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.