Tuesday, July 14, 2009

Babesia questions

For convenience we can divide physicians into two camps: those who follow the IDSA and those who follow ILADS. This is an over-simplification. Many physicians fall in between. I am seeing more infectious disease physicians cross over into the chronic Lyme side of things. Many other physicians are becoming more interested in treating Lyme as a chronic disease and treating it as such. The paradigm has broadened for many of us; chronic Lyme has evolved into chronic tick borne disease. Many patients do not improve or recover, at least not fully, unless other co-infections are treated as well. The treatment of co-infections exposes Lyme aware physicians to increased criticisms by IDSA leaning physicians because the presence of these entities is frequently more difficult to demonstrate than Lyme--Borrelia burdorferi.

Readers must be reminded that in the main, laboratory evidence suggesting the presence of Babesia tells the physician only one thing: the patient has been exposed to Babesia. Here I am referring to serological antibody tests. Other, more convincing tests, for the non-believers, include a blood smear which shows the organisms or a FISH test offered by IgeneX. These tests are not particularly sensitive missing most cases. Serologically, we can test for two strains of Babesia through commercial labs: B. microti and B. duncani. There are numerous other strains of Babesia for which no simple test exists. Clongen lab can perform a Babesia "species" PCR test which is very specific but not all that sensitive. It screens for the presence of Babesia DNA for about 15 species of Babesia.

In routine lab panels described elsewhere, anybodies directed against B. microti and B. duncani or WA1 are routinely obtained. It is always nice to have one's clinical suspicions mirrored in a laboratory test. But like most things Lyme: the diagnosis of Babesiosis is a clinical one.

Many clinical signs and symptoms have been ascribed to Babesiosis. In my practice the primary symptom is sweating. Patients have night sweats, sweats after a hot shower, day sweats or chills and flu like symptoms which recur cyclically. A secondary feature is muscle pains in preference to joint pain.

Another helpful test is the evaluation of a wet mount slide. Many patients show a crescent shaped organism which resembles Toxoplasmosis. I do not believe this organism is Toxo: many patients with the organism have negative serology (antibodies) directed against Toxo. I will explain why I mention this finding in connection with Babesiosis in a moment.

The standard treatment for Babesiosis has been Mepron, usually combined with Zithromax.
Mepron is a yellow liquid which is unpleasant tasting and very expensive. It contains a single ingredient: Atovaquone. Malarone, on the other hand, contains two anti-parasite ingredients: Atovaquone and Proguanil. Malarone is a less expensive, convenient tablet.

Malarone seems to address this crescent shaped parasite whereas Mepron does not. It is my suspicion that this other, yet unknown parasite, is responsible for much muscle pain, including that associated with fibromyalgia syndromes.

Even though the dose of Atovaquone in Malarone is only 1/3 of that present in Mepron, I have found it is effective for Babesia symptoms. My experience has informed me that it is the length of therapy, not the dose of Atovaquone which helps ameliorate Babesia related symptoms and presumably infection. Anti-Babesia or parasite therapy can be augmented by adding the herbal medicine, Artemsin, usually 200mg twice daily.

So yes, there are more positive serologies for B. duncani than B. microti here on the east coast which contrasts with the views of local health officials, still, the diagnosis of this syndrome is made strictly on clinical grounds. There exists a subset of patients with antibodies to Babesia who never exhibit symptoms of this infection. Most of these patients improve even though this specific co-infection has not been treated. Presumably, in these cases, the infection was mild and eliminated by a well functioning immune system. Even so, the presence of these antibodies can be used to substantiate the diagnosis of chronic Lyme in patients who are Lyme seronegative: where there is smoke there is usually fire.

A basic rule of thumb which has served me well for over 25 years of medical practice still holds: treat the patient, not the labs.

Another comment: Zithromax is not very is not very effective against Lyme disease; its cousin macrolide Biaxin is. Biaxin is frequently avoided when antibiotics are combined because of its it "sloppy" tendency to cause adverse drug to drug interactions: it doesn't play well with others.

Biaxin may reduce blood levels of Atovaquone by 40%. Still, in patients where the treatment of Lyme is imperative along with the treatment of Babesia, this combination has still been effective in many patients.

Another, quite effective drug can be mixed with Malarone for Lyme disease: Cleocin. But this drug carries its own unique risks, especially C. diff colitis, the nemesis of physicians treating chronic Lyme and related disorders. As always the need for probiotics can not be stressed enough. I prefer the combination of Sacchromyces with an Acidophilus mix.

13 comments:

PJDurda said...

Imugen, Inc of Norwood, MA offers a diagnostic PCR test for babesia infection as well as lyme serology.

Starlings Preschool said...

You note the duration of therapy (with malarone) seems better at getting rid of symptoms than high dose, shorter duration, with Mepron.

What duration of the malarone/artemesinin therapy seems to work for you? Does this crescent shape parasite come with other hallmark symptoms besides muscle pain?

gale said...

dear MD
1.Could you tell the dosis for malarone?

2.Why is it that the finding of this crescent-shaped parasitic organism can not be brought to the attention of medical "authorities"?

hopeforyou said...

Can you please tell me what the shelf life is of Mepron past its stamped expiration date?

Also, I thought that all antibiotics could cause C. Diff. Your comment indicates some are worse than others. Could you please explain?

Thanks!

bitten said...

Just off of IV antibiotics now and very early in my Lyme treatment it was/is muscle pain that is very severe. In the short relapse it is muscle pain in the legs that remains. It was erradicated earlier with Mepron/Zithromax. Maybe I should add Malerone?

Seibertneurolyme said...

LymeMD,

Do you have any new insights on the motile gram negative bacteria that Clongen has observed in many patients? Are the standard bartonella/mycoplasma meds the most effective for this organism?

Things like Levaquin, Cipro, Factive or either Rifampin plus Zithromax or Doxycycline?

Thanks for any updates.

lymie said...

Is it possible that, like other coinfections, the testing for toxoplasma is not all that good, that some strains are not included?

See article here:

http://tinyurl.com/lwsa3b

And here:

http://tinyurl.com/nj3tzd

Jack said...

Dear LymeMD,

I like the way you think.

I've been reading up on S. boulardii fungemia, due to personal experience. It's not pretty. The literature is just beginning to recognize possible problems. S. boulardii can colonize and not only in immunocompromised/ catheterized patients, but also in patients w/ preexisting garden-variety yeast infections. Unfortunately MDs are not on the look out for it and the package inserts are not owning up to the possibility.

Leonie said...

Dear Lyme MD, Can you please let me know how to contact you. I live in Australia and need help. Thanks very much,
Leonie Cent
leoniecent@bigpond.com

Michael said...

I'd love to connect with you, also. I'm in CA and looking for additional help. Please e-mail me on how to contact you at: mgaizutis@yahoo.com.

Thank you...


Michael

James said...

Does lime disease can be treated with antibiotic Biaxin?

ReBorn Again said...

Artemisinin is a great treatment for babesia and far safer than pharmaceuticals!

Kenneth P. said...

LymeMD. Can you talk about whether WA1 can become persistent? What would cause therapy to fail after over 18 months of continuous treatment. What are known causes for a babesia infection that does not resolve with treatment?