This took me a long time to figure out. It is an interesting story. Maybe only if you are a Lyme nerd like me. Patients with Lyme disease have weird vitamin D levels. Most are diagnosed with vitamin D deficiency. In fact patient have come to me saying they have a severe vitamin D deficiency which never corrects no matter how much vitamin D their doctors give them. Strange, isn't it? Everyone knows that vitamin D is a nutrient that is essential for bone health, your body needs it adsorb calcium and build strong bones. Wait a minute. Its not a vitamin at all. Its a hormone. Vitamins are co factors needed in trace amount to facilitate the actions of enzymes in the body. Hormones are messenger molecules. Vitamin D is stored like a fat soluble vitamin, but it doesn't act like one. Other vitamins are taken in via the diet. Vitamin D is mostly manufactured in the skin due to the action of the sun. It turns out that vitamin D is a busier hormone than we thought. It also has important regulatory effects on the immune system.
And do these Lyme patients really have a vitamin D deficiency? NO. Some are vitamin D toxic! Doctors are looking at the wrong thing. Vitamin D exists in several chemical forms. The major circulating form is the OH,25 form. This is the form that doctors generally measure. It should exist in the highest concentrations in the blood. This form has little to no biological activity. When you measure the 1,25 form of vitamin D the level is usually in the high normal range or even in the toxic range. This is the form of the hormone that is biologically active. Something funny is going on. A value which should be high, inactive vitamin D is low; a value which should be low, active vitamin D is high. The patients are definitely not vitamin D deficient. We better stop giving them all this vitamin D. What does vitamin D do in the immune system. High levels of vitamin D bind to receptors in immunologically active cells, including a group of cells called helper T cells. When these receptors are turned on by vitamin D it causes a response call a Th2 response and it shuts down something called a Th1 response. This is not as complicated as it sounds. Give me a minute. These two different helper T cell responses are associated with two different potential actions of this aspect of the immune system. The Th1 response is associated with chemicals and peptides which are pro-inflammatory and lead to an attack against intracellular germs, like Lyme L-forms. The Th2 response reduces inflammation and shuts down the germ killing response. These buggers are smart! Somehow, by altering the balance of a hormone called vitamin D, the germs have manipulated our immune system in a way which improves their chance of survival.
Normally this conversion of vitamin D to the active form occurs in the kidney. Some observers think that the germs are making this process occur on a cellular level. In other words, infected cells cause the change by some local effect.
Well, what do you do about it? And what does it have to do with a guy named Marshall. Dr. Marshall is PhD doctor, not an MD. He claims he cured himself of a disease called Sarcoidosis, not Lyme by using his methods. He argues that the same vitamin D abnormality is present in Sarcoid as well as other autoimmune, inflammatory diseases. He believes it occurs because a collection of L-form bacteria are in the host cells. The L-forms are not just Lyme. Other bacteria are known to be L-forms, including Chlamydia and Mycoplasm species. All of these L- forms together, conspire to cause this anomally which shuts down a critical immunological response. The theory then goes that if you can get vitamin D levels very, very low, then the Th1 response predominates and the Th2 response becomes negligible. Once this occurs, very low doses of antibiotics are all that is needed to kill the L-forms, which he and his followers claim are causing all the trouble. In order to make this happen you have to live a miserable cave like existence for about two years. You avoid all light and all dietary sources of D. Then you take a medicine which inhibits the vitamin D conversion which occurs in the kidney. When I read some of his reports I saw a claim that 30% of his chronic Lyme patients were cured. Heck, 90% of my patients are cured and I don't have to torture them. Most docs who treat a lot of Lyme have abandoned the so called Marshal protocol. But let's not throw out the baby with the bath water. I think Dr. Marshall makes some excellent points. One problem with the approach is that we clearly know that when treating Lyme patients, L-form infection is not the only issue. This is made clear by the remarkable effectiveness of drugs like Rocephin, which are unable to kill L-forms. It seems reasonable to assume that this aspect of the immune system normally functions with some balance between the Th1 and Th2 responses. Normal folks with properly functioning immune systems do not have super low vitamin D levels. So I think it is reasonable to not give extra vitamin D if the levels are normal. I think it is reasonable to reduce vitamin D levels which are clearly toxic. Such patients should avoid the sun and dairy products. I do wonder if bile acid drugs like Questran help lower vitamin
D. And in some patients the drug Benicar seems to help. It is really a blood pressure medicine of the angiotinsin receptor blocker class. But it has a nifty side effect of inhibiting renal conversion of vitamin D from the inactive to the active form. So it can help correct the imbalance of vitamin D seen in these individuals. One would hope that patients would fair better when there is a physiologic balance between these two aspects of this immune function. The truth is we still know very little about this. It is worth looking at. If nothing else, the mixed up vitamin D levels may have its greatest utility in helping to make the diagnosis of chronic Lyme disease. That's all for now.