Friday, November 7, 2008

Patient with positive serology for 4 tick borne infections and surprising presentation

A 50 something year old male patient joined my general family practice about 3 and 1/2 years ago. He was fairly healthy but described an unusual history. Some months before he suffered a rib fracture. His orthopedic surgeon prescribed miacalcin, the hormone calcitonin, to speed up the healing of his fracture. He developed acute psychiatric symptoms. He became depressed and then manic. He was diagnosed with bipolar disease and anxiety precipitated by calcitonin. Over the next two years his psychiatric disorder worsened and he was placed on an increasing number of psychotropic agents by various psychiatrists, who were somewhat miffed by the odd atypical presentation in this man.

A little over one year ago he came to me office complaining of skin discoloration. He had two rashes. One was a classic EM rash on the right thigh.

A little more history. He was an avid deer hunter. He did have some fatigue and neck pain. He did recall a brief, minor episode of fever and chills three months preceding the rash. Besides the psychiatric symptoms he was generally robust and felt quite well.

Blood samples were sent to Quest Diagnostics: The CBC was normal. B12 and folate were normal. His vitamin D levels were normal. Babesia microti- elevated IgM titer. Bartonella Quintant- elevated IgM titer. Anaplasmosis phagoctytophilum- very high IgM titer. Borrelia burdorferi- Western Blot- 9/10 IgG bands and 3/3 IgM bands. Lyme C6 antibody index- over 6.0.
At this point his psychiatrist had him on Depakote- a mood stabilizer 1750mg per day (a very high dose), Seroquel- an anti-psycotic used for severe mania and Klonopin, a tranquilizer used for anxiety and the anti-depressant Lexapro.

He came to my office to review the lab results. He looked remarkably well. I felt like I needed some of his Klonopin to figure out how to treat him.(Humor- if the board is reading this). I stared with Zitromax and Mepron for 3 weeks only. At that point his neck pain was gone. He had no chills or flu like symptoms. He had only mimimal fatigue and nominal joint pains- mostly knees. His mood swings were perhaps a little better. He was treated with a month of Amoxil one gram twice daily and Cipro 500 mg twice daily. No Herx- feeling well. He was treated with Amoxil- same dose and Doxycycline 400 mg per day for 6 weeks. Blood to Labcorp: CD57 120, CBC- WBC count 5.2 (normal) but new right shift. This means there were more lymphocytes and fewer neutrophils than usually seen. The Lyme WB showed IgG bands 10/10, IgM 2/3
bands. Bartonella, Babesia and Ehrlichia were negative. The C6 titer was 5.5. The folic acid level had increased from 18 to greater than 24. He was not taking vitamins. After 12 weeks Flagyl was added. He was now taking Amoxil- same dose, Doxyclycine- same dose and Flagyl 500 mg daily. His energy level was normal. He had not medical symptoms. His psychiatric symptoms were improving quickly and his pychiatrist was quickly weaning him from psychotropic medicines. After an additional 8 weeks his Doxycycline was changed to Biaxin. He had no symptoms related to tick borne illness, except mild anxiety and mood swings.

Six months after his first presentation, still on the same antibiotics, his psychiatrist had stopped Depakote and Seroquel. The dose of Klonopin was in a process of being tapered off. He was still on Lexapro. Two months later he was off Klonopin. His prior antibiotics were discontinued. He was changed to Minocin 100 mg twice daily. Most recent labs: Lyme WB IgG 9/10, IgM 1/3. CBC- no change- persistent right shift, C6 index- 5.2. Routine labs including autoimmune and markers for inflammation are normal.

His "Bipolar" disorder is in remission.

He is convinced it all started with that darn Miacalcin. The PDR states that Miacalcin is synthetic calcitonin, a hormone secreted by the parathyroid glands. It's primary effect is to strenthen bone by inhibiting the activity of osteoclasts, the cells which remove bone matrix. It is rarely reported to cause depression and anxiety: reasons unknown. It has not been linked to bipolar disease. Does it have a feedback effect on vitamin D or cell mediated immune functions? This has not been reported.

The psychiatric symptoms preceeding the acute typical presentation of Lyme and tick borne illness by some years.

I suspect he had chronic Lyme causing an atypical psychiatric disorder with superimposed acute re-infection. Miacalcin? A red herring?

He is in his mid 50s. He is the picture of health. He has no physical or cognitive limitations. He mountain bikes miles. And by the way, he still hunts deer.

7 comments:

dogdoc said...

Neat case. Animal models show calcitonin induces greatly increased active vitamen D 1,25 DHCC production by the kidney. Lot of research interest it looks like in role of Vitamen D for adjunct immunosuppression in various disorders- RA, MS, SLE, CD, ect. with many positives results. ? vit D altered immunity and brought out chronic LD and psyc signs then picked up other TBD from new bite? ? unrelated entirely and coincindental.

