Old drug, new drug: nimodipine

Mary, a 35 years old woman was extremely healthy – until she wasn’t.  The culprit was Lyme disease, an ancient, thin, spiraled bacterium called a spirochete – one that is insidious and opportunistic.  But Lyme disease is more often than not so much more.

Our ability to stave of infection frequently depends on a healthy immune system.

Many factors can adversely impact normal immune function.  Stress is a huge factor.

Lyme and Mary’s immune system had been locked in mortal combat with Lyme for some time. Life stressors mounted and a tipping point was reached. Lyme won the battle and spread throughout her body attacking many organ systems.

These were some of the stressors. Her father died of a sudden heart attack, a child was diagnosed with autism, her husband was emotionally abusive and this led to an ugly divorce.

Mary managed stress by gardening – more and more. Ironic.

The fatigue was overwhelming. It felt like she had been run over by a Mack truck. Mary was diagnosed with chronic fatigue syndrome/CFS, myalgia encephalitis or systemic exertional intolerance disorder – three names for the same thing. She simply could not function. Sleep was miserable, too much or too little. She struggled to get out of bed. She needed help with simple household chores. She rarely got dressed; she no longer put on makeup and she took few showers. Sadly, Mary blamed herself for her poor health. She lost all self-esteem.

Headaches diagnosed as migraine came out of the blue. Pounding, throbbing, ice pick, with temporary loss of vision nausea. The pain was unbearable.  Several doctors were of no help and she seriously considered suicide.  


Symptoms mounted. Doctors said it was psychosomatic. Family members believed the doctors. Mary was abandoned by both family and friends.

Mary had so many symptoms, symptoms which inexplicably came and went.

She frequently felt like she had the flu. She had night sweats, drenching at times.

Her whole body hurt at times. Sometimes the pain was localized to a particular joint or body part.

She experienced frightening cognitive impairments, poor memory, trouble thinking clearly, difficulty finding words. She frequently felt disoriented and depersonalized. She experienced depression, air hunger, sudden bouts of crying, intermittent joint swelling, weakness, numbness and tingling and trouble sitting up and standing.  


With changes in posture, from lying to sitting and then to standing symptoms her heart raced, brain fog increased, she became dizzy, felt she would black out and had to immediately sit down or lie down.

We know Mary has Lyme and Babesia. But she is not going to get better if we treat her only with antibiotics and anti-Babesia drugs.

Migraines:  There are a variety of new ways of treating migraines including those that antagonize calcitonin gene related peptide, a relatively new and sometimes successful therapy. Migraine therapy will be reviewed in detail in the future.

POTS:  With further questioning Mary had problems with her bowels, bladder, vision and temperature regulation.  POTS is a piece of the larger disease, dysautonomia or broken autonomic nervous system. A patient history, exam with measurement of vital signs in different positions can confirm the diagnosis. A tilt table test is unnecessary. There is a close connection between dysautonomia and CFS. Mary’s heart rate only increased by 20 points with standing not the requisite 30. Of course she was too dizzy to stand for long.

There are many effective therapies which usually work when prescribed properly. Described elsewhere.

Even when tests for POTS are negative, patients with chronic fatigue syndrome may benefit from POTS’ therapies including salt tablets and fludrocortisone.

Lyme patients, patients with chronic fatigue syndrome and patients with POTS all complain of brain fog. An old/new drug may be incredibly effective.

The calcium channel blocker nimodipine, which must be prescribed carefully dilates cerebral blood vessels and increases blood flow in the brain treating chronic encephalopathy. Patients with Lyme, POTS and CFS may all suffer with dysregulated blood flow to the brain.

Nimodipine may work well with other neurotropic drugs including Adderall and Namenda.

I have treated Mary for less than a year and she has done very well.

She is back at work, part time, telecommuting and even smiling at times.

Summer flu, Lyme or Covid?

Lyme patients, those suffering with chronic illness must be considered immune suppressed and at higher risk for serious Covid related illness.

There are dangers at the edge of the woods and dangers from neighbors and family.  The world is surreal.  But it is the real world, the one we have to live in.

