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Wednesday, October 29, 2008

Evolving strategies

It is becoming clear to me that most patients have co-infections. The idea of combination therapy is morphing into combination therapy which transitions into co-infection therapy. Trying to treat "everything" at one times is counterproductive. Patients Herx too much. Let's take a typical mild/moderate case. We can start with Amoxil/Biaxin/Plaquenil. We have a cell wall agent, a protein synthesis blocker and a drug which is synergistic with Biaxin-reduces inflammation and may have some anti-cyst properties. If symptoms quiet down after some period of time we can transition into anti-Babesia therapy. Mepron and Artemesin can be added. To minimize the number of drugs Amoxil can be withdrawn. If "Lyme" symptoms recur, Amoxil can be reintroduced. I like Amoxil because of it's flexibility. The dose can be increased and Benemid can be added to increase serum levels if desired. Also, one can ease into Babesia therapy by introducing Artemesin before Mepron-or Malarone, to control secondary Herx responses. After Babesia symptoms clear the Mepron and Art are stopped. Bacteria in blood can be addressed(Bartonella, Mycoplasma and possibly Ehrlichia). Rifampin can be introduced. Plaquenil can be stopped. If needed, Levaquin or Cipro can be started. Amoxil would be stopped. Biaxin can be changed to Doxycycline to cover Mycoplasma and Ehrlicia better. We still have to address Cystic Lyme forms. If the patient is generally better, Lyme treatment can be resumed with Flagyl, Amoxil and Biaxin or Doxy. This can be continued until the patient has been asymptomatic for about two months. At that point, may be in remission. This can only be determined if the patient remains symptom free off therapy. The order of treatment can be modified based on a clinical sense of what is causing the mosts symptoms. Flagyl can be added early on for more agressive Lyme therapy or Bartonela/Mycoplasma can be treated first instead of Babesiosis. Bartonella and even Babesia do not always require therapy. They are opportunistic. Once Lyme has cleared the immune system may eliminate them.

All of these concepts are in a state of flux. The main idea is to overlap therapies which make transistions easier. It also important to attempt to reduce the total number of anti-microbials taken at any one time to minimize drug to drug interactions. One more comment: I find Biaxin to be more effective than Zithromax, but Zithro has less drug to drug interactions. Biaxin and Diflucan can cause prolongation of QT intervals and increase the likelyhood of heart block and even fatal arrythmias. EKG monitoring is advisable with these drugs.

The paradigm is complex and evolving.

Additional information: Clongen WBs are good. Clongen finds bacteria in blood smears and performs a variety of strains. A Bartonella PCR test is available for all strains. A PCR test for 15 strains of Babesia is under develpment.


dogdoc said...

I'm in agreement with all. Reguardless of any controversial stuff, there are studies showing the Babesia and Lyme rates in Maryland ticks to be equal and both very high. They didn't study Bart. In a patient whose cellular immunity has been compromised, there are a whole host of ubiquitous infections that are likely to be lying in wait held in check by the immune systemjust waiting to be reactivated or let loose. Most of us by adult hood will have been exposed to community pnemonias (chlamdia and mycoplasma), neurotropic viruses like the simple HHv6 and others. Immune deficient folks will also go around picking common things up like Bartonellas. I've done a lot of studying of secondary infections in people with immune deficiencies of various types (figured they were good models). I've also looked into treatment requirements and lengths of "zebras" just in case. Didn't know I'd have to study immunology, bacteriology, pharmacology, and infectious disease. Don't think I've put this much into my brain since vet school. Anyway, I think we can cover knowns, opportunists, and possible zebras if we do it carefully. Been working on this one intensively for a while.
We definately cannot treat for everything at once- drug reactions abound if we go there. In a mild patient with fewer, less severe coinfections, it probably doesn't matter as much how it is approached as far as order. In moderate to severe patients who already have suppressed cellular immunity and considerable well entrenched coinfections... there it is much harder. Until the bugs are knocked back enough that the immune system can take back over, we are trying to juggle keeping everything suppressed enough so nothing is at overwhelming levels. You can't treat one thing and get it over with necessarily- you can get it knocked back, but the little that's left will just come on back when the treatment is stopped because the immune system can't hold it at bay. I think we see this commonly with Babs. But if we don't keep everything knocked back, the additive immune suppression of all these bugs makes it hard to get anywhere at all. Hence the heavily treated patient for years that we still haven't cleared. We can't treat it all at once, but if we are crafty about it, I think we can keep everything at least treated frequently enough to hold it at bay BUT without switching around all the drugs all the time. Also, I think we can do this and keep longterm combinations of effective drugs for the slow and difficult to treat beasties (as well as cover zebras and other known, less coomon tick bourne infections). I'm going to save now and continue in the next post.

dogdoc said...

