Cognitive dysfunction

The majority of chronic Lyme patients suffer with some degree of cognitive dysfunction.  The term “brain fog” is commonly used. Patients don’t feel as sharp. It becomes difficult to think clearly. Short term memory and working memory are poor. Finding words, completing sentences becomes difficult. Patients feel like they have the sudden onset of ADD (attention deficit disorder). Patients frequently experience disorientation and confusion and a long list of other symptoms. 

It has been suggested that all patients with “neuro-lyme” should be given IV antibiotics. This is not realistic since most patients have brain symptoms. Spirochetes may cross the blood brain barrier within days of infection.

Coinfections alter the clinical p

icture and must be dealt with separately, in specific ways.

Cognitive changes may correlate with white matter spots seen on brain MRI or with poor blood perfusion on nuclear medicine SPECT scans.  

Cognitive symptoms for the most part are due to inflammation, not permanent structural damage; so, in most cases, these symptoms are reversible with appropriate therapy. 

In most cases I like to start with oral antibiotics, ones that are effective against the pleomorphic forms of Borrelia (round body forms and others), and ones that pass the blood brain barrier.  I will talk about treatment in a subsequent BLOG. 

Unfortunately many patients get worse with treatment: we refer to this as a brain Herxheimer reaction. 

The best thing to do may be to hold antibiotics for several days and then restart at a lower dose, as tolerated.    Intravenous glutathione, (only IV), and I have tried all other forms, liposomal, oral, intranasal and even rectal is the only form that works. Glutathione (GTH) when it works, can seem like magic.  HBOT, hyperbaric oxygen therapy can be very effective. I have also found that Welchol works for some patients. 

Welchol is interesting. Being in the field (of chronic Lyme doctors), early on I was told that Welchol and related drugs remove biotoxins.  This is plainly incorrect. The important biotoxin, quinolinic acid (QUIN), does not cross the blood brain barrier. QUIN binds to NMDA receptors, it promotes action of the neurotransmitter NMDA. Drugs that antagonize NMDA are well known to many. These drugs include phencyclidine (angel dust and others). In the Lyme brain the opposite is happening. Excessive activation of NMDA receptors causes (glutamate-excito-toxicity) with increased cell death, associated with a wide spectrum of neurodegenerative disorders, including Alzheimer’s disease.

It turns out that bile acids, thought to be detergents to emulsify fat have neuro-regulatory function. Cholesterol also has neuro-regulatory effects. Welchol may help neuro-inflammation by unanticipated mechanisms.

Other drugs which help moderate the effects of QUIN include the mood stabilizer Lamictal and the Alzheimer’s drug Namenda. Both have a role in the treatment of QUIN toxicity.

It is perfectly OK to treat symptoms as the patient heals. A word of caution with depression: SSRIs, typically used for depression may have a paradoxical effect in the “Lyme brain.” Lamictal, discussed above may be effective. Also, Wellbutrin may be better tolerated. 

Stimulants are very effective for ADD symptoms as well as for fatigue, including: Ritalin, Adderall and others. 

Brain fog and cognitive problems (a patient told me she felt her brain is broken) hopefully improve, incrementally, over time, with active treatment, supportive therapies with an active effort not to make sure the patient does not become worse.  (Do no harm)

Although I do not like to start with IV antibiotics, if patients show no improvement after 4-6 months, and I am sure the diagnosis is correct, it is time to consider IV antibiotic therapy.

Pain

The second-most disabling symptom experienced by Lyme patients is pain. Lyme patients of all kinds of pain. Frequent the pain confuses physicians because it is migratory and transient, here one day and somewhere else the next. This is paradigm busting. Lyme patient may describe the pain in ways which sounds strange. Pain is subjective and very difficult to describe. Chronic pain is extraordinarily common in our country. I was surprised to read that is estimated that 40% of the entire country suffers with some form of chronic pain. Interestingly, the incidence of chronic pain is extremely variable in other countries ranging from 10% to 50%.  Pain, not unlike fatigue, is a brain disorder. MRI changes with a loss of gray matter are seen patients with chronic pain. These changes reverse when the pain resolves. In standard medical literature it is said that chronic pain rarely resolves. That has not been my experience.

