This 30 year old patient was well until 2 months after she had noticed a tick bite on the top of her head. Then, over time, she developed a coterie of familiar symptoms: fatigue, migratory joint pains, both large and small joints, headaches, numbness and tingling, muscle pain, brain fog, memory loss, confusion, trouble recognizing objects and performing mathematical calculations, lability of mood, night sweats, numbness and tingling, itching and others.
These symptoms waxed and wanted in various proportions over a six month period before I met her several weeks ago.(During this time she had been treated by two LLMDs).
To many readers the diagnosis is not in doubt.
So what does the lab say?
Prior Western Blots performed by Labcorp found, IgM band 23 and IgG band 41 alone.
A repeat by Stony Brook found IgM bands, 18,28,41,58,72,93 and IgG bands 58,62 and 93.
Even though Stony Brook identified 6 IgM bands, no 23 band was found. However, the 93band turned up in both the IgM and IgG series.
Both the 23 and 93 bands are considered so Lyme specific that for some ppractitioners either alone can suffice to cinch the diagnosis.
Of note: other bands such as 18 also vary by lab.
This was on my desk today.
I am not promoting any specific Laboratory.
Thursday, March 15, 2012
Wednesday, March 14, 2012
Western blot biases
I think I have this one right.
Western Blot kits are either store bought or produced internally. These difference seem to lead to preferential expression of bands ostensibly related to variable degrees of antigenic expression.
Clongen and Labcorp (using the same kit) express more 23 bands.
Stony Brook expresses more 93 bands
IgeneX expresses more 30,31 bands.
Perhaps they are all correct.
I have found this helpful in my efforts to reconcile the different reports.
Western Blot kits are either store bought or produced internally. These difference seem to lead to preferential expression of bands ostensibly related to variable degrees of antigenic expression.
Clongen and Labcorp (using the same kit) express more 23 bands.
Stony Brook expresses more 93 bands
IgeneX expresses more 30,31 bands.
Perhaps they are all correct.
I have found this helpful in my efforts to reconcile the different reports.
Pacemaker
I will briefly present two patients with Lyme carditis and heart block. The first patient was urgently admitted to the hospital ICU with a heart rate of 18 twelve years ago. While the cardiologist prepared placement of a permanent pacemaker a Lyme test came back positive. A temporary pacemaker was placed and the patient improved. This patient developed an allergy to Rocephin and IV therapy was stopped prematurely. All told, his treatment included two weeks of Rocephin and another two weeks of oral doxycyline. I saw him this week. He is in robust health.
The second patient was not as lucky; I am treating her now. She too developed complete heart block, two years ago. A permanent pacemaker was placed. Her Lyme test was not CDC positive. She went on to develop a host of symptoms. Lyme was diagnosed by another LLMD. She had already failed months of oral therapy when we first met. She has started contemplating disability. She had miserable endurance and a brain that was not working. A SPECT scan showed diffuse hypoperfusion in both hemispheres.
First we treated for Babesia until the night sweats and flu like symptoms abated and then we started an intensive regimen of IV antibiotics, eventually to include 3. Six months down the road her brilliant brain is back. We are both thrilled. (Insurance only covered the first two months; she has gone broke in the process). Endurance still stinks and is ever so slowly improving. Ups and downs - going in the right direction. She still needs long periods of rest for recovery after only minimal activity.
She is half way through the disability process - now what?
A good quandary.
The second patient was not as lucky; I am treating her now. She too developed complete heart block, two years ago. A permanent pacemaker was placed. Her Lyme test was not CDC positive. She went on to develop a host of symptoms. Lyme was diagnosed by another LLMD. She had already failed months of oral therapy when we first met. She has started contemplating disability. She had miserable endurance and a brain that was not working. A SPECT scan showed diffuse hypoperfusion in both hemispheres.
First we treated for Babesia until the night sweats and flu like symptoms abated and then we started an intensive regimen of IV antibiotics, eventually to include 3. Six months down the road her brilliant brain is back. We are both thrilled. (Insurance only covered the first two months; she has gone broke in the process). Endurance still stinks and is ever so slowly improving. Ups and downs - going in the right direction. She still needs long periods of rest for recovery after only minimal activity.
She is half way through the disability process - now what?
A good quandary.
Monday, February 27, 2012
ADD and Herbs
A 56 year old heretofore high functioning business executive presented with multiple cognitive difficulties, primarily impaired executive function. Information presented to the brain was poorly processed. Watch for ADD or ADHD called "adult onset" ADD. There is no such thing. Adult ADD is the continuation of childhood disease. True ADD presents during early childhood and is generally associated with a family history. Symptoms may include: brain fog,trouble focusing, inattentiveness, spotty memory loss, inability to winnow out key information, slow problem solving, loss of mathematical and/or verbal skills, trouble following conversations, impulsively and others.
The SPECT scan in ADD and Lyme may show similar findings: decreased activity in the frontal lobes. In both cases, dopaminergic (drugs that promote dopamine neural pathways) may be of benefit.
