Joseph Shawfield
56-year-old male · presenting for rheumatology / infectious-disease review
Age56
SexMale
Weight250 lb
BuildMuscular / athletic for size
OccupationSoftware developer (extended sitting; not sedentary otherwise)
LocationVolusia County / Longwood, FL
Phone407-223-0115
Primary careJenna Wimmer — Hope & Help, Winter Park, FL
Patient ID542571 (Quest)
Prepared2026-06-22
This is a patient-prepared summary assembled to organize a multi-month history for clinical review. It is not a diagnosis and does not replace clinical judgment. Every value below links to its source lab report. Précis structures this patient self-documentation to secure FHIR R4 / US Core standards, with export to Epic, AWS HealthLake, and other FHIR endpoints.
Overview
at a glance32.5
CRP mg/L HIGH · ref <8.0source
11.3
WBC K/µL HIGH neutrophilicsource
Neg
RF · CCP · ANA all negativesource
Neg
Tick-borne panel (4 organisms)source
One-line picture
New-onset symmetric swollen hands and wrists with diffuse myalgia and fatigue, on a background of years of tick exposure and a persistent eschar. Markedly elevated CRP (32.5) and neutrophilic leukocytosis with negative RF, CCP, ANAsource and a negative tick-borne antibody panelsource. Rapid improvement on a short prednisone course, then a severe blistering rash about a week after stopping.
Baseline & relevant history
- Build: muscular / athletic for size, 250 lb.
photo (Note: high muscle mass would usually raise creatinine — yet creatinine is low at 0.64, with a high BUN/creatinine ratio of 28.) - Activity: not a sedentary lifestyle, but extended sitting as a software developer.
- Joints: no prior joint problems other than a knee ACL injury — the symmetric hand/wrist swelling is genuinely new.
- Current medications: Prednisone (recent ~1-week course) and an antihypertensive — Valsartan / Lisinopril (ARB / ACE-inhibitor).
Central question for this visit
Is this seronegative inflammatory arthritis (RS3PE or polymyalgia rheumatica), psoriatic arthritis, gout, or a chronic tick-borne infection — or a combination — and does the new rash change the picture? The steroid-responsive, seronegative, very-high-CRP pattern with untested infection status is the crux.
Timeline
multi-month history~15 YEARS AGO
Bullseye rash (erythema migrans) — treated at the time. Consistent with a prior Lyme infection, establishing a long-standing tick-borne exposure history. prior Lyme
PAST ~2 YEARS
Multiple tick bites with regular outdoor exposure and the same camping location near High Springs, north-central Florida, for yearsUF FL tick map. One bite developed a dark-scab eschar that persisted about 6 months; now healed but still felt at the site.
Animal exposure: multiple animals in the home, including dogs that sleep in the bed — a recognized flea / Bartonella exposure route, relevant to the still-untested Bartonella question. exposure
Animal exposure: multiple animals in the home, including dogs that sleep in the bed — a recognized flea / Bartonella exposure route, relevant to the still-untested Bartonella question. exposure
NOVEMBER 2025 · BIKE WRECK
Bike wreck caused left-side bursitis.
Over the following ~6–8 months, gradually began noticing hip soreness in the girdle, with rolling over in bed becoming hard — a classic girdle / PMR pattern.
Over the following ~6–8 months, gradually began noticing hip soreness in the girdle, with rolling over in bed becoming hard — a classic girdle / PMR pattern.
NOVEMBER 2025 · CARDIO / NEURO EPISODE
A "weird kind" of shortness of breath, heart skipping (palpitations), and possible facial palsy — a separate episode, not related to the bike wreck. May have been driven by severe lack of sleep (sleep was highly affected).
Note for the clinician: facial palsy and palpitations are recognized tick-borne (e.g., Lyme) manifestations, worth weighing despite the negative Lyme antibody.
FEBRUARY 2026 · TICK EXPOSURE AGAIN
Tick bites again in February 2026. exposure
MARCH 2026 · FATIGUE ONSET
By March 2026, feeling tired. Around the onset: myalgia and heavy sore hips (hip bursitis), with malaise and worsening sleep disturbance.
PROGRESSION
Symmetric swelling of the hands and wrists became the dominant feature.
EPISODIC THROUGHOUT
Night sweats and chills. One or more episodes of dark urine. Overnight stiffness that flares after sugar or alcohol and resolves next day. Intermittent gastric symptoms, lightheadedness, mild difficulty focusing on screens.
06/02/2026 · TICK-BORNE PANEL
Tick-borne antibody panel (PlushCare, run by Quest). Lyme, Anaplasma, Babesia microti, and Ehrlichia all negative / not detected. Report notes a blood smear or PCR is recommended for acute Babesia, that a single antibody is not sufficient, and that B. duncani may not be detected by this assay. view results ↓source
06/10/2026 · INFLAMMATORY + METABOLIC PANEL
Drawn before starting prednisone (JasonHealth, run by Quest). CRP 32.5 (HIGH), WBC 11.3 (HIGH) with neutrophilia, RF / CCP / ANA negative, ESR 11 (normal), liver enzymes low/normal, kidney function normal. view results ↓source
AFTER 06/10 DRAW
Started prednisone (about a one-week course). Rapid improvement in the hands.
