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Wednesday, April 15, 2009

Lyme and Bartonella: A Tale of Two Herxes

I recently saw a young woman now in college, with a long and complex history of Lyme and tick borne illness. She had been treated by another physician for 5 years with an arsenal of oral antibiotics. Her lab work in the past revealed positives results of one kind or the other for Lyme, Babesia, Ehrlichia and Bartonella. The oral medications had targeted all of these specific microbes. She had previously refused any IV antibiotics despite her physician's recommendations. She has many disabling symptoms including, muscle and joint pains, weakness and neuropathy and especially cognitive dysfunction. The issue of greatest concern was tick borne encephalopathy, usually called neuroborreliosis. As you will see, there is a reason why I use the former name. Let me interject here- this patient was quite assertive about directing her own care. She was on spring break so she wanted to go through any necessary Herx to correspond with her calendar. For encephalopathy I generalize recommend a course of IV Rocephin over a period of 12 weeks on average. At times I add a second agent, but generally only after the Herx occurs and a stable clinical response has been established over time. This young woman had dark purple stretch marks- striae, on her trunk. She also had classic Bartonellosis which has been rare in my practice.

After starting Rocephin she Herxed for about a week and then really began feeling very well. Her cognitive functions were the best they had been in years. But, as I said, she wanted to push the envelop and get all the Herxing over at one time to accommodate to her time table. The Rocephin Herx occurred two weeks ago so she had only one week of feeling great. I reluctantly agreed to add Zithromax. The insurance would not approve IV Zithromax so it was prescribed by mouth.

The response was rapid, dramatic and not for the better. She took a quick nose dive. The fatigue was severe. The brain fog and memory loss were much worse. She had mild sweats and oddly- the striae had increased in hue and size.

As of this writing she and I am negotiating with my patient how to best handle the situation. She wants to let the Herx rage while I am inclined to back off the Zithromax for the time being.

The point of interest to me is that in this patient, with seropositive Bartonella and the classic striae as described in the literature, experienced a dramatic Herx with Zithromax. This may be evidence that classic Bartonella does in fact respond very well to Zithromax. This may lend further credence to the thinking that those co-infection syndromes which respond only to quinolones, Zithromax with Bactrim, or Zithromax with Rifampin may not be closely related to Bartonella.

In point of fact the "mystery" bacteria seen on wet mounts do not behave like Bartonella species. Bartonella is an intracellular bacteria and should be found predominantly in red blood cells. These other organisms are entirely extracellular.

The question is then, why did treating Bartonella cause such a severe brain Herx. An argument could be made that Baronella had crossed the blood brain barrier and that Bartonella brain infection was a major component in the patient's encephalopathy.

There is a weakness in this argument. The encephalopathy was clearing up very well with only Rocephin. I suspect that a longer course of only Rocephin would have had an excellent clinical result. This suggest that Lyme, not Bartonella was the cause of encephalopathy. The rapid killing of Bartonella may have led to an influx or neurotoxins or inflammatory cytokines which led to the dramatic "brain Herx" or worsening of cognitive symptoms. This seems to make more sense to me.

It may be appropriate to call the clinical scenario tick borne encephalopathy rather than neuroborreliosis, since it is not known if the brain symptoms are due simply to Lyme infection or also due to co-infection.

I am aware that well documented cased of Bartonella infecting brain tissue exist, but they are rare.

The topic is certainly up for debate. I am only sharing my thoughts at this time as I am trying to understand the process as it is unfolding in this patient.


BryanR said...

My thoughts are that rocephin being a cell wall inhibitor mostly just induces the bacteria to dormancy hence the moderate herx followed by feeling great.

Zithromax is a much more aggressive drug targeting the bacteria as it makes protein and therefore really kills it and pisses the bacteria off. Hence, you get the ongoing herx.

In line with this is the observation that the relapse rate after "recephin remissions" is much higher than with other antibiotics.

The literature backs this observation up. I can provide references on request; going to sleep now, don't want to spend an hour looking them up.

Lyme report: Montgomery County, MD said...

