Monday, December 8, 2008

Lyme and a thrombotic Herxheimer reaction?

A new patient came to see me for chronic Lyme disease. The scenario was classic: history of tick bites, positive lab results and typical symptoms. He was in his late 50's. He had no history of thrombotic or cardiovascular disease. Shortly after starting antibiotic therapy he was admitted to a hospital for a myocardial infarction
(heart attack). During this hospital stay he also develop a blood clot in a leg which broke off and lodged in a lung (pulmonary embolism).

He was tested for medical causes of increased blood clotting- hypercoaguable state.
There are many genetic causes. There are also acquired causes. He tested positive for "lupus circulating anticoagulant"- this an acquired cause with genetic predisposition. His hematologist told him he may have lupus.

Lupus is a clinical disorder with a complex of symptoms and findings. He clearly does not have lupus. Circulating lupus anticoagulant is associated with autoimmune disease such as systemic lupus and other similar disorders. Infection is also a potential cause of this clotting disorder. Lyme is associated with increased autoimmunity as well as increased coagulation due to pro-inflammatory cytokine responses.

Generally antibiotics have anti-inflammatory effects. This is not always the case. For example, treatment recommendations for ulcerative colitis- an inflammatory bowel disorder includes the antibiotics Cipro and Flagyl. On the other hand, the use of antibiotics with the other inflammatory bowel disease- Crohn's disease may provoke a flare- (A pro-inflammatory effect?)

These pro-inflammatory and anti-inflammatory effects are hard to predict. There is the issue of timing and a variable impact on even similar autoimmune disorders. There are many influences which may tip the balance of the immune response.

Herxheimer responses are associated with a pro-inflammatory response. It is necessary to rev up the immune system before treatment can be successful.
It is well established that these effects can be quite negative in the short run. They generally cause no permanent impairments. It is the storm before the quiet.

I must entertain the possibility that this patent's heart attack and pulmonary embolism were directly related to an unexpected Herx. An autoimmune process was triggered which increased blood clotting leading to these two events. Thankfully the patient is no worse for the wear.

I would rather chalk it up to a coincidence. Unfortunately (for me), I don't believe in coincidences.

4 comments:

dogdoc said...

Hi Doc, Can you test ahead for the hypercoag state accurately enough to tell? I read of heparin therapy being used as a Th2-Th1 shifter in patients that already have hypercoag state. Would simple aspirin type tx help- is it a platelet aggregation phenomenon in people?

lymie said...

Some people use a hemex panel to detect hypercoagulation.

Claire said...
This comment has been removed by the author.
Claire said...

Goodmorning LymeMD,

My daughter has the anti-coagulating Lupus thing too. Her Neurologist actually just found it last month. She tested negative for lupus on his testing, however. He suggested a Hematological evaluation.

The thing is, she has been under the care of a Hematologist this whole time (past 3 years), due to severely low RBC's (treating with procrit, iron infusions and B12 shots due to deficiency), her Hematologist said a few months ago her Lupus anti-coagulant was normal?

Perhaps your theory is correct than? Maybe its from a herx?

My daughter has a severe case of Lyme/Babesia - positive tests. (also suspected "BLO"- negative Bart. test)

This is very interesting, Thank you for your blog, I find it fascinating!