A 70 year old male patient was diagnosed with Lyme disease 6 or 7 months ago. He reported a history of tick bite and rash in 2002. He received a short course of antibiotics at that time. When I saw him initially he complained of knee pain and swelling, fatigue, generalized arthralgia (joint pain), numbness and tingling and an irregular heart beat. He was seropositive by Western Blot. He was treated with Amoxil, Biaxin and Plaquenil. After two weeks he reported that the antibiotics were causing nightmares and insomnia. He attributed this to Biaxin. The regimen was changed to Amoxil and Minocin. The knee pain and other symptoms rapidly improved over the next two weeks. Then one week later he complained of confusion and unsteadiness. I diagnosed a "brain Herx." I added Plaquenil back, as well as Welchol, presumptively to remove "neurotoxins." I also reduced the dose of Amoxicillin and Minocin. He continued to improve rapidly once more with a cessation of neurocognitive symptoms. However three weeks later he had a bout of gastroenteritis and the antibiotics were held for a few days. Like many of my patients, he was "lost to follow up" for a couple of months. The patient stopped the Amoxil and Plaquenil and took only Minocin, on his own which he increased back to the full dose, without consulting with me. He returned to my office after a total of 4 months of treatment stating that he was 85% better. I scolding him for non-compliance: it didn't do any good. I added Flagyl only 250mg twice daily. When he returned a month later he told me that the Flagyl had made him "spacey" so he stopped it after a few days. He was feeling close to normal. Call me! I tried him on Zithromax and Plaquenil about 6 weeks ago. I made the change because he was also complaining of sinusitis. It seemed that there may have been problems with Amoxil, Biaxin and other antibiotics. He came back to see me today. He felt perfectly fine: back to normal for the past four weeks. And by the way, he had only taken the Zithromax for a few days because it upset his stomach. Everything was fine he was taking only Plaquenil. To review: Brain symptoms, joint pain, neuropathy symptoms, palpitations and fatigue were gone. He Had been treated for a little more than 6 months. This was the best he had felt in years. So far the symptoms were not returning.
This is not my typical patient. Most actually do what I say; they take medicines as prescribed and return for follow up as instructed. In his defense, his wife had major surgery during this time frame; personal mitigating circumstances interfered with our process.
When patients go into remission it is unlikely that the Lyme bacteria have been eliminated. Let me insert an additional piece of information. This patient had a fairly strong IgG response on the standard Western Blot: 4/10 bands were reactive.
Patients with IgG responses may have some blocking immunity for intact spirochetes.
Per the immunology text book: symptoms related to intracellular infection relate mostly to the immunologic response to the infection- not the presence of the germs in and of themselves.
One could postulate that 1) The patient had a blocking IgG response to keep the spirochetes in check and 2) The immunomodulating effects of Plaquenil were keeping the lid on a potentially toxic T cell response to the intracellular component. The fact that he responded so favorably with primarily Minocin supports the hypothesis that the main issue in his case related to intracellular disease.
It was clear that cystic forms of the bacteria were still present. However, if they converted to spirochetes or L-forms the above two mechanisms would be in place to keep the disease quiescent.
I decided to leave him on just Plaquenil for the time being to see if this would foster a long term clinical remission. Sure, it doesn't follow any standard paradigm. But I can't argue with success.