The Covid nightmare, is in some ways like 911, a watershed event that will forever change our prior naivety regarding person to person transmission of deadly germs.

I am optimistic that meds given early in the course of illness will prove effective. Current candidates include

The summer flu. It has long been acute stage Lyme misdiagnosed by the doc-in-a-box. Now we have another bigger worry.

The presentation of the two illnesses can in some cases be identical:  fever, malaise and achiness. 

Testing should be done, although deficient for both.

Do not get the Covid antibody test. 100 non-vetted companies, tests.  Get the nasal swab sent for PCR which directly identifies the RNA virus. There are still false negatives and you may want to repeat the test.

Lyme testing. Many of us are operating remotely doing telemedicine. That obviates the ability to send specimens to more reliable Lyme labs:  Stony Brook, MDL, IgeneX etc. We have to manage with LabCorp or Quest.  Get the Western Blot test, not the reflex to WB.  Also get C6 peptide.  Coinfection testing must include Babesia duncani, WA1, IFA IGG.

Do not worry too much about poor Lyme blood tests.  Patient history is the most reliable test.

If there is any doubt treat both.   Doxycycline and (ivermectin which many Lyme patient feels has been effective) is a good starting place. If you are worried about sun induced toxic skin reaction, I recommend you stay in the shade and tough it out for at least 3 weeks. This is the only drug that has widespread effectiveness against many coinfections.  Amoxicillin, Ceftin and Minocycline are not adequate substitutes.


Search my blog for more about ivermectin.


Despite what you may have heard or red otherwise, Covid cases and deaths are very underreported.  Same as Lyme.  With Lyme some elected officials have helped promote the cause.  With Coivd, unfortunately, it is the other way around.

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Telemedicine vist

Telemedicine visit

Your doctor does not want to see you in his/her office. At least your doctor should not want to see you in his/her office. Not now.

We are in the middle of a pandemic – goes without saying. Covid-19 stands for coronavirus disease 2019. Its novel because it is new and something the human immune system has not previously encountered.  We have experience with other deadly coronavirus infections. SARS had a mortality rate of around 15% and MERS was scary deadly with a mortality rate in the smallpox range, 30+ percent. Covid-19 is less deadly but much more contagious. The true numbers of those infected and the mortality rate are to date unknown.

Covid-19 is the dreaded pandemic, more than an epidemic.

An epidemic occurs with rapid dissemination of an infectious illness through a susceptible population. It may be worldwide as occurs yearly with influenza.

A pandemic is worldwide dissemination of a new deadly infectious disease. This is the stuff of sci-fi movies.

A friend’s parents live in a Maryland Assisted Living facility and tested positive for Covid.  Both presented with diarrhea and without fever or cough. Unusual presentations may not be unusual.

A typical physician’s medical examination room is an 8X10 or somewhat larger rectangle with relatively poor circulation. It is a perfect incubation chamber for coronavirus. Infectious particles may persist in air – droplets and aerosols and on incompletely sterilized surfaces. I am more concerned about transmission to patients from asymptomatic medical staff.

Covid is present in at least two thirds of our state’s nursing homes. Family members are barred. The virus is invariably introduced by unwitting staff members.

When possible, and it mostly is, stay at home and stay safe.

Telemedicine in Maryland is defined as a medical encounter with the use of an audiovisual aid such as a computer using a HIPPA approved platform. Telephone calls are excluded from the definition of telemedicine.

State licensure rules regulate the use of this technology for out of state patients. Most states have loosened the rules. But changes in regulations vary tremendously from state to state.

Telemedicine is more personal than phone medicine and feels more like a normal doctor-patient visit. I can get a sense of the patient’s general overall health based on his/her appearance. Objective data is missing but patients can help fill in some of the blanks.  Patients have easy access to home BP devices, oximeters, scales and thermometers. I can look at a throat, rash or swelling. I can see where pain is without having to guess. I can get a general sense of breathing based on observation. And many patients can get an EKG with a wristwatch or other portable device and show me the tracing on the screen. Prescriptions are electronic.

If a patient needs more advanced care, at an ER for example, the platform is extremely helpful vs a phone call. 

