Post-Exertional Malaise in Soldier With Lyme Disease
Post-exertional malaise can severely limit physical and cognitive function.
A young soldier with Lyme disease developed worsening fatigue, exercise intolerance, and neurologic symptoms.
The case highlights the complexity of persistent illness after Lyme disease.
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 dismissed from active duty after failing treatment for multiple illnesses including Lyme disease.
The case was first described by Melanson and colleagues in the paper “The Epistemic Fallacy: Unintended Consequences of Empirically Treating (Clinically Diagnosed) Chronic Lyme Disease in a Soldier.”
“A 21-year-old, Division 1 student athlete patient presented with heart palpitations and frequent unprovoked adrenaline rushes,” wrote the authors. Initially, his symptoms were dismissed as stress.
Four months later, testing for Epstein-Barr virus (EBV) was positive while Lyme disease serologic testing remained negative. The patient was diagnosed with EBV reactivation and prescribed rest and recovery.
Despite graduating, he remained on medical leave because his symptoms failed to improve.
Persistent Symptoms Expanded Beyond Fatigue Alone
The patient was later presumed to have persistent mononucleosis-like symptoms and traumatic brain injury (TBI) associated with possible post-concussion syndrome related to sports injuries.
He subsequently underwent Hyperbaric Oxygen Therapy (HBOT). However, after only two sessions, treatment was discontinued because his symptoms worsened, including:
- Heart palpitations
- Flank pain
- Myalgias
- Neuropathy
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Lyme Disease Was Treated Clinically Despite Negative Testing
Although repeat Lyme disease testing remained negative, the patient was treated clinically based on symptoms, possible tick exposure during military training, and the absence of another definitive explanation.
He received three courses of doxycycline, but additional Lyme disease testing remained inconclusive.
This case also raises difficult questions about whether a persistent tick-borne infection can ever be fully excluded in some patients with ongoing symptoms. Negative or inconclusive testing does not always resolve the clinical uncertainty. Some clinicians may consider whether additional antimicrobial treatment could benefit selected patients, while recognizing that these decisions remain controversial and highly individualized.
In some patients with persistent symptoms, it can be difficult to determine how much ongoing illness may relate to Lyme disease versus other contributing medical or neurologic conditions. A careful evaluation for alternative or overlapping diagnoses remains important.
Post-Exertional Malaise Limited Physical and Cognitive Activity
The patient was forced to stop treatment after worsening joint pain, intermittent nerve pain, headaches, fatigue, cognitive difficulties, anxiety, depression, and increased chest pain.
The patient later sought care through a functional medicine physician. His evaluation focused in part on possible mycotoxicosis related to environmental exposures during military living and training conditions.
He was found to have a homogeneous single nucleotide polymorphism involving the MTHFR gene suggestive of impaired metabolic detoxification along with an abnormal urine mycotoxin panel.
He underwent treatment with IV phosphatidylcholine, IV glutathione, IV Leucovorin, and subcutaneous B12. While he noted mild improvement in fatigue and stamina, treatment was stopped after three months because of cost.
Despite treatment, the patient remained severely impaired.
“The patient was unable to perform moderate-or-strenuous physical exercise or cognitive activity due to cognitive impairment, severe fatigue, and post-exertional malaise.”
The authors also described worsening asthma, allergic-type reactions, chemical and food sensitivities, histamine intolerance, and heat- or 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,” the authors explained.
Chronic Fatigue Syndrome / ME Was Eventually Diagnosed
He was subsequently diagnosed with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) following resolved acute mycotoxicosis.
The Army Medical Evaluation Board ultimately determined that the patient was unfit for duty due to:
- Lyme disease
- Mycotoxicosis
- Chronic fatigue syndrome
- Allergic rhinitis
- Vasomotor rhinitis
The authors described the severity of symptoms and impaired function in this young soldier despite extensive evaluation and empiric treatment efforts.
This case also highlights how difficult it can be to evaluate patients with persistent fatigue, exercise intolerance, neurologic symptoms, and autonomic dysfunction following Lyme disease.
Questions Raised by This Case
The following questions are addressed in this podcast episode:
- Have you seen patients with this range of symptoms?
- What is HBOT?
- What is integrative medicine?
- What is empiric treatment?
- Was Lyme disease a consideration?
- What other illnesses were considered?
- Are there patients with Lyme disease who fail treatment?
- Are there patients with the other illnesses discussed who also fail treatment?
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Thanks for listening to another Inside Lyme Podcast. Please remember that the advice given is general and not intended as specific advice to any particular patient. If you require specific advice, please seek that advice from an experienced professional.
Frequently Asked Questions
What is post-exertional malaise?
Post-exertional malaise refers to worsening symptoms following physical or cognitive exertion. Symptoms may include profound fatigue, pain, cognitive dysfunction, and delayed recovery after activity.
Can Lyme disease testing remain negative?
Yes. Some patients with persistent symptoms may continue to have negative or inconclusive Lyme disease testing despite clinical suspicion.
Can persistent tick-borne infection be difficult to fully exclude?
In some patients with ongoing symptoms, persistent tick-borne infection may remain difficult to fully exclude despite negative or inconclusive testing. These situations can create ongoing clinical uncertainty.
Can neurologic and autonomic symptoms persist after Lyme disease?
Some patients report ongoing fatigue, cognitive impairment, dizziness, exercise intolerance, neuropathy, and autonomic symptoms even after treatment.
Inside Lyme Podcast Series
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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). Jan-Mar 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.