My patients with chronic Lyme disease may suddenly relapse
after years of feeling well.
A new mouse study shows not just persistence of Lyme
bacteria after 30 days of antibiotic treatment with ceftriaxone but “resurgence”
of infection. The authors of the study tell us their findings are controversial
and caution us not to change the way we treat patients based on these findings.
Of course not.
The study is published in PLOS January 2014. The levels of bacteria in experimentally
treated mice were found to decrease at months 2, 4 and 8 but surge to
pretreatment levels at 12 months. The DNA load of bacteria in in the group
treated with salt water and the group treated with 30 days of antibiotics was
the same at 12 months. As seen in other
studies, the post-treatment spirochetes were “non-cultivable.” They can cannot
be cultured in laboratory media. These spirochetes were clearly different from
their pre-antibiotic forbearers. Other
mouse studies have demonstrated non-cultivable organisms. It has been suggested
that these bacteria are attenuated and do not cause disease. Various metrics
performed in this study do not support this thesis. Although these spirochetes
do not culture, they transfer to other mice via ticks used in xenodiagnoses.
Intact, viable spirochetes were microscopically observed in the same tissues;
joints, heart and blood vessels.
According to standard bearers of the disease like Steere, as
described in his paper “Diagnosis of Lyme Borreliosis,” -- the 2 tier CDC test is essentially always
positive in patients with disseminated disease after 4 weeks; PCR of synovial fluid in patients with
negative serology should not be performed because positive results will be
false positives; and usually, patients with objective evidence of dissemination
have one or more of the following: EM
rash, atrioventricular cardiac conduction delays, myopericarditis, facial palsy,
meningitis and meningioradioradiculoneuritis (Bannsworth’s syndrome).
I think maybe we are talking about two completely different
diseases.
In our patients (with Lyme disease) Western Blot testing is
neither accurate nor dependable. In our experience IgG bands, especially the
5/10 discussed by Steere are almost never seen. Positive Western Blot responses
are primarily IgM in all stages of the disease.
( Regarding the Steere/CDC two tier test for Lyme It is fascinating to
read that the IgM bands are based on Engstrom’s work using B. burgdorferi strain
297, that the IgG bands are based on Dressler’s work with Bb strain N40 and that the antigens in standard FDA approved kits come from yet a third strain
of Lyme, Bb B31). These studies were
pre- 1994 and presented at the Dearborne conference.
When I find a positive PCR
for Lyme in joint or body fluid it is essentially always a true positive
result. The fault with PCR is low sensitivity.
Aside from different sero-reactions, my patients with late,
disseminated disease have: constitutional symptoms like fatigue; neurocognitive
and neuropsychological problems; arthralgia (joint pain) with arthritis (inflamed
swollen joints) rare; peripheral neuropathy and autonomic neuropathy and
usually have none of the above manifestations. Of course my patients do have arthritis, meningitis,
radiculitis, EM and carditis, but these are exceptions, not the rule.
I think I explain the split personality of the disease. The
characterization of the disease from the perspective of academic medicine is
based on inherent biases and the need to have something concrete which can be
easily characterized and defined. The
other personality of the disease stems from a patient-centered clinical process.
Medical practitioners know that disease is frequently not black and white and
that it usually forgets to read the text books.
Those on the academic side are interested in having a
debate. They are by nature competitive and feel they have to prove they are
correct. Recently Barbour described the
3 decades long debate and compared the two sides, one his side: all of
academia, science, public health authorities – on the other side: a few
non-academic practitioners and patient advocacy groups. This is not a valid
debate point. Many famous persons and institutions have been wrong throughout history. And important medical academics like Fallon
do in fact disagree with the main view.
I think biases within the academic world are very
important. For example: “Germs are killed by
antibiotics – end of story.” Barbour
elicits the image from “The Terminator” movie where a robot is turned to molten
metal and magically resurrects itself as analogous to our thinking about Lyme
bacteria suggesting we are imbuing the spirochetes with supernatural properties. He proffers the concept that the remains of
dead Lyme bacteria may trigger a post-Lyme syndrome. The science is saying
something else.
I suspect Lyme spirochetes are not entirely unique in their
response to antibiotics. Many microbes are never completely destroyed by
antibiotics and may contribute to chronic illness in some manner. This may apply
to mycoplasmas and chlamydias for example.
Academic medicine should take notice. Something unique and
very significant is going on when patient groups are able to get laws changed
in opposition to their unyielding views. The prevailing paradigm is changing. New thinking requires the experts to set aside
their egos and preconceived notions and take a fresh look at the problem with
new eyes.