Please use the doxy.me or another similar platform. It’s easy to use and does not require an app. And I can hear much better as well.

Mold toxins in perspective, a science based approach

Mycotoxins – the noxious chemical defense of these ancient and troublesome microorganisms.  Recently a  patient showed me a urine test. Mycotoxins were present in high concentrations. The patient was prescribed cholestyramine and the next test was almost clear. He said “his mold level” had improved. He fundamentally misunderstands the problem.

First, we want to know if he is right about his “mold level.” Are there a significant number of pathogenic mold organisms living in our body actively secretin caustic toxins?  Mold is not generally found in our bodies, at least at high or clinically significant levels.

Sure, we are all a waking zoo of microorganisms: bacteria, yeast viruses, perhaps some protozoa but no mold. Although yeasts and mold are cousins and frequently killed by the same drugs they act very differently.

I ask again: why are the toxins found in our urine at measurable concentrations.

Most readers likely believe that the primary source is largely aerosolized spores emanating from hiding places – wet basements and the like.

In actuality the biggest source of mold/mold toxin is food.  Many foods we eat all the time may have high levels of mold. We have all found moldy bread in the fridge at one time or another (I certainly have). Before the putrid green and blue areas appear mold long present. Just not in numbers easily observable to the naked eye. Our berries are covered in mold before the white exudate appears. Mold is present in many foods: cereals, grains, corn, fruit, peanuts and peanut butter, eggs, milk, meat, coffee beans, coffee – especially from our Keurig with its inaccessible wet, warm environs, a perfect culture media, etc.

The more serious, life threatening mold infections, for example aspergillosis of the lung or brain generally occur in those seriously immunosuppressed.  Ordinarily, aspergillus is a common food mold, a good source of aflatoxin and ochratoxins. Another common food mold, penicillin is a good source of ochratoxin. There are many other food molds and food toxins.

Black mold, Stachybotry lives in our homes. It eats cellulose, things like ceiling tiles, tiles and fiberboards. Its spores are aerosolized, along with very noxious trichothecene toxins.

Many mold toxins are xenobiotics recycled from liver produced bile to the intestines and back again endlessly (or perhaps 20 times). Enterohepatic recirculation may be beneficial in some circumstances. In this scenario the liver is assaulted by the same destructive toxins over and over again.

I have written about this system in a few posts. The bottom line is that this process explains why bile acid sequestrants (BAS) like cholestyramine and Wellchol work. Activated charcoal also works because at high concentrations it performs like a BAS. In fact, like the BASs, activated charcoal (24 gm daily) lowered cholesterol by 25%. These drugs grab bile acids and biliary toxins causing excretion through the colon – and the liver makes new bile acids, primarily from cholesterol.

The drugs  lower the overall level of toxins in the blood and therefore spare the liver and kidneys by a second mechanism.

 But we have not fixed or addressed the underlying problem.

Dietary sources of mold and mold toxins are significant.  We may need to seriously change our diets.

We may need to remediate our homes, especially wet basement areas if black mold spores are in the air.

But these molds do not really or should not really take up residence in our bodies.  They are not part of our normal microbiota.  But this in not always the case, especially with deep, chronic infection and immunosuppression.

 Where is the mold then hiding?  Sinuses, lungs and skin are possibilities. Specific antimicrobial therapy is indicated, either intranasally or with systemic agents.  The mold may be eliminated, or numbers significantly reduced. Retreatment may be par for the course.

A lot is made about epigenetics, especially MTHFR variants Genetic variations may interfere with “methylation.” DNA methylation is part of a switching -- turning genes on and off, with far reaching consequences. This is a real phenomenon. Complex and poorly understood.

Eliminating exposure to toxins is the most important part of therapy. You cannot get better if the fundamental problems is ignored.  BASs and vitamins for MTHFR can be given simultaneously- icing on the cake -- not the cake.  MTHFR for another day.

Detoxing and science and doctors

I talked to a patient today who is mad. Mad at doctors who are unprofessional, disrespectful and who disparage other doctors. This is what I recommend.  Calmly call out the doctor's misbehavior. Be the grownup. Rise above the petulant, entitled child who never grew up.  This describes many doctors.  My patient wants to be proactive, respond to ill=treatment form doctors.  Something about ratings in Apps. No comment.

