Just a couple of weeks ago, I had a new patient on my schedule—someone who specifically requested a consultation for Lyme disease.
I opened her chart before the visit, expecting to see at least some preliminary workup. She had already seen several specialists—including rheumatology, neurology, and infectious disease—and her chart included a long list of symptoms: fatigue, brain fog, joint pain, palpitations, headaches, and what she described as “air hunger.” But one thing stood out immediately: there was no documented evaluation for Lyme disease or tick-borne coinfections.
There was no Lyme disease immunoblot.
No documented coinfection testing.
Not a single note indicating that a tick-borne illness had been considered.
She lived in an area where Lyme disease is endemic and spent time outdoors. Her symptoms were compatible with a tick-borne illness, although they were not specific to Lyme disease. Yet Lyme disease did not appear to have been included in the differential diagnosis.
Listening to Her Story
When she arrived, she described a downward spiral that had started nearly a year earlier after a summer hike. She did not recall a tick bite or notice a rash. However, she developed a viral-like illness followed by a slow, persistent decline.
She had been treated for anxiety and given medications for insomnia and inflammation. She had also been evaluated for conditions ranging from lupus to multiple sclerosis. But her symptoms continued, and she was left without an explanation.
Looking for What Others Missed
We started over by taking a full history, reviewing her potential exposures, and mapping how her symptoms had evolved. Based on the complete clinical picture, I ordered additional testing that included:
- Lyme disease IgM and IgG immunoblot testing
- Babesia and Bartonella testing
- Repeat bloodwork and inflammatory markers
This was a clinical decision based on her history, symptoms, possible exposures, and previous evaluation. Laboratory testing can support a diagnosis, but its results must be interpreted within the complete clinical context.
The Results—and the Plan
A few days later, her laboratory results included:
- A positive Lyme IgG immunoblot with 6 of 10 reportable bands
- A positive Babesia duncani IgG antibody result
A positive Lyme IgG immunoblot supported previous exposure to or infection with Borrelia burgdorferi, but the test could not determine by itself whether every current symptom was attributable to active Lyme disease. Similarly, a positive Babesia duncani IgG result could indicate previous exposure and did not independently establish active babesiosis.
Nevertheless, when the laboratory findings were considered alongside her exposure history, symptom pattern, examination, and previous treatment response, the results supported the Lyme disease diagnosis and raised clinical concern for a concurrent Babesia infection.
She had previously received a short course of doxycycline, but her symptoms had not improved. Doxycycline is used to treat Lyme disease but does not treat Babesia. A possible Babesia coinfection therefore offered one potential explanation for why doxycycline alone had not addressed her complete clinical picture.
After discussing the potential benefits, limitations, and risks of treatment, we began therapy with atovaquone and azithromycin. For the first time in months, she felt that there was a path forward.
A Systemic Oversight
This was not the first time I had evaluated a patient whose previous workup had not included tick-borne illnesses—and it will not be the last.
Lyme disease and possible coinfections may be overlooked when:
- Nonspecific symptoms are attributed primarily to anxiety or stress
- Appropriate testing is delayed or not considered
- Care is fragmented among multiple providers
These patients often need someone to review the entire history, reconsider the differential diagnosis, and determine whether additional evaluation is warranted.
Closing the Gaps
Lyme disease is a clinical diagnosis informed by the patient’s history, potential exposure, physical findings, disease stage, and appropriately interpreted laboratory testing. It requires listening, pattern recognition, and a willingness to ask, “What might we be missing?”
A comprehensive Lyme disease consultation may include reviewing the patient’s exposure history, symptom progression, previous testing, treatment response, and the possibility of other tick-borne infections.
This patient did not simply need reassurance that her previous tests were normal. She needed someone to consider what had not yet been evaluated.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
