Tuesday, March 10, 2015

What is Bartonella?



What is Bartonella? When one forays into the world of chronic Lyme disease the word Bartonella immediately comes up. What is it? I have written about it from time to time and treated it for a long time. What do we know?  Medical textbooks and published papers are at odds with “Lyme” literature. Bartonella is classified as a new and emerging infectious disease. Clinical infection is largely seen as opportunistic. This means that Bartonella under normal circumstances is unlikely to cause clinical disease: it has low pathogenicity. Commercial laboratories only offer serological tests for two species, B. henselae and B. quintana.  Newer information informs us that numerous other species, including: B. koehlerae, B. vinsonii and B. berkhoffi have been found in the blood of Lyme patients. Doctors have known about the prevalence of Bartonella species in some populations for some time. A study published in 1996 looked at the incidence of three species of Bartonella found in inner-city IV drug users in Baltimore: 33% showed antibodies for Bartonella elizabethae, 11% B. henselae and 10% B. quintanta. This population was not tested for scores of other Bartonella species; infection may be universal in this population. Unlike Lyme, it is well known that Bartonella is transmitted by other biting insects, fleas, flies and mosquitoes, not just ticks. IDSA types still like to argue about whether or not Bartonella is a tickborne illness. Some people like to argue about everything. It is fact, not conjecture, that Bartonella may be transmitted by tick bite. Severe forms of the disease are well described by mainstream medicine: cat scratch fever, trench fever, angiomatosis, endocarditis and others. The more nuanced forms of disease, including those seen in Lyme sufferers, are invisible to mainstream medicine. Mainstream doctors need to look a little closer.  In 2007 a paper in “Infection,” described vasculitis and polyneuropathy caused by B. henselae. A well-known paper published in a CDC journal in 2012 made connections between Bartonella and Lyme. The paper connected non-specific symptoms: fatigue, neurologic and neurocognitive abnormalities and joint and muscle pain previously described in occupationally at-risk patient populations.  The Bartonella I think of has greater specificity. A characteristic rash, shown below, parallel red lines or discolored stretch marks, is not described in mainstream medical literature. Red bumps or papules may be seen in life-threatening disease (angiomatosis) according to the usual sources, not the rash pictured below. The Bartonella which causes tendinitis, typically plantar fasciitis (pain on the bottom of the feet) and shin splints is not described in mainstream medical literature. 

 Bartonella, as I know it, is frequently associated with specific neuropsychiatric symptoms, which may include:  irritability, anxiety, rage and many others. This too is not described in mainstream literature. Bartonella as a potential cause of other medical syndromes, for example, interstitial cystitis is also not described in mainstream in medical literature. Then there is the issue of treatment. Bartonella is supposed to respond to tetracycalines and Biaxin according to standard sources. In my world Bartonella responds best to Rifampin and the other drugs do not work.

Although many think of Bartonella as primarily a red blood cell bacteria, it actually primarily resides primarily within endothelial cells, the cells that line the inside of blood vessels. The bacteria is transmitted by an influx of red blood cells which play a role in its life-cycle.  Because of its intracellular locus Bartonella can be as intractable as the other Lyme-associated microbes. 

Here is a snapshot from one of my patients last week. 

This 30 year old male had been in clinical remission from Lyme disease for over a year, after 2 years of extensive treatment. A perfect storm of emotionally stressful events occurred in his life and symptoms returned. He complained of severe fatigue, cognitive difficulties, muscle and joint pains and severe depression. He suffered with anxiety, most Lyme patients do, but he denied irritability, anger, rage and foot pain. And, he had never had a rash like this before. He does have a history of a prior Bull’s eye rash.


Bartonella causes inflammation of blood vessels, a form of vasculitis which likely causes this characteristic rash, undiscovered by mainstream medicine. Vasculitis in the brain is well known to cause neuropsychiatric symptoms, for example, lupus vasculitis. The mechanism of synergy, by which Lyme and Bartonella seem to cause specific psychiatric symptoms is unknown. 

In this patient, Bartonella was always there, even though clinical Lyme was conquered.  Unfortunately, emotional stress weakened the immune system and the tiger got of the cage. 

Specific treatment may not always be needed; therapy decisions are based on the clinical scenario of the patient undergoing treatment.

Here are some general pointers regarding treatment. I have found that rifampin works the best. It must always be given with another antibiotic (to prevent rapidly occurring resistance). Commonly prescribed co-therapies include Zithromax, doxycycline and Bactrim. Bactrim has mild anti-Bartonella effects and is a good add on to rifampin.  Quinolones, including the widely touted Levaquin may be used. I do not like to use this class of drugs because of side effects, which include: spontaneous tendon rupture and high rate of causing C. diff colitis. When I do use a quinolone I usually reach for Cipro because it is a little less toxic and can be started at lower doses and gradually ramped up. When these measure failure, gentamycin or tobramycin are usually very effective. These drugs can only been given IV or IM, have toxicity and requiring close monitoring. 

Atypical syndromes, like interstitial cystitis, may respond best to combinations of Zithromax, rifampin and doxycycline or minocycline. 

The question, “what is Bartonella?” has certainly not fully been answered. But, clinical approaches to what I like to call “Bartonella syndrome,” have evolved and generally perform well in the clinical setting. 

Much of this piece is based on the clinical experience of many doctors and patients, not what is considered medical "evidence." A patient I spoke with last week thought this kind of information constituted evidence as defined by evidence based medicine. "Evidence based medicine," which underpins mainstream medical practices relies on published studies but primarily on the opinion of experts who have interpreted the published studies, especially the ones they like.



10 comments:

WLP Romania said...

thanks for posting.

