Post-exertional malaise after Lyme disease: a soldier’s case
Post-exertional malaise can limit physical and cognitive activity.
The symptom is commonly associated with ME/CFS but may occur after Lyme disease.
A soldier’s case illustrates the challenges of diagnosis and recovery.
Post-exertional malaise (PEM) is a worsening of symptoms following physical, cognitive, or emotional exertion and is one of the defining features of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).
Welcome to another Inside Lyme Podcast with your host Dr. Daniel Cameron. In this episode, Dr. Cameron discusses the case of a 21-year-old soldier who was ultimately dismissed from active duty after failing treatment for multiple illnesses, including Lyme disease.
The case was first described by Melanson and colleagues in a paper entitled “The Epistemic Fallacy: Unintended Consequences of Empirically Treating (Clinically Diagnosed) Chronic Lyme Disease in a Soldier.”1
What is post-exertional malaise?
Post-exertional malaise, sometimes written as post exertional malaise, refers to a worsening of symptoms after physical, mental, or emotional activity. Symptoms may worsen immediately or be delayed by hours or days. Recovery can take days, weeks, or longer depending on the individual and the severity of illness.
Post-exertional malaise is commonly associated with ME/CFS but may also be reported by patients recovering from Lyme disease and other chronic illnesses.
The following case illustrates how post-exertional malaise can become a major source of disability, even after evaluation and treatment for multiple conditions.
“A 21-year-old, Division 1 student athlete patient presented with heart palpitations and frequent unprovoked adrenaline rushes,” wrote the authors. His symptoms were initially dismissed as stress.
Four months later, testing for Epstein-Barr virus was positive but serological testing for Lyme disease was negative. “He was diagnosed with EBV reactivation and prescribed rest and recovery,” the authors wrote.
The man graduated but remained on medical leave since his symptoms had not resolved.
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He was presumed to suffer from persistent mononucleosis-like symptoms and traumatic brain injury (TBI) attributed to possible post-concussion syndrome related to sports injuries, the authors explained.
The patient was then treated with Hyperbaric Oxygen Therapy (HBOT). However, after two sessions, it was discontinued due to an increase in symptoms including heart palpitations, flank pain, myalgias, and neuropathy.
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Although repeat testing for Lyme disease was negative, the man was treated clinically for Lyme disease based on symptoms, possible tick exposure during military training, and the lack of other definitive findings.
He received three courses of doxycycline. Further Lyme disease tests were inconclusive.
Symptoms of post-exertional malaise
The patient was forced to stop treatment after it worsened his symptoms, causing an increase in joint pain, intermittent nerve pain, headache, fatigue, cognitive difficulties, anxiety, mild depression, and increased chest pain.
Symptoms commonly associated with post-exertional malaise may include:
- Severe fatigue
- Cognitive impairment
- Difficulty concentrating
- Reduced stamina
- Exercise intolerance
- Pain flares after activity
- Worsening neurologic symptoms
- Delayed recovery following exertion
The patient then sought treatment with a functional medicine doctor. His workup focused on mycotoxicosis in part due to his living and training environments.
He had a homogeneous single nucleotide polymorphism in the MTHFR gene suggestive of reduced metabolic detoxification and an abnormal mycotoxin urine panel.
He was treated for three months with IV phosphatidylcholine, IV glutathione, IV Leucovorin, and subcutaneous vitamin B12. He reported minor improvements in fatigue and stamina but stopped treatment due to cost. His follow-up urine mycotoxin panel was negative.
As his symptoms persisted and exercise intolerance worsened, clinicians broadened the differential diagnosis beyond Lyme disease and mycotoxicosis.
The man remained ill and was unable to perform moderate or strenuous physical exercise or cognitive activity due to cognitive impairment affecting short-term memory and focus, severe fatigue, post-exertional malaise, asthma, increasing allergic-type reactions, chemical and food sensitivities, histamine intolerance, and progression to heat- and ultraviolet-induced urticaria.
Additionally, the patient struggled emotionally with anxiety, depression, environmental stimulation such as bright and flashing lights and loud noises, and sensitivity to stress.