Continuing on- I see a way perhaps to make it all happen. Bear with me as I explain. I see three starting phases of treatment. First based on Biaxin/Plaq/Amoxi et al. Second based on Biaxin/Doxy et al. Third based on Doxy, Levaquin et al. I'll explain the et als in a minute. They fight all the rest of the peices. But the core gives us extended lengths on drugs for the major players including slow growers (and covers us for zebras in careful et als and how they are combined). It also uses for as long as possible, dual synergistic (or at least not antagonistic) drugs for the tough slow growers to decrease resistance forming over time. This is the basis for treating almost every tough long term treatment bacterial disease in our history. The et als provide triple therapy at times. So here it is - will discuss details at the end.

I. Biaxin, Plaq, Amoxi (discuss flaygyl down below) going to Biaxin/Plaq/Mepron/Art trial +/-Amoxi.
II. Biaxin/Doxy/Plaq (discuss Larium down below) with cycles of one additional treatment at a time - length and exact ones patient specific, but including:
> Bactrim
> Cell wall(amoxi) & flagyl
> Mepron, Malarone, Art (discuss below)
III. Doxy/Levaquin (discuss plaq, larium below) with cycles of one additional treatment at at time- length and exact ones patient specific but including:
> Rifampin (or Rifabutin)
> Cell Wall & flagyl
> Mepron, Malorone ,Art (discuss below)
I'm going to save now and continue detailed discussion in next one.

dogdoc said...

Ok- details of what and why. Phase I- Amoxi/Biaxin/Plaq. Like amoxi for Lyme spirochete- safe to high dose and get penetration in cns if meninges inflamed (will be at start in many), well tolerated, and gets inactive form of Chlamydia well to reduce load there if we happen to have that one too. Biaxin- Like for Lyme- tissue penetration excellent, clinically effective. Can also start to help supress Babs and Bart and also to work on many others if present- has activity vs chlamydia, mycoplasma, ect. plaquenil- not sure I buy current theories on synergism or antiniflammatory action (truly unproven); however, clinically synergistic in Lyme with Biaxin it seems, shows in-vitro the ability to decrease cyst formation (nice with Amoxi) and at higher concentrations shows spirochetal activity vs borrelia. At very high concentrations shows cystic borrelial activity. However, plaq concentrates in interesting places. Has many times the level in CNS as it does in serum. Some tissues extremely high like liver. But enough in CNS to cover and assist amoxi. My theory on syngergism of the favored starting combo. I would start these drugs sequentially. First Biaxin. Then in 5 days, plaq. Then in 5 days amoxi. To spread out that first herx (well remembered personally) but also to get biaxin and plaq up to blood and cns levels so when we hit with amoxi, cyst formation is inhibited. More dead, less hiding. I would start cholestyramine and welchol at high levels 10 - 14 days before antibiotics start (use the combo or 4x per day on the powder). Again, minimize the initial reaction by lowering initial levels of lipoprotein toxic substance before we kill a bunch off and send them thru the roof. Then I would cut CS to twice a day after first herxs and dc fairly shortly into phase one (except in breaks- discussed later). Has the capacity to interfere with enterohepatic cycling of drugs and lower acheivable blood levels. May be reasons for some of our drug failures. Some drugs would be predictably affected (rifamycins and doxy) but many others have potential. Not by direct binding in gut (can avoid taking simultaneously)- but by preventing enterohepatic circulation of active metabolites excreted in bile. Moving on in phase I- after stabilized and done herxing on Biaxin, Plaq, Amoxi, I would consider 3- 4 weeks metronidazole to reduce cyst load (probably significant even before starting antibiotics in chronic patients) esp in CNS to clear brain fog quicker. Tough one I know- was able to get tough patient on it in a funny manner. Gave one dose on weekend, herxed for 2 days bad. Recovered by the next weekend. gave another dose, herxed but not as bad. The next weekend, gave a dose- not bad and was able to start on full dose with just a normal herx. Did this by accident- stubborn hubby didn't want to wait. Tried it (before done herxing on the biaxin which was not what I said to do) and crashed. Recovered and tried it again because after the crash he felt better (probably the biaxin kicking in and coincidental). Wasn't as bad so tried it again and then was fine and went straight to full continuous dose. Anyway- really does seem to assist with knocking brain fog back fast. Back to the philosophical discussion- reason for it as soon as you can would be to decrease the reservoir of Borrelia lying in wait to come out and play. Also, these guys are hiding in places where they probably inflame and induce cytokines just by sitting there. ESPECIALLY in microglia. Flagyl is a small lipophilic molecule with excellent cns penetration- right place at the right time. Also gets one of lifecycle forms of chlyamdia if that is about and in- vitro shows a good prevention of conversion to cyst properties. Moving on in phase I- here is a quandry- would like to get Doxy on with Biaxin asap for synergism and resistance (and action vs other players). However, would like to see if Babs a big clinical issue with a test of Mepron without Doxy on board to lower its blood levels. Compromise is go a month more without doxy for a Mepron/ Art trial (still with Biaxin +/- still with Amoxi)to assess extent of issue (important for phase II- more later) and get Babs knocked back to a dull roar to decrease clinical signs in those with it as a big symptomatic contributor. If a big change in trial, can go longer here and/or adapt phase II to be better at supressing Babs while intermittantly going back and treating on it. Wouldn't waste a lot of time and money going for the complete kill at this time- immunity not there yet to back us up. Just a quick and dirty knock it back a notch and try to maintain it suppressed at lower level until rest is better supressed and then we can revisit the kill. More on that later. For the Artesminin- it has been extensively studied in Malaria. It is used most effectively in that when a longer acting drug is on board at the same time- it has rapid kill and short lived effects (probably associated with increased metabolism and subsequent drop in blood levels). I would decrease the herx in the opposite fashion- mepron first and wait until stable and feeling better, then art rapidly going to full dose. Will get max effects in 3 weeks of Art so D/C after this to decrease resistance forming. Then we preserve our ability to cycle in and out later and get more out of it than continuous usage would give us. Sorry about all the detail- have been working on this hard for a month and everything is where it is for a reason. Ok will save again and move on to phase II of initial treatment.