In this case, fatigue, low grade fevers and joint, muscle pain, headaches and strange neurological symptoms including formications, ( feeling of something crawling under the skin) were also present.
And there was a positive Western Blot.
This highly intelligent patient at first did not want to learn about Lyme disease. "Just treat me as you see fit. Your the doctor." I explained to her it was critical she become Lyme literate. Its not as simple as bringing your car to the garage.
After two months she showed signs of improvement. At three months she was doing superbly.
She confided in me. She had added Samento, Banderol, Reservratol and Astralagus to the antibiotics: her own special mix. I guess she had been doing a little reading.
I pay attention to what my patients are taking. Some use the Cowden protocol. Other follow Buhner. Others take a hodgepodge of herbs such as: mushroom extract, olive leaf oil, oregano oil, teasel root - the list goes on. Many take a variety of vitamins and other non-herbal supplements. There is no one size fits all. My colleague who practices traditional Chinese medicines uses combinations of herbs, many not found on standard lists. He alters the mixes based on his clinical assessment of each patient. He has remarkable success. A lot like I do with antibiotics.
Successful CAM herbalist have studied there trade for years.
It seems online forums are replete with comments like "did you take this, did you take that, did it work for you?" Here's a hint. Folks who are better don't spend a lot of time on forums.
Do yourself a favor: please seen an expert.
The SPECT scan in ADD and Lyme may show similar findings: decreased activity in the frontal lobes. In both cases, dopaminergic (drugs that promote dopamine neural pathways) may be of benefit.
In this case, fatigue, low grade fevers and joint, muscle pain, headaches and strange neurological symptoms including formications, ( feeling of something crawling under the skin) were also present.
And there was a positive Western Blot.
This highly intelligent patient at first did not want to learn about Lyme disease. "Just treat me as you see fit. Your the doctor." I explained to her it was critical she become Lyme literate. Its not as simple as bringing your car to the garage.
After two months she showed signs of improvement. At three months she was doing superbly.
She confided in me. She had added Samento, Banderol, Reservratol and Astralagus to the antibiotics: her own special mix. I guess she had been doing a little reading.
I pay attention to what my patients are taking. Some use the Cowden protocol. Other follow Buhner. Others take a hodgepodge of herbs such as: mushroom extract, olive leaf oil, oregano oil, teasel root - the list goes on. Many take a variety of vitamins and other non-herbal supplements. There is no one size fits all. My colleague who practices traditional Chinese medicines uses combinations of herbs, many not found on standard lists. He alters the mixes based on his clinical assessment of each patient. He has remarkable success. A lot like I do with antibiotics.
Successful CAM herbalist have studied there trade for years.
It seems online forums are replete with comments like "did you take this, did you take that, did it work for you?" Here's a hint. Folks who are better don't spend a lot of time on forums.
Do yourself a favor: please seen an expert.
Tuesday, February 14, 2012
Remission. Brown Recluse Spider
This 62 year old female went to a local ER complaining of a bite and a painful red rash with a high fever. She looked toxic and was admitted to the hospital. The rash was somewhat mysterious. She was seen by three different ID doctors who ultimately diagnosed staph cellulitis secondary to the bite of a Brown Recluse Spider. Neat diagnosis. After a few days she was discharged from the hospital.
She developed other symptoms and sought care elsewhere: joint pain, brain fog, severe headaches, numbness and tingling and others. She had periods of frank confusion. At times she was unable to speak.
Two LLMDS diagnosed Lyme and Babesia. She was treated aggressively, inclusive of several months of intravenous Rocephin. Eighteen months later, 70% improved, she walked into my office.
She was treated another 7 months. That was two years ago.
Today she came in for a non-Lyme issue - in complete remission for two years.
Brown Recluse Spiders do not live in Maryland. Their habitat includes the Midwest and the south.
Even if they lived here - they are generally docile and bites are rare. But they don't live in Maryland. Never have.
Still, this is a common diagnosis.
Brilliant.
She developed other symptoms and sought care elsewhere: joint pain, brain fog, severe headaches, numbness and tingling and others. She had periods of frank confusion. At times she was unable to speak.
Two LLMDS diagnosed Lyme and Babesia. She was treated aggressively, inclusive of several months of intravenous Rocephin. Eighteen months later, 70% improved, she walked into my office.
She was treated another 7 months. That was two years ago.
Today she came in for a non-Lyme issue - in complete remission for two years.
Brown Recluse Spiders do not live in Maryland. Their habitat includes the Midwest and the south.
Even if they lived here - they are generally docile and bites are rare. But they don't live in Maryland. Never have.
Still, this is a common diagnosis.
Brilliant.
Wednesday, February 8, 2012
Low back pain
A 40 year old female awoke one morning finding she could not get out of bed - sudden incapacitating back pain - and other symptoms: severe muscle weakness and pain, numbness and tingling. Called 911. ER docs diagnosed acute back pain and sent her home - but also pulled some blood.
The phone rang a few days later. Lyme. Two tier CDC positive She had more symptoms: increasing joint pain, headaches, neck pain, sweats, and others. No brain fog to write home about. Pre-existing migraines became more frequent and severe. Back pain was exquisite.
