Wednesday, March 31, 2010

Co-morbidity

I had a recent conversation with a patient. I told her we need to sort out other co-morbidities. Co-infections? No. This was a new term for this very Lyme literate patient. I was not saying the patient did not have Lyme disease. Not at all. Patients with Lyme disease frequently have a variety of other medical problems which contribute to their illness to varying extents. And, in some cases, it is not Lyme which is making the patient ill, regardless of what the Western Blot says: if the signs and symptoms do not fit -- Lyme may not be the primary issue. Or, perhaps Lyme's contribution to the illness is minor. For example:

Fatigue--profound fatigue, is almost invariably a prominent symptom. What else causes this? Other causes include hypothyroidism, B12 deficiency, anemia, depression and insomnia. After these are excluded, my patients are sent for sleep studies. Sleep disorders are a major cause of fatigue. Lyme patients have higher rates of sleep disorders compared to the general population. Patients may have obstructive sleep apnea (OSA) or central sleep apnea, a brain disease. Sleep apnea is associated with numerous other medical disorders: cardiovascular disease, diabetes and others. Sleep apnea is also associated with neuro-cognitive dysfunction -- sound familiar? And sleep apnea is associated with alterations of immune function. Specifically, high levels of inflammatory cytokines, TNF alpha, interleukins have been measured in these patients. Sleep apnea is a significant co-morbidity which interfers with the healing process.

Oher sleep orders are common as well. Restless leg syndrome is a common cause of poor quality, non-restorative sleep. This condition may be respond to supplementation with high doses of iron, sometimes intravenously, based on ferritin levels (it is not clear why these patients have profound depletion of iron). This movement disorder shares common features with Parkinson's disease, a movement disorder mediated by dopamine deficiency in the basal ganglia, a deep area of the brain. Both disorders are treated with dopamine agonists such as Mirapex. This should not be confused with cortical brain dysfunction--loss of executive dysfunction--related to insufficient dopamine activity in the cerebral cortex. This is treated with dopamine agonists such as stimulants which work in these areas of the brain.

A second sleep test, an MSLT can evaluate for narcolepsy and other disorders. Narcolepsy has been considered a disorder of arousal but is now understood to be a disorder of sleep. This may be effectively treated with Xyrem, a drug which is safe but suffers a bad reputation.

Sleep disorders: a common co-morbidity, cause fatigue and cognitive impairments, as well as mood changes and irritability. Not to say I don't start Lyme therapy early in the process - I must also fix the "non-Lyme" to see what remains.

This is but one example of numerous potential co-morbidities.

Patients may have: rare genetic disorders, rare metabolic disorders - or acquired mutisytem-disorders. One of my patient suffers with stiff man syndrome. This is a rare autoimmune disease caused by destruction of a GABA precursor. Another suffers with a toxic yeast syndrome which mimics chronic Lyme. Neuro-cognitive changes and new onset headaches may be caused a brain tumors or other cancers. It is know that Lyme may be associated with brain tumors.

Medical texts are ripe with esoteric diseases: mystery diagnoses. These are the patients that seek our help. It is not always Lyme.

14 comments:

Gina said...

Thank you - very informative!

bluesdoc said...

Interestingly, my own case demonstrated the opposite (?converse, inverse?) situation. Because I never had weakness or fatigue, my (very experienced) lyme doc thought that despite having LD, that my symptoms (severe brain fog/buzz, pounding heart, back/rib pain, etc) must be from either a co-infection or genetic inability to clear toxins, etc. This perspective delayed an antibiotic full court press, which was eventually effective in lysing symptoms. But the delay was a huge and life-destroying setback. In the long run, all I needed was ILADS doses of doxy/tinidazole. So far, anyway....

Renee K said...

Good post and seems fit my case, the Lyme is there but so are other issues which may have allowed the Lyme to florish..luckily I have a doc who is open to it not being all about the Lyme.

I started feeling much better after addressing sleep, hormone and vitamin and mineral deficiencies months before starting to specifically treat Lyme.

glytzhkof said...

Interesting term, I thought it sounded a bit strong and over the top, but apparently it is a regular medical expression. Co-morbidity.

bobcat said...

Thanks for this important post. Very insightful. These are the things that a lot of us probably need to hear, and I don't mean to diminish the importance of treating Lyme. It's just that we tend to look at Lyme with blinders on. I'm sure most of us have co-morbidities.

Seems like dysatuonomia is another popular co-morbidity (failing the tilt-table test, etc).

bobcat said...

ps--and I wonder if dysautonomia could be a cause for Central Sleep Apnea? I am not very educated, just guessing. I read CSA can have neurological origins. What category of neurology that falls under (be it autonomic, etc), not sure.

LYMELAURA said...
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LYMELAURA said...

Eight in the morning, a complete night without sleeping, what life is this?

MJ said...

"Recently, there have been reported cases of SSRI/SNRI antidepressant drugs and metronidazole induced serotonin syndrome,[18][19] this information is not included on the metronidazole patient information leaflet. SSRI and SNRI antidepressants include Prozac, Lexapro, Celexa, Zoloft, Effexor, etc."
http://en.wikipedia.org/wiki/Metronidazole#Potentially_fatal_serotonin_syndrome

Melissa said...
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seekinghelp said...

Interesting.Did you send your Lyme literate patient to the sleep center. How is he/she is doing. This is my condition I should talk to my LLMD. I am gald that you are trying to do something. I have seen many doctors who just prescribe a sleep medicine.

Rev Deb said...

My son is 33 and has been treating Lyme for 3 years. he was recently put on i.x. rocephin, 1 gram, but says this is causing suicidal thoughts and wants to stop. I think the suicidal thoughts are realted to the Lyme disease and the die off from the toxins and think he should stay on the rocephin. Have you heard of rocephin causing suicidal thoughts?

Andrew said...

Hi there.

I've recently been diagnosed with Lyme and I've found your blog to be really informative and articulate. Thank you so much. In my case it's taken two years of seeing different doctors before finally getting the diagnosis. I've been writing an account about my agonizing search for a diagnosis (and about the complexities of diagnosis in general) on my blog at www.thenexttenminutes.com. Thanks so much for what you're doing here.

Andrew Peterson
author of "The Next Ten Minutes: 51 Absurdly Simple Ways to Seize the Moment."

Michele said...

Many of us have microfilia disease and don't know it. It will manifest full blown after about 2-3years from infection. Microfilia are found in the midgut of the tick. They eventually mature into parasitic worms which reside in the lymph nodes. The microfilia resides in the tissues resulting in muscle pain. If you use meds for parasites and get fever, headache, chills it is the body's response to the die off of the worms. I have been using treatment for this and have done better in 6 days than in the last 3 years. I was near death which is the parasitic nematodes goal. I knew it. Please check this out