If you are like me you sometimes grab an orange from the basket, hold it under the faucet for a few seconds, peel and eat it.  Perhaps you grab a waxed apple and do the same. You should scrub the fruit with a natural detergent. Your produce is likely grown in an invisible stew of things like the widely used pesticide 1,3 dichlorpropene banned in the European Union, Roundup, Organophosphates, Arsenic related and others to name a few.  Big agra-business makes the oranges and apples shine – with more chemicals.  The FDA assures us the levels of toxins and carcinogens are safe. Organic produce has less of the same but is exposed to the same contaminated water table and soil, our toxic biosphere.  The FDA tells us the levels of these entirely safe.  The Mayo Clinic suggests natural products used by organics farmers are not proven safer than unpronounceable chemicals known to quickly kill white mice.  Who told them that?

Weeds, like unwanted bacteria are becoming increasingly resistant to the usual pesticides calling for more drastic measures. Nice. 

This is not my usual topic and I know little about the subject and have much to learn.  But I hear a lot about detoxing. This what it might mean to me. 

Enter the word Xenobiotic.

You already know about probiotics and antibiotics. 

Xenobiotics are foreign, non-biological substances which may be toxic to tissues including liver and kidneys. Very bad toxic substances we ingest daily. 

Likely the doctor has never heard the word.  Give them scientific source material. 

Xenobiotics can be difficult to eliminate and cycle endlessly through enterohepatic re-circulation.
This is where activated charcoal comes in.  It waits in the intestines for the toxin laden bile, grabs the xenobiotics and eliminates them through the colon. Charcoal and cholestyramine eliminate mold toxins (mycotoxins) the same way. They may also eliminate your expensive medicines. Follow directions. 

Frequently sage allopathic doctors, especially infectious disease experts, jump down the gullets of Lyme patients who say they are “detoxing.” The word detoxing is foreign to mainstream medicine and practitioners. It raises the antennae of doctors who are quick to denounce such talk as voodo pseudoscience.  

Lyme bacteria do not have toxins they will opine. 

It’s true Lyme bacteria lack the endotoxins of pathogenic gram-negative bacteria. That’s not at issue. 

I always try to teach patients how to talk to doctors. The answer is, “Of course not. The chronically ill patients may have difficulty with toxic xenobiotics (look up the word doctor). General inflammation challenges the ability of the overworked liver and kidneys to remove the toxic chems.  And doctor, if you are content with paraquat and roundup in your diet it doesn’t apply to you.” (Less snarky -- unless the doctor is a narcisistic, arrogant piece of excement).

The doctor may come away realizing there is something here to learn. Nah. 

In general, don't mention detoxing. Its not worth it. 

Charcoal helps with Herxeimer reactions because it binds cytokines. This can be further explained if the doctor if she/he is still standing in the exam room. This straightforward, unassailable science. 


A lot of doctors don't like science. Ironically they are quick to lable those with whom they disagree anti-science. Old news. 

Don't be angry with doctors. Set realistic expectations. Unless they attack me. Then go for the jugular. JK.

Organic foods  are better.  GMOs are not the problem. They are the bright, shiny object which distracts. A discussion for another day.

DSF, dose, activated charcoal managing the Herxheimer reaction

My patient is feeling optimistic. The best she has felt in years.  Disulfiram/Antabuse, AKA DSF is the game changer.  She takes a tiny amount.  I prescribed 10 mg compounded capsules, a very low dose. She started with one capsule every 4 days and has increased the dose to 2 caps, 20 mg daily. She reacts to this small dose, significantly.

She feels OK the first day of disulfiram pulse. The second day she is assaulted with a variety of symptoms: fatigue, brain fog, muscle/joint pain, shooting pains, muscle twitching, head pressure, etc. She feels increasingly better over the next 4 days and the cycle repeats.
She is happy. No longer depressed. Really happy.

She tells me she manages the second day Herxheimer reaction with doses of activated charcoal.
I’m naturally skeptical.  Everything has to make sense. Scientifically and logically.