An MRI showed a bulging lumbar disc. An orthopedist and chiropractor were satisfied.
Physical therapy and chiropractic manipulation did not help.
Oddly enough, the back pain improved with antibiotics. And nearly went away.
After one year of treatment for Lyme and co-infections, she stopped antibiotics - on her own, feeling better.
Now, a year later, she returns. Back pain has increased. Tingling, numbness, joint pains, jaw pain and low grade fevers are back. Migraines bad again.
She is worried Lyme is back. So am I.
A zillion people have bulging discs. Studies have shown that many asymptomatic people have herniated discs per MRI. (including me - I had sciatica years ago)
When the chief complaint is back pain Lyme is low on the list of differential diagnoses. It is the constellation of symptoms, taken as a whole, that changes the list Unfortunately, most doctors stop with the chief complaint and do not go any further. Other symptoms are for another day. If there are too many symptoms patient may be labeled "a crock." "High serum porcelain level" I heard in medical training. And God forbid the patient utter the word Lyme.
Bulging discs don't generally hurt. There are tons of causes of low back pain. Frequently, the cause is never known. Not in this case.
Kudos to the ER docs.
The phone rang a few days later. Lyme. Two tier CDC positive She had more symptoms: increasing joint pain, headaches, neck pain, sweats, and others. No brain fog to write home about. Pre-existing migraines became more frequent and severe. Back pain was exquisite.
An MRI showed a bulging lumbar disc. An orthopedist and chiropractor were satisfied.
Physical therapy and chiropractic manipulation did not help.
Oddly enough, the back pain improved with antibiotics. And nearly went away.
After one year of treatment for Lyme and co-infections, she stopped antibiotics - on her own, feeling better.
Now, a year later, she returns. Back pain has increased. Tingling, numbness, joint pains, jaw pain and low grade fevers are back. Migraines bad again.
She is worried Lyme is back. So am I.
A zillion people have bulging discs. Studies have shown that many asymptomatic people have herniated discs per MRI. (including me - I had sciatica years ago)
When the chief complaint is back pain Lyme is low on the list of differential diagnoses. It is the constellation of symptoms, taken as a whole, that changes the list Unfortunately, most doctors stop with the chief complaint and do not go any further. Other symptoms are for another day. If there are too many symptoms patient may be labeled "a crock." "High serum porcelain level" I heard in medical training. And God forbid the patient utter the word Lyme.
Bulging discs don't generally hurt. There are tons of causes of low back pain. Frequently, the cause is never known. Not in this case.
Kudos to the ER docs.
Thursday, February 2, 2012
25 band Doxycycline
A patient has joint pain, unimpressive, and otherwise doesn't looke "Lymie."
Stony Brook's Lyme WB reports 41 and 25 IgM bands, interpreted as negative by CDC criteria.
IgenX reports the "23-25" band as a single entity and would have reported the result as CDC positive.(I think).
Bands 22,23,24 and 25 have been associated with highly specific Osp C.
Labcorp reports only the 23 band, not the 25.
Interpreting these results in a low index of suspicion case could be tricky.
Question: Is it reasonable to use IgenX criteria when interpreting results from a different lab?
After 3 weeks of doxycycline patient feels better.
Does the patient have Lyme? Is there any harm treating if Lyme seems unlikely?
It is nice to know that unlike other tetracycalines, doxycyline is excreted in the feces (not the kidneys as well) mostly as inactive conjugates or chelates - having minimal effect on intestinal flora. (Goodman and Gilman).
Other Lyme non-believers believe doxycyline and minocyline are effective for arthritis, even rheumatologist. Gabe Mirkin thinks these drugs work because mycoplasm,chlamydia and others are associated with "reactive arthritis."
Reactive arthritis is a "real" entity described in Harrison's textbook of medicine. Of course long term antibiotics are not recommended.
Stony Brook's Lyme WB reports 41 and 25 IgM bands, interpreted as negative by CDC criteria.
IgenX reports the "23-25" band as a single entity and would have reported the result as CDC positive.(I think).
Bands 22,23,24 and 25 have been associated with highly specific Osp C.
Labcorp reports only the 23 band, not the 25.
Interpreting these results in a low index of suspicion case could be tricky.
Question: Is it reasonable to use IgenX criteria when interpreting results from a different lab?
After 3 weeks of doxycycline patient feels better.
Does the patient have Lyme? Is there any harm treating if Lyme seems unlikely?
It is nice to know that unlike other tetracycalines, doxycyline is excreted in the feces (not the kidneys as well) mostly as inactive conjugates or chelates - having minimal effect on intestinal flora. (Goodman and Gilman).
Other Lyme non-believers believe doxycyline and minocyline are effective for arthritis, even rheumatologist. Gabe Mirkin thinks these drugs work because mycoplasm,chlamydia and others are associated with "reactive arthritis."
Reactive arthritis is a "real" entity described in Harrison's textbook of medicine. Of course long term antibiotics are not recommended.
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