dogdoc said...

Onto phase II- keep Biaxin, keep Plaquenil, add doxy, consider Lariam and add cycles of addl drugs. reasonings- doxy and biaxin synergistic in many infections, work at similar step in protien synthesis but in two different locations, and help possible resistance formation in players needing longterm treatment (borrelia, mycoplasma, chlamydia, bart). Harder to form two completely seperate mechanisms of resistance simultaneously before you die- use this trick in a lot of tough infections. Doxy is nice to have on board early also- covers a lot of zebras as well as rickettsia, ehrlichia, ect. Is syngergistic with antimalarials in that disease so may give us a Babs suppressive edge. Keeping biaxin through two parts gives us a nice long continuous phase. Plaq stays because of similar reasons in phase I (is also syngergistic with doxy on some zebras). On zebras, won't bore you with details unless you want me to. May want to consider adding a touch of Larium- once a week with no loading to decrease side effects. It gets used this way vs babs when $ an issue or to keep at bay longterm in "Mepron failed" chronic cases. It gets used with plaq and doxy or biaxin and doxy so all are tested combos. Interestingly enough, it also has syngerism with some zebras and biaxin. So when stable on the biaxin, plaq, doxy, +/- lariam, then start adding in one additional drug cycle at a time with length, type, and order depending on patient. Bactrim DS would be one here- for "pseudo- bart" (say that b/c biaxin and doxy +/- rifampin drugs of choice in bart in aids- well studied those patients and TMS and Levaquin not considered reliable enough for bart in those patients). However, certainly could help with resistant bart- folate metabolism is very different mechanism of action from doxy/ biaxin. Also could be active against some babs from a different angle than the other drugs we use. Good for some zebras as well and for some other cns opportunists we might not be thinking of. Used and thus tested in combo with doxy, biaxin, plaq by some as alternative to mepron. Another add on drug cycle would be cell wall antibiotic (amoxi- although could branch out if a reason in that patient) with flagyl the last 3 or 4 weeks. Same reasons as in phase I- may want to D/c plaq at flagyl time if just too many drugs. Another addon drug cycle would be mepron and malarone with art. Reason for mepron and malarone (just once daily)together is because use with doxy- doxy lowers atovaquone blood levels by up to 40%. So adding in a bit of malarone would increase atovaquone part of it to overcome doxy effect AND also to get synergism of the two drugs in malarone. would d/c plaq and larium during this cycle. Inbetween cycles, I would do at least a week or two with only the basic drugs (biaxin/doxy/plaq) to allow blood levels of cycle drugs to cease. I would do a short course of nystatin at this time to keep intestinal yeast at bay. I would add in cholestryramine at this time as well- possibly increasing the dose of doxy a wee bit to compensate so we don't get subther. levels. The length and number of cycles could be customized to patients signs and response to therapy. When no longer improving with each round, move onto part 3.
Phase III. Drop biaxin. Keep doxy, add Levoquin, +/- on the plaq and lariam depending on how babs is doing. Add cycles of treatment as in II - rifampin, cell wall ab = last 3 weeks with flagyl, and mepron/malarone/art as before. reasonings- addition of levaquin at this point is going to pickup longterm treatment failures due to resistance or tissue penetration from major players (borrelia, mycoplasma, bart, chlamydia). tendons have had a chance to be rid of most of borrelia and heal. Levaquin is active on its own and synergistic with doxy or rifampin with some zebras. Rifampin at this point adds another drug with excellent cns penetration and activity vs a number of players and zebras. The other cycles continue to knock down borrelia/ cysts formed in previous period since last dosing of flagyl and keep knocking babs back a notch at a time.
