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Monday, November 10, 2008

Bartonella Yes! or Not

A longstanding patient, a woman in her mid 40s complained of new onset arthritis about 3 years ago. My standard work up for ReA (reactive arhtritis) included antibody testing for Salmonella species. In previous blogs I have noted that chronic Lyme syndrome resembles ReA as described in Harrison's textbook of medicine. At that time I performed a standard Lyme WB which as negative. I will again note that Harrison's indicated that treatment for the putative infection did not alter the course of the arthritis. At that time I was looking at the work of several other physicians. Dr, Gabe Mirkin, a local radio personality and iconoclastic physician had been recommending the use of antibiotics for arthritis and other chronic illnesses like fibromyalgia. He reported that he "cured" his wife's rheumatoid arthritis with antibiotics.He strongly harped about the infectious disease connection to chronic illness and was censured by is colleagues who considered him an eccentric "nut." Be believed that chronic Myoplasma and Chlamydia infections were the cause. I thought there might be some validity to his claims. You don't hear much about Mirkin. I think he was ahead of time. But like the parable of the 3 blind men, he was feeling a different part of the elephant. Literature widely available in rheumatology texts, for many years, has consistently demonstrated that tetracycalines were effective for rheurmatoid arthritis. For some reason, rheumatologists have ignored this data. It upset their paradigm. They believed it worked via an anti-inflammatory effect, not antimicrobial. In fact, this is an argument which is still marshaled against the use of antibiotics for chronic "rheumatological" disorders. I am troubled by the logic that Methotrexate and Enbrel, which may cause immunosuppresion and cancer, are safer than long term antibiotics. I tried her on a course of Levaquin which improved her symptoms. It was taken for only two months. The patient seem to go into remission.

Six months later she returned with a collection of different symptoms. These included: fatigue, recurrent joint pain, numbness and tingling, blurred vision and forgetfulness. A Lyme work up was initiated and she was started on Doxycycline.
Her labs showed low vit D OH 25 (8) and Lyme WB now positive on 10 band IgG in the
18, 28 and 41 positions. Two weeks later Ceftin was added. One month later she complained of arm weakness, fatigue, tingling and numbness blurred vision. Her memory was better. She had generalized malaise and was concerned that the abtibiotics were causing side effects. She was changed to Amoxil and Biaxin as well as Plaquenil, and a five day course of Flagyl. One month later nearly all her initial symptoms were better. She did have continued burning sensations and noted heel pain. Her fatigue and cognitive issues were better. Three months later symptoms were fluctuant but headed in the right direction. A yeast infection was treated.
Urinary symptoms were present. She was treated with a course of Cipro and antibiotics were stopped. She felt well. Four months later symptoms returned. These included: palpitations, shortness of breath, fatigue, heel pain. All prior cognitive issues were resolved and had not returned. She was placed on Biaxin and Plaquenil.
Two months later she was worse. Some forgetfulness had returned. Amoxil and Flagyl were reintroduced. She stopped the antibiotics after a month and felt well. Six months later symptoms recurred. She had burning sensations, a sensation of cold feet and hot flashes. There was no pain, fatigue, cognitive dysfunction or weakness.
More lab studies were done. The FSH revealed that she was not post menopausal. Other studies from Labcorp showed that her vitamin D ratio was reversed with high 1,25 levels. Her Lyme C6 peptide had increased from 0.16 to 0.54. B12 and folate were normal. Her Bartonella serolgoy was interesting. Bartonella henselae IgG 1:640 positive, B. quintana IgG 1:1280 very positive. She was started on Levaquin and will receive follow up.

The patient's course perhaps demonstrates the persistence of Bartonella. It certainly demonstrates my evolution as a LLMD. This patient is unusual in that she took repeated courses of antibiotics which she stopped on her own, experiencing remissions and relapses. Each relapse improved with relatively short courses of antibiotics.She had prior serological tests for Babesia which were negative but this was the first time I had tested her for Bartonella. She had avoided much lab work due to cost and had largely been treated empirically.

Bartonella is real. It may be associated with tick borne disease. In Harrison's text it is associated with: cat scratch disease (which can have life threatening complications), Trench fever, endocarditis and other rare but serious disorders. Recommended theapy includes: Zithromax, Doxycyline, Rocephin and gentamycin for endocarditis. Bartonella bacilliformis is an acute, serious illness. It seems to be limited to Peru. Bacillary angiomatosis, caused by By B. henselae and B. quintana is seen primarily in AIDS patients. It is associated with cutaneous lesions and a life threatening multi-system disorder. Interestingly, the 16S DNA sequencing test is the gold standard. Serology is thought to be unreliable. Specifically, Harrison's states that Bactrim, Penicillins, Cephalosporins and CIPRO were not effective.

This begs the question(s): Is Bartonella a significant tick borne infection? What are Baronella like organisms? Why do LLMDS claim they are in the Bartonella genus?
Why do some patients respond to quinolones when other drugs fail? Did I do the right thing, prescribing Levaquin for this patient? Does she have real ongoing infection with Bartonella or do these IgG antibodies represent inactive, curred disease?
Should I insist she have a 16S sequencing of any bacteria which may show up in her blood? Do Bartonella species in fact behave differently in patients with tick borne illness or our we on the wrong path? I would like to know the answers.

As a side bar: What are those coccobacillary organisms that keep showing up in the blood of my patients. It doesn't appear to be particularly pathogenic. Sepsis (blood) infection, with pathogenic bacteria is very serious indeed with traditional organisms such as Strep, E.coli and many others. Bacteremia occurs with brushing our teeth. It should be very transient. Hundreds of dental bacteria remain unidentified.
Are we tilting at wind mills? Are we in fact trying to nail Jello to the wall as claimed by our detractors? One doctor says something. Another agrees. The flock jumps on board. Is this any different than what IDSA doctors do? We can do better.


cehansen said...

Does this mean that you have changed your mind about bartonella/BLO being an opportunistic infection?

I think you mentioned at one point in this fascinating blog that you had had Lyme, or a family member. Were co-infections involved?

Lyme report: Montgomery County, MD said...

I don't know what these bacteria are. They are present in very sick patients. I still think they are opportunistic. See today's blog about a patient I saw. Clongen is attempting, as we speak, to DNA sequence the bacteria.

Hopefully an answer will be forthcoming.

Neither my father in law or myself have been treated for co-infections.

My SO is being treated for Babesiosis as we speak.

DeadPoets said...

Why would one tend to have HIV if bacillary angiomastis were present?

I'm fairly confident I don't have HIV yet I have the above disorder with subcutaneous nodules all over body. A lot of Lymies do.

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