Friday, March 20, 2015

Is it Lyme or MS? (revisited)



A 45 year old male recently presented to my practice. He suffered with a progressive, debilitating, multisystem disease over a period of 5 years. An MRI of the brain was performed and the results were unnerving. The scan showed numerous white matter lesions, greater than 20. The diagnosis of MS was suggested by the radiologist.

Mainstream authorities all agree: There is no diagnostic test for MS. The diagnosis can only be made when other causes of the symptoms and findings have been ruled out. It is a diagnosis of exclusion. MRI protocols, proteins in the spinal fluid, abnormal evoked potentials, alone or in combination cannot conclusively make the diagnosis the MS. 

This patient lives in a Lyme endemic area and has had numerous tick bites over a period of many years. He suffers with fatigue, weakness, trouble walking, poor endurance, headaches, cognitive symptoms and memory loss, depression, tinnitus, night sweats, flulike symptoms, migratory joint pain, mood swings and episodes of rage.

The left lower extremity was particularly weak showing a “foot drop,” apparent with gait testing. The patient was instructed to walk on his heels but the left foot is unable to elevate and the foot flops to the floor. An EMG showed the cause to be inflammation of the peroneal nerve, a peripheral nerve. This is not a feature of MS which involves only the central nervous system. Lyme, however, effects all aspects of the nervous system.

White matter lesions in the brain reflect damage of heavily myelinated nerve fibers in the deep portions of the brain. Myelin is a white, fatty, insulating substance which covers these neurons. Some nerve cells are not covered by myelin, for example, those covering the top of the brain. These nerve cells have a gray appearance hence the cortex (outer surface) of the brain, is composed of gray matter.
White matter lesions can have many causes. They can be normal; you are allowed one per decade of life. The lesions may be seen with atherosclerosis, diabetes causing small blood vessel disease, hypertension, migraines, infections, vasculitis and Lyme disease and there are many other potential causes listed in texts and various sources.

Multiple sclerosis is characterized as a demyelinating disease. It results from an autoimmune process which attacks this coating of the deep nerve cells. MS is divided into 4 types. In 85% of cases it is relapsing and remitting. Patients have discrete neurological events (central nervous system only) which generally get better over time. MS is not diagnosed based on a single event. Subsequent events occur over time involving different parts of the central nervous system.

Typical “events” may include: optic neuritis with loss of vision; weakness, generally localized; numbness and shooting pains originating from the central nervous system, vertigo and loss of bowel and/or bladder function.  In most cases patients get better. Interim periods of time, devoid of symptoms, are followed recurring events causing different symptoms. Over time, the symptoms may not remit and become permanent.

These events are dramatic and distinct. MS is a disease of fits and starts.

The Multiple Sclerosis Society states common symptoms of MS include: fatigue, trouble walking, numbness and tingling, weakness, changes in vision, changes in bowel and bladder function, changes in cognition, depression and pain. The National Multiple Sclerosis Society states that one half of MS patients end up with a chronic pain syndrome. By my way of thinking, the recognition of such symptoms after the fact speaks to a more insidious, gradual inflammatory brain disorder and a multisystem disorder more characteristic of late Lyme disease. Why has the disease morphed?

MS is not defined by MRI findings. In the case of the above mentioned patient, there is a history of tick bite, positive Lyme test and evidence of a progressive, multisystem disease. These white matter lesions, numerous as they are, are most likely the results of Lyme, neuroborreliosis.

The cause(s) of MS are thought to be both genetic and environmental (including infection).

MS has an interesting epidemiology. Cases are rare around the equator. The incidence increases proportionally to the distance one is away from the equator. For example, it is more prevalent in the Northern U.S. and Candida and Northern Europe and Scandinavia. The rule does not hold true for the Asian continent where the incidence remains relatively low throughout the continent. Sporadic epidemics of MS have been described, suggesting an unknown, probably viral, infectious cause. Chamydia pneumonia has been shown to be the culprit in some cases. Coincidently, there is a lot of overlap between the geographic distribution of MS and Lyme. 

The MS Society has a clear opinion about Lyme: it is not associated with MS. It is easy for the Society to make this claim: they follow the IDSA approach. Lyme responds to 3 weeks of antibiotics. White matter lesions in a previously treated Lyme patient are therefore the result of MS, not Lyme. 

How Lyme causes these lesions is not entirely clear. It has been proposed that the highly immuno-inflammatory proteins expressed on the surface of Lyme spirochetes may evoke an autoimmune reaction, one that has not yet been categorized. This raises the question: are some forms of neuro-Lyme a type of MS or a close relative? Can Lyme cause MS?

This is a murky arena. A subset of patients may respond best to MS therapy combined with Lyme therapy. Perhaps some patients do have both Lyme and MS.

There exist 10 FDA approved drugs for the long term management of MS. Some suppress the immune system, like drugs used by rheumatologist for rheumatoid arthritis. Others modulate immune responses and others have anti-viral properties. Neurologist typically treat acute flares of disease with high doses of intravenous steroids. Many of my patients got worse when given steroids. When patients have Lyme (and are also treated by neurologists for MS) I like to steer them to immune modulating and antiviral therapy (interferon).

Clearly, MS is a real disease, apart from Lyme. Not all MS is caused by Lyme. However, there seems to be a large universe of patients suffering with Lyme disease who have been incorrectly diagnosed with MS.

P.S. After only a month of oral doxycycline the patient has experienced dramatic improvements in many symptoms.

2 comments:

T9im said...

Hi Doc:

Nice post on MS. On a related point you may want to visit Dr. Terry Wahls, MD web site. She is a MD who came down with MS and through diet and medications was able to restore her health.

Thanks again for your informative posts.

Grandma Nina said...

Hi. doc!
You write:"it is more prevalent in the Northern U.S. and Candida and Northern Europe and Scandinavia."

I think it should be
"it is more prevalent in the Northern U.S. and CANADA and Northern Europe and Scandinavia.

I love your blog!