Lyme report: Montgomery County, MD said...

I don't know where you get all this great information. Thank you. The B12 folate stuff is great. The famous LLMDs don't know anything about it. These simple markers may be a great way of screening for blood borne co-infections.
Here's a snapper. Patient with wildly out of control neuroborreliosis and everything else bad Lyme can do: Blood smear shows large number of coccobacilli which stain gram negative. Species Bartonella PCR negative. Dr. Kilani is going to do a 16S DNA fingerprint test. I don't have time to discus her case. I have only seen her twice. Of course it's easier to post success stories. I have a pile of charts on my desk- when I find the time.

I'm off for the weekend.

dogdoc said...

Internet has turned out to be an amazing resource- when you get good with the different search engines, you can quickly pull up studies from around the world. Many teaching hospitals and universities post up for student use, many lecturers have their powerpoints up, most journels and medical societies have their current issues and commentaries up, ect Before last July, I didn't know all of this even existed. It sure changes research. I'm lucky in that I read read and assimilate/ link info fairly rapidly - my normal rate again finally.
I think you posted the B12 stuff just to have me look it up (smile). Seriously, I am interested in all potential pieces of the puzzle. I'll work on the gram negative coccobacilli- are they entirely extracellular or intracellular as well? Have a great weekend!

atomicdoc said...

Hello,

I just came across this web site, thanks for putting this information up. When I get the time I'll scan through the older postings and comment if I think there is anything that might be of interest.

I don't know about the calcitonin, maybe or maybe not the trigger (how bad was he injured at the time).
I'm guessing that there was something dormant that was triggered during the first injury and once established it progressed.

The left shift is interesting and I wonder if there was/is a viral component to the whole picture rather than recrudescent quiesent bb (the use of the word "chronic" is not well recieved by the ID community so I like to speak their vernacular instead...).

Anyways, I suspect that with the recent infection the previously resident infection was overrun with the new infectious process. Im guessing that it basically supressed the previous agent (this effect has been studied a lot in the bio-warfare/pandemic mitigation areas ie. pre-infect the population with one disease(hopefully a controllable and treatable one) to quench another uncontroallable, untreatable or hard to treat disease).

Hopefully the original infection is totally gone and will not recrudess once the tick born portions are eliminated.

In this regard, from some case histories I have seen the effect where bb seems to be able to supress viruses in particular. I don't know if this is the adjuvant effect of the bb proteins or not but may very well be tha case. I have come across a well written publication from the early days of lyme where the adjuvant effect and corresponding effect on the micro vasculature of the brain was well documented. This ties into some recently published data where blood flow anomolies and its effect on the micoganglia has been linked to psycotropic disorders (See PS below) and may support the anti viral adjuvant concept

This virus suppression effect also seems to occur with other bacteria that have moderate to strong adjuvant effect. In particular it has been reported that controlling bacteria infections in swine has resulted in a corresponding increase in viral infection. I have often wondered if this effect was not the result of effect of the antibiotic on the immunue response but rather the removal of the immune stimulating adjuvant being released by the bacteria.

PS.
It would have been interesting to see if there were any nuclear studies done during the bi-polar stage. A paper that was just released has claimed a high co-relation between certain types of hypoperfusion/hypometabolism and bi-polar as well as schizophrenia disorders and I have often wondered if this may have an infectious link. This case may be very relevent to this area.


In any case, thanks for posting this stuff and to the dogdoc for his input. Im interested in what you find about the gram neg bacteria.

Lyme report: Montgomery County, MD said...

I have seen Lyme patients present with almost every known psychiatric syndrome. The perfusion deficits vary. Frequently they are frontal temporal at other times they are more parietal. ADD, anxiety and depressive syndromes are much more common than bipolar syndromes. Dementia is the big issue.
All I can say is that effective anti Bb therapy improves many of these psych disorders.

I don't know much about the role of viruses. I do know that Lyme infection seems to activate long dormant viruses. I can work the other way as well. Docs have looked at the role of CMV, EBV and HHV 6. I generally avoid this realm. I am a clinician and have nothing effective to offer.

FunkOdyssey said...

You have nothing to offer for viruses? What about anti-virals -- valcyte, etc? I've heard anecdotal reports of improvement in Lyme patients with anti-viral drugs when viral titers were high.

Lyme report: Montgomery County, MD said...

I've got enough problems prescribing antibiotics. I will leave Valcyte to someone else. As far as I know, California is the only state which gives doctors the freedom to prescribe experimental drugs like Valcyte. It is toxic and requires close monitoring. It may very well work for CFS associated with EBV and other chronic infections. I wish you luck finding a physician who can prescribe it for you.