Tuesday, September 20, 2011

Babesia, re-visited

Those in the chronic Lyme community have a narrative for explaining the chronicity of Lyme disease or at least the persistence of Borrelia despite the onslaught of immune responses and antimicrobiobials, including such things as: genetic switching - up and down regulating of key surface proteins at key times, protection of the bacteria within a niche, polymorphic switching from spirochetes to cysts and then back again, biofims, and other proven effective stratagies for survival. Despite this evidence, we are still convincing the few.

With chronic Babesiosi we lack such a narrative. Patients are frequently treated for months or longer without clinical resolution. Patients have repeatedly shown me positive FISH(RNA)results for Babesia after extensive therapy, still sick with the disease. As one of my patients recently described in a YouTube video, two ID specialists at Johns Hopkins dismissed this evidence claiming that IgeneX is not a trustworthy lab and suggested the patient seek psychiatric care.

Although there is a great deal of overlap between the symptoms of Lyme and Babesia, certain symptoms are quite specific for babesiosis, inlcuding: recurrent flu like symptoms with low grade fevers, air hunger and night sweats.

Frequently the diagnosis of babesiosis is made on clinical grounds. There are over 100 known species of Babesia but only a few are though to cause human disease. In the US we look for B. microti and B. duncani. Another, yet unnamed species, MO1 has been shown to cause human disease in the US. Others are likely.

Babesia in humans is an infection of red blood cells. The protozoa invade and reproduces within red blood cells. When the cells rupture Babesia forms quickly attach to other red blood cells. Babesia has two hosts: mouse and tick, both of which are required for the parasite's normal life cycle. The tick is considered the definitive host because this is where sexual reproduction of the organism occurs. Humans are considered an unintended, bystander host, unlucky enough to have been bitten by the wrong tick. In humans Babesia is seen as any of three forms: sporozoites which microscopically have a spherical form, trophozoites which have a ring appearance and merozoites which may have the "Maltese cross" (tetrad) appearance.

Unfortunately, Babesia sp infect only a small percent of circulating red blood cells and direct evidence of its presence via microscopy is rarely evident.

Standard, and largely unchallenged dictum states that the microbe lives only within red blood cells, it does not hide in tissues, all of the forms are killed by the same antimicrobials/antiparasitics. The narrative to support the parasite's longevity seems lacking. Well, lets look at some recent medical literature: Clinical Infectious Diseases, 2008, Florescu, highlighted as important by the IDSA.

Two cases of Spenic Infarct are discussed. Both patients were critically ill, one succumbed. At autopsy Babesia-infected red blood cells were noted with the spleen, liver and lymph nodes. One then wonders, is the parasite seeking safe harbor within the microvasculature of these organs?

Of interest, the authors observed that the first patient who survived was co-infected with anaplasmosis "which may have contributed to the prolonged course of the illness." The implication is obvious to chronic TBD believers. The authors report that Babesia has been associated with retinal damage, ostensibly as a consequence of "microobstruction" of tiny blood vessels (by the parasites).

The authors report that multifocal coagulative necrosis has been shown to occur with B. duncani at least in Syrian hamsters. This means that Babesial infection within narrow blood vessels likely caused blood clotting associated with multi-organ damage.

In May 2011, The CDC reports a study of Babesia sp. EU1 (of reindeer) which found hemosiderin laden macrophages in multiple tissues, meaning that infected red blood cells were ingested by macrophages. Babesia DNA was found in: bone marrow, brain, heart, kidney, liver, lung, lymph nodes, small intestinal wall and spleen. Perhaps Babesia can sequester itself with organs.

In summary: Babesia can likely cause blood clotting with localized tissue damage. It may persist only within tiny blood vessels or it may be able to exist within tissues. There are many species of Babesia. They may exhibit different biological behavior. Little is known here.

The evolving science may help us uncover a better narrative by which we may describe patho-anatomic-physiological mechanisms supporting the notion of chronic Babesiosis.

In the meantime, our clinical experience and our supporting laboratory data cannot and should not be ignored.

13 comments:

Curtis said...

I hope you realize how appreciated your blog is. I feel like I'm hanging on by a thread and this is one of the few resources that gives me hope.

glytzhkof said...

Thanks for all new info. I visit your site almost every day.

la quinta kid said...

Hi Doc. Many of us check your blog and look forward to your posts.

Thank you.

worriedmom said...

Thanks for the Babesia discussion!

Lisa said...

I rely on information in your blog and read everything you write, as soon as you post it, you are most appreciated... and yes, I was a field biologist, until I got so sick, and have now been diagnosed with borellia and babesia duncanii and microti- (for babesia, an igenex "fish" test). I was on mepron 6 months, am now on zithro, suprax, and malarone 3+ months and counting - and presently am "yawning" and have waves of body heat and am sweating all the time, having nightmares and if I can get to sleep at all, am waking up drenched at night - I am wondering if this is a herx or med reaction - or both - thank you LymeMD for your great blog....

renee said...

This is a very valuable blog, thanks. I am a biologist and I appreciate the detail you go into, I for one want answers and that means getting as specific info as I can without actually attending conferences, which I don't have time/$ for. I feel like a unique case:
I began having worsening migraines 16 years ago, at a time when I was immersed in mostly dog ticks (on a daily basis)on Pendleton Marine Base in SoCal. At the time I was told repeatedly that Lyme didn't exist here, so I was very non-chalant about tick bites.