Herxheimer reactions are modulated by the immune system, something like a cytokine storm. This is all very complicated so let’s not get lost in the weeds. These cytokines are a complex set of proteins which regulate activity of the immune system (traffic the immune system). When Lyme is killed cytokines and the immune system are kicked into high gear. This leads to inflammation, too much inflammation, a bad thing. We need to reduce cytokine activity and/or cytokines themselves.

It’s exciting to learn that activated charcoal is incredibly effective at binding cytokines. When blood is filtered through activated charcoal cytokines are removed.

How does that help us? Blood has to be removed from your body and filtered. Not likely. Activated charcoal is the “universal antidote” and good for reducing bloating and gas. It stays in the gut. It does not get into the blood where cytokines live.

Ah ha. Like cholestyramine, it interferes with the natural recycling of bile (from the liver) to the intestines and back to the liver. OK. And..

A published study looked at oral charcoal in mice loaded with malaria and treated with an intravenous antimalarial drug.  Charcoal reduced brain swelling and reduced key cytokines. Gut only charcoal did all this. 

Cytokines may be cycled through enterohepatic pathway and processed through the intestines.  Charcoal may be there waiting to gobble them up. (Conjecture on my part).
I finally have an idea why Wellchol/cholestyramine lowers C-reactive protein. CRP is cytokine driven.

Normal functioning of the enterohepatic pathway impacts the concentration of medicines, toxins and other substances present in serum. I discussed this in another post. Messing with the enterohepatic re-circulation of bile can do good and bad things. This is a very complex and vital part of our physiology.

The best treatment for Herxheimer reactions may be antioxidants (oxidative stress) and activated charcoal.

I do listen to my patients and believe what they say. I worry that many desperate patients are taken advantage of by various scams. I worry about overpromoted nostrums, a mass placebo effect.  Think-- The Emperor’s New Clothes.

My patient today snickered at my skepticism.  I am humbled.  She was right and I was wrong.

I still want people to stop think Herxheimer reactions are caused by toxins and cholestyramine/Wellchol and charcoal remove toxins. Speaking of  toxins specific to the Herxheimer reaction. This does not make scientific sense. (I am not saying other toxins are not removed, I am speaking of the mechanism of the Herxheimer response).

Yes, the best starting dose (and ending up dose) of disulfiram is variable.  Starting low is a good idea. 10 mg seems to be a good starting place, for sensitive patients. Options include 25 mg, 62.5 mg and others generally are well tolerated.  Gradually increasing the dose likely mitigates damage caused by an overly eager immune system.

Take home points:  DSF, start low.  Herxheimer reactions -- antioxidants and charcoal.
Also, if you had a bad reaction with a higher dose of DSF you may do well with a small starting dose.

CFS, SEID, (a little POTS?)

If you treat Lyme you see boatloads of patients with chronic fatigue syndrome and many with POTS. CFS, myalgia and encephalitis has been renamed SEID, systemic exertional intolerance disorder. Many patients with SEID have orthostatic intolerance.  When they stand up for any period of time they feel the need to sit down or lie down. Is there a connection we are missing?

POTS, postural orthostatic tachycardia syndrome is a manifestation of dysautonomia, a broken autonomic nervous system. This important part of the nervous system does many things. With POTS with focus on a cardiac manifestation.

A lot of disorders are diagnosed based on cutoffs. The numbers are somewhat arbitrary. For example, POTS is diagnosed when supine pulse goes up 30 points with standing.  Perhaps a lying down heart rate goes from 60 to 90 when a patient stands, and stays there and may increase.

A patient may need to stand for 15-20 minutes before the change occurs.  Some patients are tortured with a tilt table test (not originally designed to diagnosed POTS).

Today I saw a 54 year old male I have been following for a number of years.  His main problem has been crippling fatigue.  Maybe he has Lyme, not clear.  Antibiotics were a little helpful (or placebo effect). With high viral titers, EBV and HHV6 the antiviral Valcyte helped, for a while. Maybe. Always looking for the next thing he asked me to prescribe rituximab (kills EBV?). NO WAY. He is always looking for a new cure. He tends to overdo exercise when he feels better and relapses.. Treatment for mast cell activation disorder has been somewhat helpful. 