IV antibiotics get into the brain. Oral Zith- not so good. Herx reactions relate to cytokine release rather than to the direct effects of killing the microbes. Sprirochetes replicate slowly. I don't think 3 weeks of Rocephin therapy is going to drive them into dormancy. The improvement seen with Rocephin therapy may relate to decreasing the spirochete load in the brain, or as others have argued, non specific anti-inflammatory effects in the brain. If you are referring to L forms I don't think they are dormant. If you are referring to cyst forms Zith has no effect. I know that you have expressed the concern that cell wall inhibitors drive spriochetes into L-forms which you believe may be the main culprit in the disease. My experience would suggest otherwise. Rocephin remains the best drug for clearing neuro-cognitive symptoms. I believe patients do best with combinations of antibiotics which work through different mechanisms. The relapses after Rocephin as described in the recent Fallon study I believe occurred because the poor partially treated patients were deprived of ongoing antimicrobial therapies.

In this piece I was trying to parse out the differences which may occur when different microorganisms are killed. I was purely thinking out loud. I do not know what the actual cause of the clinical response was. My description of the clinical response was accurate.

Paula said...

A bit off topic, but want your opinion Doc - does Klonopin reduce brain inflammation? It seems to somewhat help w/ my brain fog..

MJ said...

Keep your thoughts out loud please Doctor, let the others think what they want!

Michele said...

I know in a blog quite a while ago you mentioned that you no longer used flagyl for cell wall form. Is there another antibiotic that attacks that form?

Lyme report: Montgomery County, MD said...

Flagyl is still helpful. Tindamax may be easier to tolerate.

Sleep is important.
Sleep disorders must be excluded.

Marty said...

Hi everyone, thanks for the great info here. I am in need of some help/direction.

Approx 2 months ago I was sick with what I thought was a flu like throat infection of some kind. I was given Amoxocillin 750mg for a week or so. I seemed to get somewhat better, but assumed perhaps the illness was viral in nature as it lingered.

Approx 1 month after the flu-like illness I developed a strange rash that looked like scratches/lines. I had never seen anything like it. It would come and go within minutes, maybe 15-30 minutes. This rash was present on my arms (bottom side) and on my lower chest right above my stomach. I also noticed what I think is a red papule about the size of a hole punch (the paper that would punch out of hole puncher on my right upper chest that seems to be there for a while now (month or two?).

I looked up scratch like rashes and came to zero in on Bartonella as a possible cause. They dont look live hive like rashes to me from pictures though the doctor felt it was a "variation of a hive like rash". I have not presented the Bartonella info to them yet as I plan to go back ASAP.

What is the best thing to do at this point? Can they really test for this illness? Should I try to get blood tests first before seeing if I can get Azithromycin?. In some readings I see Levaquin and other medications recommended.

It seems like doctors are very unfamiliar with this illness. Any suggestions on how to best proceed?

Marty at

tessa said...

IV Rocephin gave me my life back! For the past 11 years I have suffered from SEVERE chronic anxiety and panic attacks, before I got bit by a Lyme Tick I had never experienced either. I was placed on IV Rocephin, 4 grams a day, about the 4 week all of my anxiety and feeling like I was hooked up to an electrical circuit went away, along with the crying I was experiencing. I have now been on IV for 4 months and feel normal. I still have fatigue but the worst of my symptoms are gone and I feel an internal peace I have not felt in years. Im also taking 500 mg of flagyl a day, that totally wipes me out. I tested positive in 2004 through UniLab ( imagine that, I must really have had it bad) and Igenex. I have an awesome doctor in Santa Rosa.

LGT said...

I have Bartonella (sore feet in morning, + for B. henselae, encephalopathy before treatment, previous Lyme infection treated for four months starting 3 wks after infection), and I had the opposite reaction:

-worsening of combativeness/reactivity and encephoalopathy on Rocephin (in my case, ORAL ceftriaxone) and Plaquenil, which persisted for more than a week until I stopped the medication after 2 wks.

-Then, started Zithromax+Plaquenil, which calmed things down from the start and for the past two months has controlled the encephalopathy, combativeness, and rage I experienced when not on any antibiotics or when on abx that probably caused herxes.

I do seem to be improving from month to month but without severe herxes. When I have stopped the medication for a few days (planning to take Factive, a fluoroquinolone, and my doctor wanted me to stop Zith for three days before and after taking Factive since they both prolong the QT-interval, he said); I experienced a relapse of reactivity and combativeness. I got back on zith+plaquenil instead of taking Factive, since my living situation requires that I be mentally stable. I might go home to my parents' house to take Factive, since I expect to herx and to have emotional reactivity symptoms.

It was my understanding that ceftriaxone (Rocephin) DOES kill Bartonella.