The migraines (somewhat a-typical, no aura) worsened and became daily, my fatigue worsened. I lost my marriage, job, went on disability, it was life altering.
It's a long history, suffice to say eleven + neurologists plugged me with every hard core painkiller and other drugs imaginable. Nothing. Only Imitrex and cousins touched the pain. Two years ago I finally met a Lyme specialist locally, got tested, and the tests showed 1) weakly positive for Babesia duncani and 2) indeterminate.
After 15 years of being told what was wrong with me, each a different answer, I wasn't satisfied. You have to understand every MD was an THE authority, and every one had a different answer. Having faith in any diagnosis after that is just very difficult, which makes taking meds that are costly and make you feel worse, also difficult - especially when when you have to feel ok enough to go to work, outdoors, in hot and cold weather, etc.

Finally I took time off from work and took Enula for 2 months (I had had little results from mepron or malarone). I was re-tested, and the FSH test for Babesia came back strongly positive. Logical or no, this test, along with the thoroughness of my MD, has given me the motivation to continue with the malarone, despite the bone-dragging fatigue and worse headaches from Herx-ing. I think it's working, and I haven't said that in 15 years.
So that's my story in a nutshell, and any information to advance our knowledge of this damnable parasite if very much appreciated!

LYMEMJ said...

I can never thank you enough for your diagnose, and the lab tests that showed Borrelia, Babesia WA1 including the Wet Mount where other bugs were seen swimming in my blood; this gave me the tools for treating more appropriately so I am taking ivermectin, a potent anthelmintic in a low dose once a week for long time now and I think this is taking me out of the woods; my heart is still sick but I am mentally sharp and my muscles are coming back. Thank you for all the time and teaching you give us here, you saved my life!

Seibertneurolyme said...

Glad to see you back to posting.

Any updates or new info from Dr K at Clongen regarding the various mystery pathogens?

Hubby is going to have a repeat bloodslide soon since it has been 6 months since the last one and his daily fevers have only recently started to resolve after 6 months and 5 high fever spikes with ER and hospital visits during that time.

Also curious as to whether you have any patients with chronic HGA and chronic RMSF? Oral Doxy seems to finally be helping in combo with oral Levaquin (for the serratia) plus a very aggressive babesia protocol. The fevers are improving, but the WBC has gone low again for the last 2 weeks and the platelets are barely normal at 156.

The serratia, HGA and RMSF all showed up for the first time in the 10 years since he has been ill after starting aggressive babesia treatment with IV flagyl. And then one dose of IV Doxy triggered the 5th fever spike. So for now hubby has no PICC line and we are spinning our wheels.

He did high dose Rifampin for at least 6 months in the past but maybe adding that to the doxy and levaquin would be an option. Can you think of anything else that might work on HGA or RMSF besides doxy, levaquin (or some other fluroquinolone) or rifampin?

Lyme report: Montgomery County, MD said...

Fry has been doing genetic sequencing of two mystery bugs. One is a mystery protozoan which has been difficult to sequence and appears to be a novel organism. Another researcher is working on something similar, perhaps a different organism. We know nothing about these parasites except that they seem to be real. They appear to be very common in sick Lyme patients. These organisms may be native to us but act as oportunist is sick patients with immunosupression.

It it not know what drugs work on these bugs. Their existence may justify therapies with antiparasite drugs which many patients claim to be effective. This is all guess work but there may be some emerging science which may support these treatments.

The swarming bacteria may in fact be a bartonella like organism from partial DNA sequencing here as well.(not bartonella). The source of this organism is also unknown and may not be tick borne.

Another mystery bug is found in white blood cells with swarming organisms. This new bug may be related to ehrlichia or anaplasma.

There is nothing new regarding therapy. All bacteria infecting white blood cells(monocytes or granulocytes), anaplasma, ehrlichia and others? seem to respond best to the combination of doxy and rifampin as reported at the recent ILADS meeting.

Clongen is now also culturing Lyme and Babesia.

Seibertneurolyme said...

LymeMD,

Thanks for the response. Hubby did add in oral doxy to his babesia meds and amazingly within 2 weeks his daily fevers which had lasted for 7 months went away. WBC continues to be a little low but RBC is now normal after the oral doxy and is the best it has been in 7 months.

Not sure if the doxy is working on babs or what, but at least it seems to be helping much more than the mino was.

Next step was to add back oral flagyl to replace the diflucan. This also seems to be stirring up things but it is too early to know what to expect as he started at half dose.

Thanks again.

Bea Seibert

Seibertneurolyme said...

Just a quick update. Huby got his new Clongen bloodslide and amazingly it shows 3 pathogens this time.

The swarming bacteria in the WBC showed up for the first time, plus the mystery dumbbell pathogen (presumed to be a blood borne parasite since it is 4 - 6 microns in size) was back (previously seen in June, 2010), plus what is most likely babesia seen intracellularly in both the wet mount and stained smear.

The lab is going to try again to culture the babesia and also is going to try to DNA sequence the bacteria.

Will let you know in 6 weeks or so if anything comes of the additional testing.

Bea Seibert

mb said...

Dear L.M.D.

I have learned more from your reflections and report than from almost any other source (except "better heath guy"-- altogether general and not MD)
It is v. encouraging to see you blogging again!
Your caring and intellect are helping thousands. Keep it up and Happy Holidays to All. MB

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