Today he is feeling the best he has felt in 10 years -- normal.  How did we get there?

When he changed position lying to standing his pulse only increased about 12 points. No POTS by standard criteria.

I wondered what would happen if I treated him for POTS.

I didn't make many changes.  He has high blood pressure.  I changed his BP med, an ARB, Cozaar, a standard go to BP med to Coreg.  Coreg is an alpha/beta blocker and has been shown to help POTS. Normal B blockers should not be used.  I started him on salt (only started  one gm NaCl) and he added more to food. ( crazy in a patient with HTN, right?)

The change in pulse corrected.  His blood pressure did not go up.  Only a small subset of blood pressure patients are salt sensitive, especially blacks and the elderly.

Will it work for others? I don't know. I don't  know if it will continue to work for him.

The experience of one patient may be a fluke and mean nothing.

Both POTS and CFS are poorly understood.  They share certain features.

Mast cell activation syndrome may overlap as well in many cases. The diagnosis is usually clinical.

This therapy must be done slowly with careful patient monitoring.

A  little dysautonomia, a little POTS, a spectrum, continuum? Maybe. Medicine is frequently gray. Black and white cut off points should be looked at critically.

A thought.

Lyme update 2020: Key points

Eradication

We go back to the three legged monster I described so many years ago. The tickborne monster has legs of Lyme, Babesia and Bartonella.

For the first time Lyme has been eradicated in an animal model (murine/mice).  Dr. Zang of Hopkins was successful with a daptomycin based 3 drug cocktail: daptomycin, ceftriaxone and doxycycline. These 3 FDA approved drugs are well known and well used. Short of human studies, considered repurposing of vetted drugs may be considered. 

IV therapy is preferred and/or the standard of care in specific cases: sometimes indications are gray.  The risks of IV therapy include infection and venous access line and possible sepsis, thrombosis/blood clots and pulmonary embolism.  The use of intravenous antibiotic does not decrease the likelihood of C. difficile infection. The mainstay of intravenous antibiotic therapy has been Rocephin for many years.  Other antibiotics frequently employed include Flagyl, azithromycin and doxycycline.  Treatment incorporating daptomycin is new and has been well tolerated.  The drug itself is actually quite old.  It has been reserved for serious, resistant infections in many institutions and infectious disease experts have cautioned against first line therapy or other inappropriate use.

The primary indications for intravenous therapy include: Acute/subacute neurological disease ranging from encephalitis, meningitis to peripheral neuropathies including Bell’s palsy and others; acute inflammatory arthritis nonresponsive to oral therapy; Lyme carditis.  Patients with chronic Lyme encephalitis, /neuroborreliosis with cognitive problems are frequent candidates.  Patients who fail aggressive oral therapy, suffering with a multisystem disorder and poor quality of life are candidates.  The choices available for oral therapy are evolving.  As a general rule, IV antibiotics and oral antibiotics should be started and added one ag a time. The anticipated duration of therapy is always completely unknown. Every case is different.

Antabuse

Antabuse/disulfiram may be a game changer. In Vitro studies (Stanford University) demonstrated efficacy against Lyme spirochetes, round forms and biofilm forms. Antabuse has been used for more than a century as an antiparasitic, a commercial agent used for rubber manufacturing and for treating alcoholism.  Antabuse inhibits degradation of acetaldehyde, a toxic intermediary of alcohol metabolism.  Alcohol with disulfiram is a miserable experience one will never forget.  There are better ways to treat alcohol abuse. Antabuse has new life as a Lyme killer.  Antabuse has been effective against resistant forms of bacteria, including Staphylococcus (including biofilms) in-vitro. It seems to have a narrow spectrum against gram positive bacteria and should be easier on the gut. 

Side effects and tolerability described in older literature regarding aplicability for alcoholism does not to apply to our experience with Lyme patients.  For example, rare neuropathy described in alcoholics is not rare for Lyme patients. Herxheimer reactions are common and frequently severe; lower doses of the drug is required.

