Ignorance is no excuse!

A troubled 43 year old woman sat across from me yesterday. She told me I was her last hope. I hate it when patients say that. She had obvious memory problems and struggled to get out her words. Sitting across from me she evinced strange, periodic jerking spasms and movements of her four limbs in a random fashion. She told me her story.

She had been well until October 2007. She lived in Southern Maryland and has spent a lot of time outdoors. It started with pains involving multiple joints, especially from the waist down. Then came the brain symptoms, hard and fast. In short order she became forgetful and confused. She continues to have trouble speaking and loosing things as her memory deteriorates. A local physician found positive tests for Lyme and Ehrlichia. She was treated with 30 days of Rocephin followed by two months of Doxycyline. She started to get better on the Rocephin but all the symptoms quickly returned when the meds were discontinued.

By August 2008 she was sicker than ever. Repeat blood work showed that the IgG Ehrlichia titer was higher. And now she tested positive for Bartonella.
Her physician prescribed Levaquin for 3 weeks and 3 months of Bicillin. Once again, she was just starting to feel better when the treatment was stopped and her symptoms returned.

Over the past 5 weeks things have taken a turn for the worst. Withing the past two weeks she has seen two infectious disease physicians. One said the patient does not have Lyme and the other said he did not know how to treat Bartonella. In the meantime she has been referred to a neurologist. She has developed progressive myoclonus- muscle jerking and increased generalized pain. Her blood pressure became dangerously high with erratic swings both up and down. She has had episodes of SVT- rapid heart beat. Her sense of balance has become diminished and she has fallen several time.

Specifically, she has had no skin nodules, stretch marks, depression, anxiety, foot pain or "depersonalization." These are signs and symptoms in LLMD literature associated with Bartonella.

She has recently lost her job, working for a group of cardiologists.
She is totally disabled.

She does admit to episodes of chills and sweats.

Her exam shows an elevated blood pressure. Her mental status is abnormal. She is forgetful with some aphasia. She had the jerking myoclonic movements as described. Sensations are abnormal, notably she has absent vibratory sense in the left foot. There is poor finger to nose accuracy or speed. The Romberg test shows her falling to the right.

Current labs: Lyme WB IgM positive 23 and 41 bands, Ehrichia chaffeenis IgG 1:1024,
Bartonella henselae IgG 1:320.

This woman clearly has three tick borne infections: Lyme, Ehrlichia and Bartonella.
Clinically, she may also have Babesia. She is very ill- an understatement.

The classic signs and symptoms attributed to Bartonella and/or BLO are absent. Bartonella is a small intracellular bacteria which may at times cause brain and central nervous system disorders. How often this occurs is unknown. Bartonella is commonly seen in the homeless, HIV- immunsuppresed patients and younger patients. Classically B. henselae has been associated with cat scratch fever, enlarged lymph nodes and "occuloglandular syndrome." There are isolated reports of meningitis and encephalitis in the medical literature.

My assumption is that the majority of her symptoms are due to Lyme rather than Bartonella. Her previous response to Rocephin and Pencillin seems to support this hypothesis. She was just started on Doxycyline, 100mg twice daily before seeing me. I recommended that she increase the dose to two capsules twice daily,

The first order of business is placing a PIC and restarting Rocephin.

Ehrlichia can be a tricky business. In is also intracellular and resides in white blood cells. Such bacteria can be notoriously difficult to eradicate.

After the initial expected "herx" the next step would be to add Rifampin. The combination of Doxy and Rifampin seems to be quite effective against Ehrlicia.
Many proponents have suggested that Rifampin is also effective against Bartonella.

It is not clear which antibiotics are most effective against Bartonella. Different drugs may be more effective depending on the particular species being treated.

Standard literature claims that Zithromax and Doxy are effective.

LLMD literature claims that Levaquin, Bactrim and Rifampin are effective. I have not seen any scientific evidence to support the efficacy of these particular agents. Based on my knowledge of microbiology, I would expect Levaquin and perhaps Rifampin to be effective.

The use of Bactrim by many LLMDS has confused me. Anecdotally, LLMDS report that it is effective against BLO. I am not sure what BLO is.

After a little research I considered the following possibility. Sulfa drugs like Bactrim have been shown to have some activity against Malaria. Rather than treating Bartonella or Lyme, I wonder if these drugs have activity against Babesia species.

Perhaps in cases where the response to Mepron or Malarone is poor or sluggish, the addition of Bactrim may provide some additional benefits.

The chills and sweats certainly suggest the possibility of a Babesia species. Alternatively, Ehrlichia can cause similar symptoms. We shall see.

This patient has been kicked around by a system which can offer her no help. To make matters worse, the system denies the existence of here illness.

For some reason, this patient in particular, has hardened my resolve to continue treating patients with Lyme and TBD. I am confident that with proper treatment she will have a full recovery. Many such patients are critically ill with a disease which remains unknown to all but a few practicing physicians. Without correct treatment, she and numerous others like her would certainly face progressive disability and/or death.