New onset chronic daily headache in a patient with Lyme disease responsive to targeted anti-Bartonella therapy

The 25-year-old female recently came to my office for evaluation of new onset chronic daily headache. This unfortunate young woman had been suffering with headaches every single day of her life the last 18 months. Historically, the problem began shortly after she returned from a camping trip in Ocean City Maryland. Upon returning home she had a sudden headache, mild flulike symptoms, fatigue and malaise. The headache is always right-sided in the temporal-parietal area. She uniquely described her headache is having a ram’s horn pattern of distribution describing a spiral pattern of pain. The pain was described is having a squeezing quality, not throbbing, associated with nausea at times. Pain intensity increases around time of menses.

One year prior to our initial consultation she been tested for Lyme disease. She had a positive EIA and 2/3 IgM Western Blot bands meeting the CDC criteria for a positive surveillance test. She was treated with doxycycline for 4 weeks which had no impact on the headaches.

Her neurologist informed her that Lyme disease not relevant to her condition and an infectious disease specialist felt that she been adequately treated for Lyme disease and that this had been excluded as a cause of her headaches.

She was prescribed a large number medications sequentially including: Topamax, Neurontin, Imitrex, Fioricet and many others none of which had any efficacy whatsoever.

The physical examination was completely normal except for subtle sensory deficits. Her ability to sense a cold object, in this case a metal tuning fork, was diminished in the hands and feet. This finding is generally dismissed by most neurologist as insignificant. In my experience, this finding is reliably present in at least 80% of my patients diagnosed with Lyme disease and is rarely present in healthy persons.

The remainder of her workup was unremarkable until I came to the blood smear. Here I documented a red blood cell filled with small stained inclusions compatible with bacteria.  A photo image is included here.

Bartonella species are perhaps the most frequent coinfecting organisms in patients with Lyme borreliosis. (Yes this contradicts my last blog). In the 2012 paper entitled “Bartonella spp. Bacteremia and Rheumatic Symptoms in Patients from Lyme Disease- endemic Region,” published in the CDC Journal: Emerging Infectious Diseases, findings from Dr. Mozayeni’s practice are described. Among 296 patients suffering with, Lyme disease, joint pain, chronic fatigue syndrome and fibromyalgia, 62% were found have Bartonella species antibodies. These species of Bartonella included: B henselae, B. Koehlerae, B. vinsonii subsp berhoffi and others designated Bartonella spp. 

Prior to 1990 there were only two named species of Bartonella. Now there at least 24 named species of Bartonella and numerous yet unnamed species in the queue whose DNA signatures have been deposited in Gen Bank. 17 Bartonella species are now associated with an expanding spectrum of human illness.

Bartonella species are fastidious, gram-negative bacteria with demonstrated affinity for intracellular localization in red blood cells and endothelial cells. Bartonella is the only genus of bacteria known to induce pathological angiogenesis (growth of new blood vessels). This may be associated with elevated serum levels of VGEF (vascular endothelial growth factor). In 2013 Maggi et al report the ability of Bartonella henselae to invade human brain vascular pericytes. Pericytes are small cells cells that surround endothelial cells and are an important constituent of the blood brain barrier. 

Blood smears may suggest the presence of Bartonella. The diagnosis may be confirmed by PCR testing. For clinical purposes this may not be necessary.

This patient was treated with  Zithromax, rifampin and Tindamax. Combination rifampin with Zithromax is known clinically to be very effective against Bartonella species. Within four weeks of treatment the headache was completely abolished. However, the symptoms returned  within 5 days when the medication was discontinued by the patient and were once again abolished when the medication was reinstated. After 3 months on continuous antibiotic therapy the patient remains symptom free.

This patient’s case demonstrates new onset chronic daily headache in a patient with newly acquired Lyme disease associated with coinfection with human bartonellosis with an excellent clinical response using targeted therapy.

Correction:  Bartonella species are rarely seen within red blood cells.  The Giemsa smear most like shows a reticulocyte, an immature red blood cell and not Bartonella.  The diagnosis is usually clinical.