Pearl said...

Thanks for this post. You mention some of the more serious manifestations of Bartonella, but left out Peliosis Hepatis. I rarely see this mentioned, and yet if doctors were more aware of it, perhaps more patients could be diagnosed with a liver scan. Many Bart patients do have liver/URQ abdominal pain.

I encourage you to check out UCSF's papers going back to the late 90's on Bartonella in AIDS patients, esp. the one on Peliosis Hepatis. (UCSF is where Dr. Jane Koehler researches Bartonella.)

They acknowledge that they see the same severe illness in occasional immune competent patients, too. I think the medical world mostly ignored their discoveries about Bartonella thinking that it was just an opportunistic infection in AIDS patients.

My Bartonella has been quite variable. Relapse symptoms were quite different than original symptoms. Rifampin does very little for me. Rifabutin is a bit better. Levaquin was awesome, but I can't take it anymore due to tendon pain. Thought the Bart was gone, but a year later it came roaring back much, much worse. I'm still surprised how miserable it made me.

Invanz caused a severe die off, so it was obviously working. IV Cipro helped. I saw the most improvement on weekly increasing doses of Ivermectin. I doubt I'll ever get rid of it completely.

Tabitha said...

Anyone who wants the most up-to-date information about bartonella needs to read Dr. Ed Breitswerdt's work. He is a researcher at NCSU in veterinary medicine who has been studying bartonella for more than 30 years. He has written many journal articles, is currently conducting research projects, and is working on creating better testing methods. He has some talks on YouTube, as well.

My experience with bartonella was both classic and invisible to the many different specialists I saw over the last several years. I have dozens of pictures of bizarre "red streak" rashes, swollen and bruised-looking veins, oddly colored "bruises" that lasted for weeks and were not caused by any injury, stretch marks that were not stretch marks...the soles of my feet felt like I had been walking on hot, rough concrete all day when I first got out of bed in the morning...my personality changed completely, to the point that my family did not know who I was anymore...I experienced panic attacks and anxiety for the first time in my life, for no reason...and this is all besides the joint and neurological and cardiac issues that led to misdiagnoses of rheumatoid arthritis, multiple sclerosis, TIAs, osteoarthritis, and huge shrugs and "I have no idea what THAT is."

I had graduated at the top of my class at an Ivy league university, homeschooled my 10 children, and worked part time as a doula and childbirth educator--and I was reduced to pure survival, constant pain, and feeling my mind slipping away. Bartonella is no joke. Because I was breastfeeding and pregnant by the time I was clinically diagnosed, I was limited to Ceftin and Flagyl for Lyme (after months of IV Rocephin) and azithromycin for the bartonella. I had thought I was better, but symptoms have been creeping back, even though I am still taking Ceftin and Flagyl. My hope is that by being part of NCSU's research study, I will get better direction in how to get completely better.

Bridget said...

My son got M.E., as a result of the swine flu vacc 5 yrs ago, He is 18, approx 2 yrs ago - the bartonella time rashes appeared on his trunk. He has a cpap at night time, because he also developed sleep apnea. He has brain lesions, punctuates, bowing. Immune dysfunction in the T cells. There are numerous questions, but I am also interested in treatment. At the moment we are getting none - we live in Ireland and no help or medical is available, though we are hoping at some stage to get funds to move back to the US so that we can avail of treatments there.

Jane said...

Bridget, please look into the Cowden protocol for Lyme and other confections. I know of many who have had success with this. It is all herbal and can be done without a Doctor. http://www.nutramedix.ec/ns/lyme-protocol.
Good luck to you and your son!

Bekah Reist said...

Hello,

My dear friend Heather has been battling severe chronic Lyme for a few years now. In Canada chronic Lyme is not recognized or treated forcing patients like Heather to seek treatment, out of pocket, in the USA. She travels to see her Lyme doctor every three months for her life saving antibiotics.

I'm hosting a fundraiser with Indiegogo for Heather's medical expenses. Would you be willing to share her campaign on your blog? I am not by any means asking or expecting you to make a donation to the campaign. I'm simply trying to gain as much exposure as possible to Heather's story, the horrors of Lyme and injustice faced by all Lyme patients. Even one simple blog post or a share on social media can help change a life. I am truly sorry that you have been affected Lyme. It's an illness I wouldn't wish upon anyone.

You can view Heather's campaign and read her story at the following link:

https://www.indiegogo.com/projects/help-heather-beat-lyme-disease--2/x/10091480

Thank you for your time,

Rebecca

Tickled333 said...

Does anyone know if successfully treated bartonella can leave scars in place of the bart rash? My son's rash has faded and is no longer red, but has turned to very light silvery marks. Was treated for 1.5 yrs. Doc says it is gone. He has never had any other symptoms, so I can't gauge by that.
TIA

Justin Macdonald said...
This comment has been removed by the author.
Justin Macdonald said...

Im curious as to your thoughts regarding rifampin dosing schedule. I see some llmds using rifampin at 600mg as a single daily dose but then others using it 300 mg bid. I know in things like tuberculosis and MAC, dosing seems to be 600mg all at once so im wondering why it seems to vary so much regarding which doctor you ask. Im well aware about pairing it with another antibiotic to prevent rapid resistance to the organism but Im curious about the dosing. It makes sense to me that dosing it all once daily would give you a higher bactericidal effect on the organism but then I feel like you may lose potential for sustaining high concentrations of the drug throughout the entire day. Im curious how you generally use it with your patients. Any thoughts would be greatly appreciated.

Rick said...

Top Bart Doc recommends 600mg Rifampin 2x per day (with Biaxin) --yes total of 1200 mg for 160 lbs