DURING PREDNISONE WEEK
Possible poison ivy exposure outdoors. Important: there were no skin issues of any kind until this prednisone / ivy week — the rash below is the first and only skin manifestation of this illness. (The old eschar was a separate, long-healed event ~2 years prior.) exposure
~1 WEEK AFTER PREDNISONE
Severe blistering rash resembling poison ivy, as the course ended. Spouse in the same household was unaffected.
photo
photoSymptoms
by system & pattern| Symptom | System | Pattern |
|---|---|---|
| Symmetric swollen hands & wrists | Musculoskeletal | Current · dominant |
| Diffuse body aches / myalgia | Musculoskeletal | Current |
| Heavy sore hips / girdle soreness (hip bursitis) ~6–8 months; rolling over in bed is hard — classic girdle / PMR pattern. | Musculoskeletal | Onset feature |
| Fatigue & malaise | Constitutional | Current |
| Night sweats & chills | Constitutional | Episodic |
| Dark urine | Renal / urinary | Episodic · 1+ episodes |
| Overnight stiffness flares after sugar / alcohol Joints fine the next day (flare fully resolves) — but fatigue/tiredness persists regardless. | Musculoskeletal | Episodic |
| Intermittent gastric symptoms | GI | Episodic |
| Small hernia near the top of the belly button (epigastric / peri-umbilical) | GI / abdominal wall | Noted |
| Lightheadedness on bending over (positional) Positional only — distinct from the "weird" shortness of breath in the Nov 2025 period (see below / timeline). | Neurologic / positional | Episodic |
| Left-side bursitis (after Nov 2025 bike wreck) | Musculoskeletal | Since Nov 2025 |
| "Weird kind" of shortness of breath Around Nov 2025; may have been driven by severe lack of sleep. | Cardiopulmonary | Historical · ?sleep-related |
| Heart skipping (palpitations) | Cardiovascular | Historical · episodic |
| Possible facial palsy Uncertain; recognized tick-borne (Lyme) manifestation despite negative Lyme antibody. | Neurologic | Possible · historical |
| Mild difficulty focusing on screens | Neurologic | Episodic |
| Sleep disturbance — highly affected | Constitutional | Ongoing |
| Healed eschar at old tick-bite site (still felt) | Dermatologic | Resolved · ~6mo |
| Severe blistering rash (post-steroid)photo Only skin manifestation of this illness; appeared only after the prednisone/ivy week. | Dermatologic | New |
Current medications
| Medication | Class / use | Status |
|---|---|---|
| Prednisone | Corticosteroid — for the joint flare | Recent ~1-week course |
| Valsartan / Lisinopril | ARB / ACE-inhibitor — antihypertensive | Ongoing |
Exact prednisone dose and dates to confirm with the patient. ACE-inhibitor/ARB therapy is relevant to interpreting creatinine, eGFR, and the BUN/creatinine ratio.
Labs & Results
structured · abnormal flagged · raw report one tap awayInflammatory & Metabolic Panel
· Collected 06/10/2026 · Fasting · Quest (JasonHealth) · Specimen TZ493654G · drawn BEFORE prednisone| Test | Result | Reference | Flag |
|---|---|---|---|
| C-Reactive Protein (CRP) | 32.5 mg/L | < 8.0 | HIGH |
| White Blood Cell count | 11.3 K/µL | 3.8–10.8 | HIGH |
| Absolute Neutrophils | 8373 /µL | 1500–7800 | HIGH |
| Neutrophils % | 74.1 % | — | |
| Creatinine | 0.64 mg/dL | 0.70–1.30 | LOW |
| BUN / Creatinine ratio | 28 | 6–22 | HIGH |
| AST | 9 U/L | 10–35 | LOW |
| ALT | 7 U/L | 9–46 | LOW |
| ESR (Westergren) | 11 mm/h | ≤ 20 | normal |
| Glucose (fasting) | 99 mg/dL | 65–99 | normal |
| BUN (Urea Nitrogen) | 18 mg/dL | 7–25 | |
| eGFR | 112 | ≥ 60 | normal |
| Hemoglobin | 13.5 g/dL | 13.2–17.1 | |
| Hematocrit | 42.0 % | 39.4–51.1 | |
| Platelets | 342 K/µL | 140–400 | |
| Sodium | 142 | 135–146 | |
| Potassium | 4.6 | 3.5–5.3 | |
| Calcium | 8.9 | 8.6–10.3 | |
| Albumin / Total protein | 4.2 / 6.7 | 3.6–5.1 / 6.1–8.1 | |
| Bilirubin / Alk phos | 0.4 / 52 | 0.2–1.2 / 35–144 |
Autoimmune / Rheumatology Serology
· Same 06/10/2026 draw| Test | Result | Reference | Flag |
|---|---|---|---|
| ANA Screen, IFA | Negative | Negative | neg |
| Rheumatoid Factor | < 10 IU/mL | < 14 | neg |
| CCP Antibody (IgG) | < 16 | < 20 = neg | neg |
Lab interpretation: no serologic evidence for rheumatoid arthritis (RF and CCP each ~65–70% sensitive for established RA). A negative ANA IFA suggests an ANA-associated autoimmune disease is not present at this time, but is not definitive.