The question is: why does Lyme hurt. 

For a start, Lyme spirochetes have a unique ability to infect nearly every tissue in the body. The germ is poly-tropic (can go anywhere) and patients are pan-symptomatic (experience multiple, seemingly unrelated symptoms found in many publications).

Pain comes from skin, peripheral nerves, central nerves, viscera and organs, tendons, ligaments, muscles, joints, head and simply from the brain itself. Generally the cause is inflammation, directly from invasion of the involved tissue or from an autoimmune processes. Pain is frequently associated with structural/physical damage to the involved tissue. The damage may only be seen with nuanced studies of which the general medical community is ill informed.

The severity of pain and the quality of pain vary tremendously and can be difficult to describe.

Traditionally, Lyme has been seen in association with joint pain and arthritis, meningitis and carditis and several others. Mainstream medicine has failed to recognize the connection between numerous  chronic pain syndromes and Lyme disease. Certain coinfection syndromes are associated with specific pain. For example Bartonella as well known to cause heel and shin pain. This will but not be my focus here.

Patient do have variable tolerance to pain for variety of reasons. This will not be my focus as well.

Physicians as a whole are poorly informed about pain and chronic pain and tend to be dismissive of patients complaining of pain. When brought up in the context of Lyme disease pain complaints are received with even less credence.

Many Lyme patients are diagnosed with fibromyalgia. There has been a long-standing debate amongst physicians. Is "fibro" a real disease or simply a garbage can diagnosis? The disease is real. Medical research shows there are path-anatomical changes in the muscles and small nerve fibers in  these patients. The physical examination is patients is clearly abnormal. I consider fibromyalgia a syndrome, not a disease. Lyme and associated infections may be the root cause in many cases.

Chronic pain patients are frequently told they look fine, not showing any signs of pain. This is how chronic pain patients appear. Pain which is unrelenting, day in and day out is torturous and unbearable and yet patients may look "fine."

Physicians should give their patients the benefit of the doubt and assume their patients are telling the truth unless proven otherwise; it is only a small percentage patients who inappropriately seek drugs. A pain management specialist told me that typically 20% of patients seen in his practice are drug seekers not suffering with pain and that this breakdown is typical for other pain practices. Why then, do physicians think the 80% of patients suffering with pain should be made to suffer an unbearable fate because of the 20%?

Please treat your pain. Chronic pain has adverse effects on sleep, mood, neuroendocrine function, functional capacity and impedes the overall healing process. Some Lyme patients live in chronic pain refusing to take opioids because they have the incorrect notion that use of opioids will suppress immune function and their ability to heal. This is not true.

Let's talk about headaches.  Neurologist infuriate me. They are married to the notion that headaches  respond to standard drugs like: Imitrex and Topomax; I’m sorry, but the brain/head forgot to read the textbook. Neurologist and headache specialists are obsessed with the idea that migraine/chronic headache patients will respond to their standard drugs. Narcotics are not prescribed because the patient will become addicted or abuse the drugs. Desperate patients go to the emergency room are almost universally looked at suspiciously. These poor souls are seeking a modicum of relief from pain that makes the sufferer want to tear off his/her head or commit suicide. This no-narcotic sort of thinking is outdated and criminal as far as I’m concerned. In the early 80s I was taught that Narcotics were only to be given to patients with terminal cancer because of addiction. In the 90s the pendulum swung the other way. Physicians were instructed to compassionately treat pain; clinical studies showed that few patients developed addiction. The pendulum has swung back the other way because the DEA is obsessed with OxyContin abuse and able to look at the big picture. This obsession has led to a sudden increase in deaths from relatively inexpensive, apparently no longer stigmatized heroin.