By the end of these phases, we will have had the patience to maintain good long stints of biaxin, doxy, and levaquin- long enough for the most stubborn of slow growers. we will have covered a ton of zebras, beat on the babs and bart well from all different angles, avoided resistance hopefully as much as possible by killing with next thing before a chance to become resistant to yet one more drug. If I was a bart for example, I'd have to develope serial and simultaneous resistance to biaxin, doxy, bactrim, rifampin, and levoquine in order to survive. If I was a babs, I would have had to survive multiple rounds of treatment with mepron and synergists plus extended treatment in between with a variety of drugs that act to suppress my growth in multiple combinations (biaxin, plaq, doxy, bactrim, lariam, ect). And so on. Hopefully will have kept all major and minor and potential bugs suppressed long enough for immune system to have fully recovered. If not, we have left ourselves places to go- we still have other cell wall drugs for resistant borrelia or to go IV and get the high blood levels to ferret the few remaining out of hiding (when the month or two people get might actually finish them off as apposed to just get them started). We've got Tiacyl for players acheiving doxy efflux pumps. We've got Ketek potentially stretching a few of the resistant there. We've got antifungals (to knock back yeast but also novel actions on some players), we've got antivirals if we have to. We've got other minor things too- mino for perhaps a differnt tissue penetration angle, ect. Anyway- lot more to say but getting really tired.
for the simpler patients, could pare down and customize. Basic tenants remain the same- maximize duration of major drugs, use combinations and sequences to avoid and catch resistance, suppress different things in a cyclical fashion so as to keep all coinfections and primary infections suppressed enough to cut the immune system some slack for quicker recovery. And keep evryone more patient and reallign their expectations with realistic treatment period (docs and patients). Whether or the full version or a shortened one because you are not so bad to start, you have a long staged treatment with expectation of continued improvement with each new thing. Much better psycologically than do this- didn't work, do this, need more, now what mentality. We have mental failures and I give ups as much as treatment failures in our toughest patients. Optimism is a good immunostimulent. We can discuss those next.
So what do you think? I didn't talk about obvious stuff like drug interactions. You'll know which of those were avoided and why. I think I went through about a zillion options and combinations to come up with this- it was like a big logix puzzle. Need to satisfy this great long list of treatment requirements (standard and zebra), avoid these interactions, provide these minimum lengths of treatments without starting a stopping drugs where resistance would be a problem because not a lot of alternatives, provide a way to suppress these organisms and keep them that way for this period time simultaneously. I like challenges. I NEED SLEEP! Night.

dogdoc said...

Oops- correction. In my tiredness of typing that all in last night, I added a mepron/malarone/art cycle to the Doxy/levaquin phase III which was not meant to be there. The intention was to stay in part II until babs was clinically kicked, end phase II with a final mepron/malarone/art cycle, and if babs had been a clinical player as far as response to therapy in the first two phases, use plaq/weekly lariam when not on rifampin. Also, might do bactrim cycle in phase III. Finally, would do a final cycle of zithr and mepron after phase III was done to see if any clinical changes still- ie to go in for final kill here after having been off those drugs in phase III to see if it built back up without more specific suppression. Sorry about that. One shouldn't type that late at night.

dogdoc said...