One option is to cut a 250 mg tabs into quarters enabling initial treatment with 62.5 mg. Compounding allows for more flexibility. Disulfiram can be compounded to any dose you like, for example, 10 mg or 25 mg. A target dose of 250 mg is frequently effective. Some patients claim that the 500 mg dose is more effective. I still combine disulfiram with traditional antibiotics for an optimal response. 

In my experience disulfiram does not eradicate Babesia. In many cases Lyme and Babesia are mysteriously linked. When Lyme clears and remits Babesia too may recede into remission. This may give the appearance the drug kills Babesia. 

Babesia

The malaria like red blood cell parasite is very problematic.   B. duncani and other unidentified organisms are very troublesome. Full eradication should be the goal.  Recurrences can be very difficult since the parasite often returns resistant to an arsenal of anti-Babesia drugs. Most “virgin” Babesia cases respond to Mepron. It is important to start with 10 cc or 2 tsp twice daily with fat. The 5 cc dose frequently recommend is inadequate. Mepron must be used with Zithromax.  Zithromax has the unique ability to concentrate inside cells at an incredibly high level. Other drugs like Biaxin, doxycycline, Bactrim and clindamycin are not effective.   I recommend more than one anti-Babesia drug even when Mepron appears effective. Bellwether symptoms:  night sweats, air hunger, random tearfulness are important but Babesia may cause many other symptoms as well. Coartem is my next favorite agent. It includes a much more bioavailable and effective artemisinin derived component, artemether. 

My third preferred agent is tafenoquine (well tolerated excluding G6PD deficiency). It comes in 2 forms.  Krintafel comes in 150 mg tabs and is used as a single dose for Malaria, repeated at intervals, e.g. weekly and  Arakoda, approved for malaria prevention.  The 100 mg tab is approved for daily use for malaria prevention. 

How long is Babesia treated? We say until symptoms are gone.  I have seen many cases of hoped for cure relapsee. I currently treat for 4 months beyond the point of complete remission if possible.  . 

Bartonella

This small bacteria lives in the cells that cover the inside of blood vessels. The bacteria may occupy red blood cells after infection until they "Uber" into blood vessel lining cells (endothelial cells).  Bartonella persistern forms have been observed.  Complex antibiotic cocktails with multiple bacteriostatic antibiotic, including tetracyclines, macrolides, rifamycins and sulfa drugs do not eliminate the bacteria. Bactericidal drugs, including gentamicin and daptomycin have proved effective. (only by injection, IV or IM). Quinolones should be avoided for safety reasons. 

Chronic nocardiosis, Morgellons?

My lab is certified by CLIA and the College of American Pathologists for blood parasitology.  I examine blood for bloodborne parasites: Plasmodium (malaria), Babesia, Trypanosomes – flagellates, microfilaria. Today I became aware of a bacterium which may appear in the blood but is not bloodborne. Nocardia. I have a patient with this infection. I have been treating her for a long time.  We think Nocardia infection it is chronic along with tickborne pathogens. The bacterium is found in soil and water and is ubiquitous, there are numerous species, some not yet speciated/characterized. We (the patient and me) have thought she suffers with chronic nocardiosis.  She has a clear, documented history of Nocardia: positive pulmonary infiltrate and positive blood culture. This is a slow growing organism. Texts say this rarely seen organism cultures slowly, 3-5 days. Her culture was positive only after 28 days. Nocardia infections is thought to primarily occur in patients with impaired immunity. She lacked clear evidence of immune dysfunction. The bacteria forms lesions in the skin, lungs and brain. Generally, IV antibiotics are recommended initially followed by oral therapy. Standard sources say skin infection is always curable, lung infection is usually curable and brain infection is curable half the time. Texts don’t address chronic nocardiosis, but I haven’t done a literature search.

This bacterium takes on an unusual appearance.  We are accustomed to rods, cocci and spirochetes.  Microscopically these appear as fungal-like filamentous structures.  The filaments vary in length.  Over the years I seen similar things I thought they were contaminants or artifacts and most likely were (not using the same stain).  Perhaps I missed something.  Of course, this was not on my radar.  Images are startling. Images of clumped filamentous structures, looking not like bacteria at all but rather the dense threads seen with Morgellons appear. The images, if correct (I have not validated them) can be found on google images. I know for a fact that some images on google images are incorrect.