New onset daily migraines and new onset chronic daily headaches are new phenomena. Lyme, Babesia and Bartonella are frequent contributors. Any treatment that works is OK. Therapies such as chiropractic manipulation, botox,  HBOT, and possibly oxytocin can be tried. Ultimately, opioids may be the only thing that works. Patients should be their own advocates and do whatever is necessary to attain a quality of life higher than zero.If their pain doctor does not get it find another who will. They exist.

Lyme arthritis can be challenging. Patient seeking my attention usually suffer with long-standing, intractable joint pain. Many of these patients only improve with very aggressive therapy. Borrelia spirochetes are anaerobic and drill shaped; the bacteria utilize these attributes to invade deeply  into synovial tissues and cartilage. Joint pain can be the only complaint making these patients different from typical, poly-symptomatic patients, and therefore, physicians, including like-minded colleagues, avoid intravenous therapies. However, intravenous antibiotics may be the only treatment that works. Long courses sometimes five months or more of intravenous antibiotic therapy is required. Oral drugs lack the power to penetrate cartilage which is largely avascular. When hard earned remissions occur, maintenance oral therapies are necessary. I have found that the combination of doxycycline and Tindamax is usually effective. I recently saw a refugee from a rheumatologist who was misdiagnosed and pumped her with a panoply of biological agents which caused a severe exacerbation of joint pain. Lyme arthritis may have different faces at times appearing much like rheumatoid arthritis and other forms of arthritis. Plaquenil and sulfasalazine, anti-inflammatory, immune modulating drugs may occasionally be helpful and are safe to use. Steroids should generally be avoided.

Lyme arthritis can look like and act like osteoarthritis. When all the cartilage has been chomped through by spirochetes, bone on bone is all that is left. Surgery may be needed. Hyperbaric oxygen therapy can work wonderfully for some patients. Patients may try low dose naltrexone but in my experiences it rarely works for chronic pain. Sometimes, drugs like Cymbalta and Lyrica are effective. Medical marijuana, available in some jurisdictions, is a new player. For some it is very effective. Alternatively, synthetic THC, Marinol can be and work well. I saw patient today suffer with Lyme arthritis was has been taking liposomal doxycycline. He feels it has been somewhat effective. In my clinical practice I have not seen much difference between standard doxycycline and liposomal doxycycline. In theory, liposomes avoid destruction by gastric secretions, have better absorption and have higher bioavailability. In addition, the chemistry of liposomes allows them to bind directly with the cell wall or membrane of bacteria significantly enhancing the efficacy of the drug. 

If narcotics are the only thing that works, take them. 

Neuropathy pain is extremely common amongst Lyme patients. I have found the vast majority of my patients suffering with chronic Lyme show some evidence of peripheral neuropathy, damage to small sensory and motor nerves. In most cases the EMG/NCV is negative. Frequently, small fiber neuropathy may be demonstrated from skin/sweat gland biopsies. A physical examination can be revealing, especially testing sensation in the lower extremities with a tuning fork. Nerve pain can be excrutiating. Patients with severe neuropathy syndromes can respond dramatically with the use of IViG.

Different types of pain of various causes may respond better to one therapy or another. For example, a nonsteroidal anti-inflammatory drug may be helpful for joint pain but provide no relief for nerve pain. The opposite is true for drugs like, Elavil, Lyrica or Neurontin. Ultimately, every effort should be made to control pain using appropriate medications and ancillary therapies. For the vast majority patients pain can be controlled and should be controlled. This is a necessary part of treatment.

Fatigue

Patients with Lyme disease are incredibly poly-symptomatic or pan-symptomatic; in other words, they frequently have every conceivable symptom and some that were not conceivable. Still on average, the three most devastating symptoms in chronic Lyme disease are: fatigue, pain and cognitive dysfunction. Let me attempt to address fatigue. Then the others.

Fatigue is feeling very mysterious thing. Words like fatigue or exhaustion do not begin to describe what many patients experience. Patients frequently report that it is difficult to move their head off the pillow in the morning – the thought of taking a shower (the thought, not the action) is daunting. This experience describe something which is qualitatively different from what most of us think of as fatigue or exhaustion. I don’t have a name for it.

