Tuesday, December 1, 2015

Lyme, gluten, mast cell activation, neuroinflammation: novel paradigm, novel approach with rapid therapeutic response


The vast majority of my patients eventually improve. Many struggle for months or years but eventually emerge from the darkness of chronic Lyme. Occasionally everything comes together and patients improve rapidly. This happened with the following patient.

A 38 year old female presented with a chronic, multisystem disorder of over 7 years. Symptoms included severe fatigue and post exertional fatigue and malaise. Sleep was never restorative. She developed orthostatic intolerance and was diagnosed with a POTS variant. Symptoms included: brain fog, memory loss, ringing in the ears, shortness of breath, air hunger, heaviness in her legs, diffuse aches and pains, headaches, loss of balance, episodes of confusion and mood changes. She presented with a near zero quality of life. Over the course of time she had a spinal tap for a severe headache. Weakness progressed and she was no longer able to open jars. She walked leaning to the right and had poor balance. She had severe episodes of confusion, for example, forgetting that her cousin had children. She experienced depression and irritability. She was diagnosed with asthma but inhalers did not help. She suffers with chronic sinus congestion. She is very sensitive to loud noises. She experiences night sweats, air hunger and weepiness. She has sensitivities to environmental factors and most medicines. Florinef, prescribed for POTS caused suicidal ideation. She had similar reactions with several antidepressants. Her overarching complaint  is cognitive dysfunction. At times she  has felt that she is developing Alzheimer’s disease. She has also suffered with chronic anxiety.

Lab results: Celiac panel Deamidated Gliadin Abs IgA 12 (nl 0-19), Lyme WB bands minimally reactive, non-diagnostic (2 laboratories), blood smear equivocal results.

Here was my thinking: Clinically she has adrenal fatigue: cortisol might help, effects on depression could be one way or the other. Her case suggests there is a mast cell issue, treatment might help. She looks neurotoxic, possibly due to infection, Lyme, Babesia etc. Patients in this boat frequently have paradoxical responses to serotonin antidepressants – avoid them.  She has gluten sensitivity. the anti-gliadin antibody is unusually high (below celiac disease range) and likely indicates a significant gluten issue.

I began to treat her: gluten free and low histamine diet. Low dose Cortef. Therapy to reduce neuroinflammation: decrease glutamate toxicity in the brain (caused by neurotoxin QUIN) and decrease glial cell activation, a major factor in brain inflammation. I chose the off label use of the Alzheimer’s drug Namenda which specifically addresses the glutamate issue. Then I chose doxycycline, an antibiotic known to decrease neuroinflammation acting as a potent glial cell inhibitor. I prescribed Pepcid, antihistamines and Xanax to reduce mast cell effects. I told her to combine Xanax with an antihistamine for Herxheimer effects. Xanax also has anti-anxiety and antidepressant properties. The cortisol was prescribed for adrenal dysfunction and POTS to some extent but also reduces mast cell hyper-reactivity. The doxy was prescribed at a low dose.

One month after I began treatment she returned feeling great. More than 50% better – after 8 years of misery.

I think she likely has Lyme disease. She has a history of exposure with high risk activities in endemic areas. Babesia seems very likely as well.

Treatment of ancillary issues, especially with an eye for brain inflammation and careful use of antibiotics was key and led to a great initial response. As always. We still have a long journey ahead.

No comments: