postural symptoms improved with sunglasses Started minocycline 25 mg qod, 1 week ago ◦ Doing ok
Increased minocycline to 50 mg qod ◦ Tolerating Insurance now covering olmesartan ◦ Medco refused to fill because of dose ◦ Able to get olmesartan 40 mg qid from Costco for $15/mo Insurance not covering minocycline because it was used on a continuous basis
Minocycline increased to 100 mg qod ◦ Caused reactions of nausea, increased fatigue, & dizziness ◦ Not intolerable ◦ Reduced to 50 mg qod Took olmesartan q 6h, except when slept for 8-9 hrs
Added azithromycin (Zithromax) 250 mg, 1/8 q 10d Decreased minocycline to 25 mg qod initially, then slowly increased back to 100 mg qod Digestion better, sleep more refreshing Occasionally takes extra olmesartan, or takes q 4-5 hrs, instead of every 6
Decreased mino from 100 to 25 qod Increased zith from 1/8 to ¼ q10 d Tolerating Careful with avoiding sun, vitamin D foods & supplements Energy, digestion & sleep intermittently improved; previously never had improved
Eventually got to mino 100 mg qod & zith 125 mg q10d – both maximum doses Decreased mino to 25 mg qod and zith to 1/8 q10d and added Clindamycin 150 mg 1/8 qod Sleep more normalized. No longer can stay up very late, & generally needs less sleep (occasionally gets by with 6 hrs) Repeat 25(OH)D 8.6 ng/ml (previously 41ng/ml)
Some antibiotics in capsules, not tablets, and difficult to divide Some die-off sx of lightheadedness & abdominal discomfort, similar to before Improved social anxiety, mental functioning, & ability to carry on conversations Feels like he is doing better
On mino 50 mg qod, zith 125 mg q10d, & clindy 37.5 mg qod Normally takes olmesartan 4/d, but occ takes q5h& runs low, so takes q7h & has more fatigue Turns 25 later this mo & no longer eligible for parents insurance
Still on zith 125 mg qd, but increased clindy from 37.5 to 75 mg qod & mino from 50 to 100 mg qod Initially some increased aches & pains, GI sx, & lightheadedness; but decreased with time Allergic to corn & eats too frequently Decreased social anxiety ◦ Much more at ease meeting people
Noticed that had no Herx with mino qod, but had increased Herx with mino q3d Then changed clindy from 150 mg q2 to q3 & also had more Herx with more rib & joint tenderness Generally noticed more anxiety and depression with clindy
Taking mino 100 mg q4d, clindy 150 mg q4d, & zith 125 mg q 10d Herxheimer reactions significantly reduced
At last visit, d/c mino Wrote script for demecycline, but not able to get because of cost; continued on mino Then d/c clindy & started bactrim DS ¼ q 4d More physical Herx with bactrim; tendinitis of both elbows & pain in L wrist With clindy more brain fog & brain sx Now brain clear & more physical sx
Going slowly with bactrim. Yesterday forgot to set his alarm & went 10 hrs without olmesartan; had unpleasant experience Went to Oregon to visit family that he had not seen for awhile; they were extremely happy for him with his ability to socialize & communicate, which had previously been a significant problem
Continues on max doses of mino & zith, & just increased bactrim from ½ to 1 q 3-4d Sleeping better & needing less sleep; now frequently awakens refreshed & never did before. Awakens with mental clarity Some flaring of his joints, especially wrists People want to socialize with him now and he is tolerating them better
Father returned from Mexico with severe cough that he caught; had not had severe viral infection for long time Had problems with body aches, esp. legs & back, & increased GI sx With cold sx continued olmesartan & d/c all antibiotics for 2-3 weeks Restarted antibiotics at lower doses & slowly increased
Able to increase mino, zith, & bactrim to max doses, usually q 3-4 d, but occasionally qod Did not d/c zith & restart clindy Some rough patches with pain; esp ribs, fingers, back, & other joints Trying to rebuild his social life, & contacted some college friends
Found pharmacy where he could get demeclocycline inexpensively, but given incorrect information
Prior to starting deme, went on 1 month antibiotic vacation, & had fewer symptoms
Restarted mino 50mg without problem; did not restart bactrim Changed zith to clindy 18.75 mg; again had depression but did not make the connection to clindy & increased to 75 mg Had more insomnia with his mind racing, & decreased energy
Increased mino to 100mg qod; tolerated dose Increased clindy to 150 mg qod Added bactrim & ramped up to ¾ tablet qod With clindy - problems with insomnia, anxiety, & depression With bactrim - problems with digestion & sweating Sleeping better, anxiety better controlled, & less whole body aches
Off antibiotics for last month; busy month- sister graduating college & on long road trip with her, brother getting married in August Continued on olmesartan q 4-5 hours
Met girl at brother’s wedding & moved to Oregon Restarted mino to 50 mg Difficulty getting olmesartan; spaced it less frequently & d/c mino Eating out more often & slightly more GI sx Bought weights & exercising; previously exercise caused increased pain
On olmesartan 40 mg q 4h, but no antibiotics Socializing more & finds that amazing; seeing his sister’s friends & girlfriend’s friends Lifting weights & joints feel fine Trying to figure out what he wants to do for his career (active web internet community & interested in learning that; taking computer science course)
Restarted zith, but too much Herxing for what he was doing so d/c. Making websites & going to school (class was at least 40 & frequently 60 hr/wk but able to keep up) Made multiple new friends In process of sending out resumes; has applied for work before, but never excited before
Hopes to be hired in next 1-2mos & re-start antibiotics once in stable situation Social skills have improved; able to communicate with multiple people at a time. No longer needs alone time Extremely excited about everything that has happened
La Jolla Institute of Comprehensive Medicine 8910 University Center Lane #530 San Diego, Ca. 92122 858-546-8055
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