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Tuesday, August 13, 2013

2013: A Brief update

Certain posts consistently have a lot of page views. This includes 2010: a brief update.  I don't agree with my 2010-self in many ways. Here is another update.

Update 2013

The diagnosis of Lyme disease remains clinical.  The primary test for Lyme disease is the Western Blot, (WB).   An ELISA may be ordered (as a separate test) as long as it is not “reflexed” to a Western Blot.  The C6 peptide ELISA is always ordered, but not interpreted according to Immunetics criteria.   Western Blots are generally sent to one of several reference laboratories. I currently prefer Stony Brook because they take insurance and their assay includes many additional bands. Frequently, WBs are sent to two reference labs.
I do not order a lot of immunological tests like C4a because I have not found these tests to be clinically useful.
A typical coinfection panel includes serology for: Ehrlichia, Anaplasma, Bartonella, Babesia microti, Babesia duncani (still frequently called WA1). I may include Rocky Mountain Spotted Fever as well as a few others.  Positive results are very helpful but negative results are neutral and do not exclude the presence of disease. A thin stained blood smear should be considered in the workup because Bartonella-like and Babesia-like organisms may be seen. More advanced microscopic tests may be performed but are not standard.  Immuno-florescent microscopy. e.g. FISH) may be helpful in some cases.  Blood cultures may be very useful.  The test is costly and positive result requires a PCR for confirmation.  PCR testing may be done with cord blood to exclude placental transmission to a new born baby.  PCR should be used with non-blood body fluids such as joint and spinal fluids. Antibodies should also be measured, i.e. WB, C6 peptide.
For the treatment of resistant Babesia, Coartem should be used rather than Larium as the next step. I generally avoid quinolones such as Levaquin and Factive because of tendon toxicity. Bartonella species may become rapidly resistant to quinolones: Biaxin/doxycycline/Bactrim/Cleocin in combination with Rifampin is a better approach. Rifampin should never be used alone because of the rapid onset of resistance. I left Zithromax off the list, which I still frequently prescribe, because it may have greater cardio-toxicity.

A wide spectrum of intravenous antibiotics may be used.  Rocephin and Flagyl remain very important.

Biofilms formation is an effective strategy for long term survival of microbes. 
This segues into hyperbaric oxygen therapy which disperse biofilms. I have written about its effectiveness and usefulness elsewhere.  I try to incorporate Hyperbaric oxygen therapy, HBOT, when feasible, especially in tough cases.
IVIG may be incredibly helpful but is usually only be approved for certain types of neuropathy.  A skin biopsy sent to Therapath, looking for small fiber neuropathy is now an important part of my practice.
An evaluation of immunoglobulins, including IgG subclasses has become part of the typical workup. Deficiencies are very common.


Joanne said...

Do you get many cases of Immunoglobulin M deficiency among your Lyme patients with IgA and IgG within normal range. I think Dr Horowitz mentioned this in one of his presentations and said that Lyme Disease was the only disease this is found that he knows of. Interesting I read that 3 in 10000 of public have this rare occurrence but 10 in 10000 of people in hospital have it.

Lyme report: Montgomery County, MD said...

I have seen this before.
Isolated IgA deficiency is common. Typical cases of CVIDS have low: IgG, low subclasses 1 and 3 and frequently low IgM.

Low IgA is clinically significant if IgG is given as this may lead to severe reactions. IgA free IgG must be obtained.

Paced Runner said...

Have you ever had a patient in their 20's with A-fib as a result of Lyme or one of the co-infections? I have researched it but cannot find many instances of it.

Female, no smoking, drugs, drinking or poor diet.

Paul M said...
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Kurt said...

I have low immunoglobulin M - it has so far been the only laboratory indication of a chronic lyme infection.