That was still not very clear.

I. Biaxin/plaq/amoxi (+/- 3-4 week metronidazole) then add mepron/art trial for 3-4 weeks (+/- drop amoxi out for that) possibly extended if a lot of response

II. Biaxin/plaq/doxy +/- weekly lariam (dep. on mepron/art trial and clinical condition) with sequential cycles of- batrim ds, amoxi (other cell wall prn) with flagyl last 3 -4 weeks, and mepron/malarone/art (d/c plaq and larium in this cycle). nystatin and cholestyramine in break in between cycles with just core drugs (up doxy prn w/cs). Cycle until babs kicked clinically and end on mepron/malaron/art cycle.

III. Doxy/levaquin +/- plaq/lariam with cycles of rifampin/rifabutin, cell wall/flagyl, and +/- bactrim.

If babs had been a major player, would do zith/mepron/art trial right after phase III to go for final kill (or work into phase 4 if we need one).

dogdoc said...

For the mild patient where would soon have immunity returning to help with babs, bart, and other coinfections....

I. Biaxin/plaq/amoxi with 3-4 weeks flaqyl when feeling better. Add quick 3 week mepron/art trial to guage clinical response at end.

II. Biaxin/plaq/doxy with cycles of cell wall drug with 3 -4 weeks flagyl at end of each. Nystatin and CS on cycle breaks with base drugs (up doxy prn). If felt clinically needed, could do bactrim and or mepron/malarone/art cycles but probably not needed.

III. Doxy/levaquin +/- plaq with cycles of cell wall drug with 3-4 weeks of flagyl at end. Nystatin and cholestyramine between cycles with up doxy prn. If needed, could do rifampin or bactrim cycles but probably not.

Then reevaluate. If had response to initial mepron trial, I might end with zith/malarone/art for three weeks.

dogdoc said...

All of the above are fairly aggressive orals for both severe patients and minor ones. However, because of this, they cover a host of coinfections well without a ton of expensive and potentially unrewarding testing (if possible, I'd still do basics we do now plus pcr for bart ssp, mycoplasma ssp, and when we can get it babs ssp. I think this would help us stage disease and determine how aggressive to go in. If not cost option, at least you are well covered in treatment. I might pcr first for borrelia even before blot if treatment naive- hey if positive, can short circuit the whole bands of this or that issue.
****** I think most of all, you never get the chance again to go in aggressively with combo orals on unresistant treatment naive bugs. You try this, then that , then this again and it doesn't work- you are sol if you have just created resistance to your major drugs that have no good substitutes. You'll never get as good of response with second round retreatments. Imaginine treating tb with rifampin monotherapy for 4 months, and then trying IMI for three months, then trying PYZ to four months then trying EMB for three months. You MIGHT get it- you would probably end up screwed with a patient who still has TB at end and now has multidrug resistant TB. You just left yourself scrambling for the IV gentamycin and whole host of expensive and even more nasty and toxic drugs than the ones you started with. Is this clinical picture ringing a bell?
I'm not saying I've got it on what to do. I'm trying to stimulate discussion and developement towards a better mousetrap for these severe lyme complex patients. We don't need two years of IV stuff to start- we could do that in TB too and we'd still end up messed up at the end. We need to think about what we have to kill, what can reduce resistance and speed therapy with the best combinations... just like we do in other tough longterm treatment diseases (lots of tough zebras out there we do this with- just TB is common example so is understandable to docs). If I hear everyone is different one more time, I might scream. I realize that and am not stupid. I've seen the light at the end of the tunnel and what direction we need to go conceptually for a while- just needed a lot better background and understanding before I could intelligently start meaningful discussion. However, all patients are going to remain "different" if we don't start trying to get systematic about this so we have something to tweak and do trials on. One last time- if I gave you a group of patients with advanced disseminated TB and 6 drugs with activity vs TB and told you all patients were different and you had to try things a few at a time until you found what worked for that patient......really think about it. How would the clinical picture go? Would disseminated TB be driving you crazy? Would all patients seem different? Would you have persistant TB at the end in a number of patients and have it seem untreatable? this is not a personal attack- I am trying to shake all of us up here. Patients are difficult and different- but total options of bugs involved and immune consequences are somewhat predictable. If we don't start getting systematic about what we try and when, we are not going to get the information we need to successfully tweak our combo treatment. It may be a very long time before we stumble across the right combo- think of TB past and present and the stages we have gone thru in the last century on it.