Tick-Borne Disease Antibody Panel (w/ reflexes)
· Collected 06/02/2026 · Quest (PlushCare) · Specimen TZ306189G| Organism | Result | Flag |
|---|---|---|
| Lyme AB screen (B. burgdorferi) | < 0.90 index — Negative | no evidence |
| Anaplasma phagocytophilum IgG / IgM | Not detected | neg |
| Babesia microti IgG / IgM | Not detected | neg |
| Ehrlichia chaffeensis IgG / IgM | Not detected | neg |
Report caveats: confirmation with a blood smear or PCR is recommended for acute Babesia; a single antibody titer is not sufficient to establish a diagnosis; cross-reactivity is variable and other species such as B. duncani may not be detected by this assay. Antibodies may also be falsely negative early in infection.
Lab Order Requisition
· 06/09/2026 · JasonHealth → Quest (PSC Hold) · ordering provider Leo Damasco, NPI 1134326366Profiles ordered: Comprehensive Metabolic Panel (10231), C-Reactive Protein (4420), CBC w/ differential & platelets (6399), Sed Rate Westergren (809), ANA Screen IFA w/ reflex + Rheumatoid Arthritis Panel (90071). Client-bill, no insurance. Collection: Quest Diagnostics, 10043 University Blvd, Orlando FL.
Clinical Photos
click any image · scroll or +/− to zoom · drag to pan
Still to add: a photo of the healed eschar at the old tick-bite site and the symmetric swollen hands/wrists. Drop them into
case/images/ as eschar.jpg and hands.jpg and they will slot in here and beside their mentions.
Differential
for discussion — weighted, not a diagnosisLeading consideration Seronegative inflammatory arthritis — RS3PE and/or PMR
Supports
- Dominant sudden symmetric swollen hands (classic RS3PE)
- Girdle onset with hip bursitis — PMR characteristically produces hip and shoulder bursitis
- Very high CRP (32.5) with negative RF, CCP, ANAsource
- Rapid response to steroids
Against / to clarify
- ESR normal at 11 (CRP is the driving marker here)
Psoriatic arthritis
Supports
- Raised by the new skin eruption; seronegative pattern fits negative RF/CCP/ANA
- Causes swollen digits and hands
- Stopping systemic steroids can trigger a psoriasis flare
Would clarify
- A dermatologic diagnosis of psoriasis would meaningfully support this
Crystal arthropathy (gout)
Supports
- Sugar- and alcohol-triggered overnight flares fit a crystal pattern
Gap
- Uric acid has not been tested (best measured at baseline, not mid-flare or freshly on steroids)
Chronic tick-borne infection
Supports
- Prior treated Lyme (bullseye / erythema migrans ~15 years ago) plus repeated tick exposure and a prior eschar — a long tick-borne history
- Bartonella — chronic, multi-system course NOT TESTED
- Spotted-fever group Rickettsia — matches the prior eschar NOT TESTED
- Being on prednisone raises the importance of excluding active infection
Note
- Standard tick panel (Lyme/Anaplasma/Babesia/Ehrlichia) negativesource, but Bartonella & Rickettsia were not on it, and antibody assays can miss B. duncani and early infection
Recommended Next Tests & Steps
- Uric acid — gout question; best at baseline, not mid-flare or freshly on steroids.
- Bartonella antibody panel, with PCR if indicated.
- Spotted-fever group Rickettsia IgG and IgM.
- Hepatitis B surface antigen + core antibody, and Hepatitis C — given steroid use.
- Urinalysis — for the prior dark-urine episodes.
- Repeat CRP — confirm it is falling on or after steroids.
- Rheumatology evaluation of the swollen hands.
- Dermatology evaluation of the rash (blistering rashes are diagnosed visually).
Questions for the Doctor
- Is this seronegative inflammatory arthritis (RS3PE or PMR), psoriatic arthritis, gout, or a chronic tick-borne infection — or a combination?
- Does the skin eruption change the diagnosis, for example toward psoriatic arthritis?
- Should I be on a longer steroid taper, and is that safe given the untested infection status?
- Which specialist should coordinate this workup?
⚠ Safety Notes
escalation guidance, not reassurance- Seek urgent care if the blistering rash involves the mouth, eyes, or genitals, spreads rapidly, or comes with fever or feeling systemically unwell.photo
- Dark-urine episodes were reported — worth confirming the cause (hemolysis, muscle, liver) is excluded; a negative tick panel does not by itself explain them.
- Active infection is not yet excluded (Bartonella, Rickettsia untested) while on steroids — flagged for the clinician's attention.
Source Documents
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