He was subsequently diagnosed with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) following resolved acute mycotoxicosis.
The young man was considered unfit for duty by the Army Medical Evaluation Board for the following reasons: Lyme disease, mycotoxicosis, chronic fatigue syndrome, allergic rhinitis, and vasomotor rhinitis.
The authors did an excellent job describing the severity of symptoms and poor function of a soldier despite evaluation and empiric treatments for CFS/ME following resolved acute mycotoxicosis and Lyme disease.
Frequently Asked Questions
What is post-exertional malaise?
Post-exertional malaise is a worsening of symptoms following physical, cognitive, or emotional exertion. Symptoms may persist for days or longer after activity.
Can Lyme disease cause post-exertional malaise?
Some patients with Lyme disease or persistent symptoms following Lyme disease report post-exertional malaise, exercise intolerance, and worsening symptoms after activity.
Is post-exertional malaise the same as chronic fatigue?
No. Post-exertional malaise refers to symptom worsening after exertion, while fatigue is only one of many symptoms that may occur during PEM.
Can exercise make Lyme disease symptoms worse?
Some patients report worsening fatigue, pain, cognitive dysfunction, or post-exertional malaise following physical activity, particularly when recovery is incomplete.
Clinical Takeaway
Post-exertional malaise can significantly impair physical and cognitive function and may persist despite treatment for multiple conditions. The soldier’s case illustrates the complexity of evaluating patients with overlapping symptoms involving Lyme disease, chronic fatigue syndrome, mycotoxicosis, and other potential diagnoses.
Persistent exercise intolerance, cognitive dysfunction, and post-exertional symptom worsening deserve careful evaluation, particularly when they interfere with daily functioning and recovery.
Related Articles
Lyme disease fatigue
Autonomic dysfunction and Lyme disease
Persistent Lyme disease symptoms
Recovery from Lyme disease
References
- Melanson VR, Hering KA, Reilly JL, Frullaney JM, Barnhill JC. The Epistemic Fallacy: Unintended Consequences of Empirically Treating (Clinically Diagnosed) Chronic Lyme Disease in a Soldier. Med J (Ft Sam Houst Tex). 2022;(Per 22-01/02/03):50-55.
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
Welcome to my life. The VA still denies I have Lyme, ME/CFS and now MCAS, etc after 6 years. Thank God for Medicare and NDs!
I am astounded this poor young man got this far. With diagnosis and that amount of treatment. For five years I’ve been literally begging my GP here in London UK to reckonise me. Yet that are flat refusing to even consider Lyme disease. I am now so sick I cannot work. I have no money for private treatment. I feel scared, alone and dismissed. As well as gaslighted into believing i have mental issues causing my symptoms. I am now desperate for help, I don’t know where to turn. To sick to even get up some days, let alone write emails of complaints. I did complain about one doctor who slapped my hand away. That just made it worst at now every GP in the surgery just roll their eyes and patronise me. I now have nothing but anger & frustration also added on top of everything else. The way they have treated me for five years has been appalling. When ever I can I’ve bought doxcycline from online. I’ve also bought iver mec to keep going. Also fen Ben.
Look for an attorney and let them fight for you, the VA does not like to recognize many illnesses.
Part of the problem are viral, bacterial infections plus parasite infestations. First thing to do is to start eating raw garlic every single day, two cloves. After that start drinking green tea two cups a day every single day plus start drinking Moringa tea infusions. Start eating oranges and red grapes and mushrooms. Find competent MD and ask him to give you prescription for Amoxicillin 750mg x 3 times a day for 7 days. Four week later you need prescription for Ciprofloxacin 250mg x 3 times a day for 5 days and you will be OK.
Dr. C, I wish you would have written the headline differently. Who failed? The soldier or the lyme treatment? You wrote the title as if the soldier if the failure. The failure is the lyme treatment’s failure and not the soldiers. With this title you are feeding the standard narrative that it is the patients failing. Patients aren’t failing…..the treatments are. And what a difference it would make if you had titled it as treatment’s fault rather than the soldier’s.