Unknown said...

Photon therapy, have you heard it? any comments?

dogdoc said...

I know a little bit. The placement of the light sources for different conditions sounds a lot like acupuncture. The blog testamonial results fit with something like that- although chiropractic and acupuncture work sounds like its part of the spa treatment experience. The manufacturers have some interesting theories about light being the communication signal in neuro and endocrine system at biowavelengths in the infrared. Also that main atp related energy processes were associated with the wavelength. I found one with the typical eastern terminology and way of thinking of flow of chi or life force thru the body. This is the typical basis of eastern physical manipulations like acupuncture. I've certainly seen that be palliative (ie keep at bay with regular treatments) for pain and in people sense of well being. We Westerners can explain that in our terms- release of endophorphins and blocking of pain pathways thru nerve stimulation. Some of my hubbys neuro focal pains will go away temporarily if you apply heat or cold and keep the neuro circuits busy with another sensation. Works in labor for some women also. I'm guessing this is the basis of all of this. I did see some scary stuff in this- ozone is fine to apply to the water in a hot tub, but I wouldn't want them running my blood thru an ozonator. This is why I really want a better medical solution to this- so people aren't forced out to stuff like that because they think it is their only chance. If Bryan ever shows back up, he might know more about it. I think he did a couple of experimental deals like this in Europe. Including one where the guy next to him died. We need a good treatment so this kind of stuff doesn't happen. I know I'm allopathically oriented- but frankly, for disease based on bacteria and parasites, we should be able to find a way to do a better job. We have with many, many other horrible and fatal diseases over history. Theres a lot of stuff we are not so good with- just usually our track record gets pretty good if we work on an infection for 50 years or so. Problem here is it is not being worked on- it somehow does not exist in the main medical and pharmaceutical communities.

Lyme report: Montgomery County, MD said...

Some patients are easy to treat and respond to very simple regiments. Complex strategies need to he held in reserve. I try to follow evidenced based medicine or at least something that resembles tried and true strategies developed by LLMDS with more experience than me.

You can go crazy thinking of all the permutations and possible strategies. Ultimately, each patient responds differently.

Flagyl first to activate immune responses (Big Herx) and push Bb into L forms and Spirochetes followed by intensive cell wall and protein synthesis drugs might work great. Or not. I probably won't be the first one to try this. Everyone doesn't have co-infections, at least not ones that require active treatment.

Patients who present with initial tick bite and classic EM rash are treated with agents which only cover Bb and get better. Many are probably simultaneously infected with Babesia, Bartonella, Mycoplasma and others. The Lyme only is treated and the opportunists never gain a foot hold.

Most patients don't need bile acid sequestrants. These are a pain to take and have side effects. Their role is far from clear.

Jemsek likes to use clindamycin as his transition agent since he believes it is active against Bb and Babesiosis. It has been used in ant-Babesial therapy. Is there any evidence that it is active against Bb? It has anerobic coverage- if it hits Bb is it active against the cyst forms?
I don't have the science behind me here. I only use this fairly toxic drug when pushed there by drug allergies.

Rather that assuming that all patients need all those pathogens treated I prefer to be a bit more circumspect. What seems likely clinically? Let's treat one thing at a time and monitor the patient's progress.

I can show you a large collection of Lyme patients who are serologically positive for B. microti and who are remission for tick borne illness when Bb was the only organism treated.

Occasionally, the much maligned IDSA.CDC is correct. They claim that Babesia is usually eliminated by the immune system. They believe that Babesisia is only present if it is PCR positive or seen in a blood smear. There are wrong regarding this point, but correct regarding the first point.

Most assymptomatic persons have been exposed/infected with Bartonella and Mycoplasma species.
It is only a disease if it is causing dis-ease.

lymie said...

I know of a lyme case that smoldered for two years after the bite, then blew up with severe multisystem symptoms. It was only after the big surge in symptoms that babesia began to express itself. So, it didn't go away without treatment and it was asymptomatic until the lyme took off. What do you make of this?

Lyme report: Montgomery County, MD said...

