A patient I saw today embodies something quite different from my run-of-the-mill Lyme disease patient. A typical Lyme patient was in good health until something happened. The disease may have come on abruptly or gradually over a period of time. But before the illness began, at a defined point in time, the patient was in fairly good health. Another patient type, like my patient today, has been sick for a very long period of time. Perhaps decades. There was no clearly defined point in time when the illness began. In this case she became acutely ill 2 years ago and worse over the past 4 months. But looking back, she has not felt well for decades. She has not functioned well for a very long time. Many such patients have previously carried various diagnoses such as: fibromyalgia, chronic fatigue syndrome, Epstein Barr, chronic depression and/or somataform disorder. They typically have a history of other troubling chronic illnesses like IBS, migraine, asthma or interstitial cystitis. Something else is wrong with these patients. Tick borne illness does not account for all their troubles. These are our most challenging patients. They are delighted to have the diagnosis of Lyme disease, something real, validating. But this may be only a starting point -- something that broke the back of a camel that was already severely sagging. These patients have been looking very hard for a long time for help.
So what is wrong? A chronic yeast problem. A genetic defect of MTHFR causing a methylation problem. Environmental toxins. Heavy metals. Mold toxins. Epstein Barr virus. Chamydia pneumonia. Mycoplasma. Bad genes. Or just bad protoplasm. All the above?
In the simplest terms chronic illness results from an ill fated interaction of a person's genetic makeup, genotype, with environmental factors. That's it. A particular gene can have various expressions in a person. These are called phenotypes. In the future I suspect all chronic diseases will be corrected with tweaking of DNA. For now we have to "holistically" integrate bio-psycho-social-environmental factors and seek out our best current solutions.
Many genetic flaws are obvious. For example, ones that lead to sickle cell anemia or cystic fibrosis. We really know very little about the function of most of our genes. Genetic flaws or mutations may be responsible for subtle illness. A gene may be "partially expressed." For example, rather than causing full-out celiac disease the flaw may cause gluten sensitivity.
Since this is a BLOG, not a chapter in a book, I will give a few examples of how this approach is helpful. A patients suffers with severe headaches. His mother and brother suffer with migraines. Rather than increasing the dose of Mepron or pounding harder on a co-infection, think about using an anti-migraine drug like Topomax. A patient has progressive memory loss. A first degree relative suffered Alzheimer's disease at a young age. Rather than upping the ante of IV antibiotics, consider a neuroprotective therapy like hyperbaric oxygen. A parent and sibling suffer with depression and bipolar disease. Rather than increasing anti-Bartonella therapy for a depressed patient, consider early institution of anti-depressant therapy. On the other hand, if the depressed patient is suffering from a personal trauma, push for talk psychotherapy rather than reaching for a pill. A patient suffers with severe Obesity. Both parents are morbidly obese. Nutritional therapy is not going to work. Consider an anti-obesity medication like phentermine. A patient has a poly-arthritis, refractory to treatment. A parent has rheumatoid arthritis and a sibling has psoriasis or lupus. Use antibiotics with anti-inflammatory properties like doxycycline or minocycline. But also use disease modifying drugs like Plaquenil, and yes, consider more potent disease modifying biologicals in selected cases. If it is determined a patient has a genetic defect for the elimination of toxins, work hard to correct this issue.
Sometimes genetics trump environmental factors and sometimes it is the other way around.
A patient with a 20 year history of fatigue is going to have adrenal fatigue, notwithstanding genetic factors.
When treating difficult patients the doctor must be aware of common disorders and not miss the easy ones. Whether or not dad uses a C-PAP, get the sleep study. Sleep disorders are omnipresent. The "nonspecific" loss of stage 3/4 sleep may be treatable despite what the sleep doctor says. Some rocks should always be turned over.
Bottom line: every organ system and every symptom must be evaluated in the context of environmental factors, like Lyme disease, and the confluence of genetic factors. Many issues many need to be addressed. Many issues beyond Lyme disease.