Where does fatigue come from where is it localized? It seems to be a brain issue. A recent study from Stanford University School of medicine has found structural, MRI changes in patients suffering with chronic fatigue syndrome. There is reduction in a white matter content, particularly in the non-dominant hemisphere in an area called the arcuate fasciculus. The level of symptomatology correlated with the extent of anatomical change. Interesting. 

Medical doctors are quick to diagnose Lyme patients with a psychological disorder: just what long-suffering souls, marginalized by mainstream medicine want to hear (for the millionth time) I suspect infectious disease doctors would be displeased if psychiatrist diagnosed Chagas disease or tularemia and  rheumatologist would take offense with psychiatrists diagnosing scleroderma or sarcoidosis. Specialist: stick to your own fields. If you don’t know what’s wrong simply say I don’t know what’s wrong; don’t make up a diagnosis, the wrong diagnosis, one that stigmatizes, ignores, marginalizes and disparages your patient, thank you.

Fatigue is associate with so many different medical disorders. Generally, most doctors quickly rule out obvious disorders such as hypothyroidism. That is about as far as they go. (They frequently get that one wrong too). Most doctors cannot comprehend fatigue that Starbucks can’t fix. 

There are some other common causes of fatigue which need to be examined. It is not unusual for me to see a patient who has suffered with fatigue for years who has never had a sleep study. The polysomnogram, the basic sleep study will frequently find: obstructive sleep apnea, central sleep apnea, abnormal sleep architecture with loss of deep sleep and/or REM sleep, restless leg syndrome and periodic limb movement disorder. When patients say they are able to quickly fall asleep or take a nap on command, a second study called an MSLT, multiple sleep latency tests should be also ordered to rule out narcolepsy.

Of course chronic infections do cause fatigue, especially those involving the central nervous system. I find that my patient who failed previous therapy need more intensive, frequently intravenous antibiotic therapies. Even the NIH sponsored studies show improvement of fatigue with intravenous Rocephin. 

If the patient was well before Lyme disease I assume Lyme and related infection is the primary cause of his/her fatigue. Looking for things such as mycotoxin exposure and heavy metal exposure may be worthwhile in patients with chronic symptoms. In my experience, inadequate treatment of Lyme disease, babesiosis and/ or other co-infections is frequently an issue.

Of course patients suffering with chronic Lyme are depressed. Only rarely does the treatment of depression significantly improve the fatigue. (Many doctors become hung up with this answer). Patients have trouble falling asleep and staying asleep. They have disrupted circadian rhythms, stay up at night and sleep during the day. I believe it is okay to treat  symptoms. A lack of sleep contributes to a cascade of falling dominoes leading to neuro-endocrine and immune dysfunction making everything worse. Medications for sleep may include trazodone, Ambien, Lunesta or Restoril. Klonopin in particular is useful when restless leg syndrome, anxiety or pseudo-seizure like activity is present.

A word about the treatment of depression. Patients with CNS infection have excessive neurotoxins floating around such as quinolinic acid. Patients may have glutamate excitotoxity. This means their brains are very sensitive to the neurotransmitter glutamate or glutamic acid. Lamictal may be the drug of choice; this agent needs to be titrated carefully because of the risk of serious skin disorder. Patient may paradoxically worsen with SSRIs like Prozac and Zoloft; Wellbutrin may be better tolerated. 

Fatigue can be treated with a wide variety of stimulants. Changing brain chemistry can help. Nuvigil has been a particularly helpful drug although insurance companies are loath to pay for it. Alternatively, ADD drugs like Ritalin and Adderall may be used with varying degrees of success. When these medications are effective improvements in function help the overall healing process.

Adrenal fatigue is real. Endocrine dysfunction of various kinds may occur. Chronic illness overwhelms the neuro-endocrine axis. Blood tests, saliva test and urine test may be helpful; adrenal supplements may be very helpful.

Other treatments occasionally help such as low dose naltrexone and now oxytocin therapy.

Lyme patients have an incredibly complex illness: do not overlook a wide array of possible contributing factors.