See today's blog.
If the symptoms were "smoldering" then the Lyme was not in remission and perhaps co-infections should have been considered. If the patient was asymptomatic then It would have been hard to justify screening for Babesia. Most patients with antibodies do not have persistent infection. Treatment for Babesiosis is based on symptomatic response. The therapy can be complex and may take 4 to 6 months. In general asymptomatic individuals are not tested or treated. If it ain't broken don't fix it.

dogdoc said...

Hey doc,
I agree many cases are simple and straightforward. I was including those in the mild to moderate catagory (assuming you could clinically differentiate which patients were likely to turn into the long protracted everyone is different group that we treat at for years to no avail like your case report to be). Perhaps you can not predict upon presentation?
I think docs who are Lyme literate (you I guess since that is who I have to look at) are very successful in diagnosing and treating the average mild to moderate case of Lyme. They follow the standard treatments and have the standard coinfections if any are present. The immune system takes care of most opportunists like babesia, mycoplasma, toxoplasma, ect. These patients may not need to be treated for co-infections once the Lyme is treated or if they do, will probably respond to "normal" length treatments. This population is not all different.
I was specifically refering to the population that was presenting severely to start with and was likely to be one of those cases like in your case report- one we work on and work on without resolution. These are the all different ones. My focus is on these patients. You can understand why as my husband is likely to end up one of them. These are the ones we haven't figured out yet that I think we could use a systematic approach of SOME kind. There has to be something underlying in these patients or they would be like the easily treated first group. What are we missing? An underlying zebra (natural or not)that we would never think to test for? A self perptuating immunodeficiency syndrome where the Lyme reactivates dormant things or is transmitted at the same time as another cell mediated depressant- all leading to a continuous unbreakable cycle of opportunistic and primary organisms causing ongoing immunosupression and disease? What are we missing in these severe patients resistant to our best efforts of treatment for everything we know?

MoreOrLesMe said...

I thought I would post my latest report to my LLMD. I’m 2.5 months onto treatment with Mepron & Biaxin. The herxs where bad for 5 days then tapered off as did much of my 20+ years of joint nerve pain.
I started Artemisinin this month have been herxing quite a bit going to drop it to 500 MG 1X Day
Tuesday, November 04, 2008
My pain level is better get like 1 or 2 day flashes pain & Symptoms followed by discolored urine Dark or clear with a white cast then I feel better than I have in years then it cycles. I fear going off of Mepron I don’t think I can cope with my previous pain levels
Depression is improved I have had days that I just feel good for no reason.
My difficulties with concentration have improved I still have bad days that I can’t remember things.
My fatigue is better I’m using coffee 20 oz (+-) I’m still taking ½ a Provigil 100 MG, ½ Dexedrine .05 MG (2) times a week when needed with Coffee when the flair up happen Last Month I was taking ½ a Provigil 100 MG and 1 Amphetamine 15 MG with Coffee
My anxiety is better I still fear the social interaction and Bush/Cheney.
I have been using Xanax 0.5 MG and Benadryl 50 to 75 MG to wind down at night I have been having
Episodes of breathlessness "air hunger” flair up then get better still much better than pre Mepron.
My appetite is much less than it was. I was hungry all the time.
My mussel control is better less shaking in my hands flair up then get better still much better than pre Mepron.
I’m still having blurred vision but my eyes are not red all the time.
My neck has better movement possibly due to less pain At times I get high pressure fluid flow sounds in my neck head area?
My urine is clear normal color of someone taking Vitamin B Complex but flair up then get but cloudy like a small amount of super fine talcum powder Or dark. I drink lots of water he says as he takes a sip.
I have been experiencing itching sensations and at times small bumps or rash.
The cysts located on my lower back / base of spine have gotten smaller

MoreOrLesMe said...

Provigil 200 MG Prescribed 1 per Day actual ½ 2 or 3 per week
Dexedrine 5 MG 1 2X Day actual ½ 2 or 3 per week
Welchol 625 MG 3 tablets 2X per day
Biaxin 500 MG 1 2X day
Mepron 750 MG/5ML 1 Teaspoon 2X Day
Plaquenil 200 MG 1 tablet 2X Day
Xanax 0.5 MG 1 or 2 per day as needed
Acetazolamide 250 MG 1 tablet per day
Prozac 40 MG 1 tablet per Day
Benadryl 50 to 75 MG at night
Pro-biotics Florastot, Acidophilus 2X per Day
NSI Artemisinin (Artemisia Annuar) 500 MG 3X Day
Vitamins B Complex, C, Potassium, Folic acid, Centrum multi A to Zink 1 day