Then there are patient images of skin lesions of the cutaneous form of the disease. Some look horrible.  Some clearly resemble lesions seen with Morgellons.

The chest X rays and brain MRIs are distinct from those seen with tickborne disease.

Again, this organism is found on skin and in the lungs and brains. In severe cases it may also appear in blood, gram stains. I don’t know if it also appears in Giemsa stains I perform.

I wonder if some cases of Morgellons are misdiagnosed nocardiosis. I wonder if Lyme immunosuppression plays a role in the pathogenesis of the disease.  Antibiotics recommended are some of the same ones used for Lyme but not exactly the same ones. The initial early treatment recommended is IV Bactrim.

Lyme and biliary disease

Most readers have some familiarity with the liver and gallbladder.  The biliary (bile duct) system includes the gallbladder and a collection of ducts coming from the liver which join to enter the first part of the small intestines, the duodenum, the first part of the small intestines (bowel) just below the stomach. 


The liver is best known as our body’s detoxification organ (along with kidneys). The liver “metabolizes,” alters and excretes medicines and other substances. 


The liver makes bile, a yellow viscous fluid stored in the gallbladder, located directed under the liver. The gallbladder contracts with meals. Bile made of bile acids, from cholesterol, aid in the digestion of fat (an emulsifier) but has many other functions.  


The liver detoxifies medications and toxins through a system of enzymes with names like cytokine P450. Toxins and medications may end up in bile. 

Adsorption of medications may be dependent on something called the enterohepatic recirculation of bile.

Most bile is recycled from the gut which is considered 95% efficient. A particular bile acid molecule may be used 20 times before it is replaced. This is not necessarily a bad thing. The process of repeated cycling may enhance the function of therapeutic drugs and delay their excretion. For liver toxins this works the other way.  Proper functioning of the enterohepatic system depends in part on a healthy gut flora and specific bacterial enzymes.  Higher doses of antibiotics may be required because disruption of normal flora and necessary enzymes caused by the antibiotic(s). 

The use of bile acid sequestrants to remove unknown toxins like cholestyramine is not supported by scientific evidence. 

Some antibiotics promote the production of biliary cholesterol sludge and gall stones, primarily Rocephin, the popular intravenous drug used to treat Lyme disease.  Cholecystitis (gall bladder attacks) with or without the presence of gall stones is a common occurrence. 

Lyme anecdotally can attack the biliary system. Cases of positive Lyme PCR/DNA from gallbladder tissues are known to me but there are no published reports to date. 

Published reports have established Lyme liver disease in the form of granulomatous hepatitis. 
Tests like sonogram, HIDA/CCK scan and others may be used diagnostically for problems with gallbladder and bile ducts.  Negative test results do not rule out gallbladder/biliary disease. 

I am treating a patient with primary biliary cholangitis (PBC). Generally, the disorder is considered autoimmune, “idiopathic,” which of course means the patient is pathological and the doctor is an idiot. Some European literature (this patient is European) connects Lyme with this enigmatic illness. The patient has a clear history of Lyme. No such connection is made in the U.S. PBC is now a treatable disease. 

Bile via an array of ducts ultimately empties into the common bile duct. Bile the empties into the duodenum into a structure called the Ampulla of Vater. The flow of bile is regulated by a muscle called the sphincter of Oddi. 

After cholecystectomy, (surgical removal of the gallbladder), prior gallbladder pain may seem to recur. The bile ducts may become dilated. When a medical workup excludes a left-over stone stuck in bile duct, liver disease, pancreatic disease and other rare diseases, the diagnosis may be post-cholecystectomy syndrome or sphincter of Oddi dysfunction.

These syndromes are more common in Lyme patients, many of whom suffer with gallbladder disease and biliary tract disease and have had their gallbladders removed. 

The diagnosis is commonly missed or not taken seriously. The disorder can be disabling. Effective medical therapy, in my recent experience, is available but overlooked.