https://www.bmj.com/content/370/bmj.m3029/rr-3
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3029 (Published 13 August 2020)Cite this as: BMJ 2020;370:m3029
https://www.mdpi.com/2079-6382/9/12/868
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https://danielcameronmd.com/anaplasmosis-and-babesia-infection-cause-cognitive-impairment/ Go Here for Podcast
Welcome to an Inside Lyme case study. I find that the best way to get to know Lyme disease is through reviewing actual cases. I will be discussing a 78-year-old confused woman with an Anaplasmosis and Babesia infection.
A 78-year-old woman was evaluated in an emergency room with fever, chills, lethargy, fatigue, and confusion. Her maximum temperature was 100.6° F.
Her blood tests were quite abnormal. She had severe anemia, low white blood count, and low platelet count.
• Anemia (dropped from 10.5 g/dL to a low of 8 g/dL)
• Leukopenia (dropped from 5.0 × 10 9 /L to 2.6 × 10 9 /L)
• Thrombocytopenia (dropped to 39 × 10 9 /L)
The doctor initially considered sepsis. Sepsis is a potentially life-threatening illness triggered by an infection. The body’s immune response can be so strong that the body can attack itself and can lead to organ damage and death.
She also had multiple tick bites.
The doctors were able to identify the parasite that causes a Babesia infection in the woman’s red blood cells under the microscope. Babesia is a disease transmitted by the same tick that carries Lyme disease.
The doctors prescribed a combination of atovaquone and azithromycin for her Babesia infection. These medications are marketed under the names Mepron and Zithromax in the US.
The doctors were also concerned that the woman might suffer from another tick-borne illness called Anaplasmosis because of her low white blood count and low platelet count. Anaplasmosis had previously been called Ehrlichia.
The combination of atovaquone and azithromycin is not effective for Anaplasmosis. The doctors added doxycycline to the woman’s treatment.
The laboratory test confirmed that she had, in fact, an anaplasmosis and babesia infection. The IgM tests were positive for both conditions consistent with early infection.
What can we learn from these cases?
What questions do these cases raise?
In my practice, each individual requires a careful assessment. That is why I order a broad range of blood tests for other illnesses in addition to tick-borne infections. I also arrange consultations with specialists as needed.
Many patients are complex, as highlighted in this Inside Lyme Podcast series.
We need more doctors with skills diagnosing and treating Lyme disease in the elderly. We hope that a professional evaluating the elderly can use this case to remind them to look for Lyme disease and co-infections and treat accordingly.
This Inside Lyme case series will be discussed on my Facebook and made available on podcast and YouTube. As always, it is your likes, comments, and shares that help spread the word about this series and our work. If you can, please leave a review on iTunes or wherever else you get your podcasts.
Sign up for our newsletter to keep up with our cases.
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**Comment**
https://madisonarealymesupportgroup.com/2016/03/08/anaplasmosis/
Treatment recommendation:
The optimal dose and duration of antibiotic treatment for anaplasmosis has not been definitively established, but it is clear that A. phagocytophilum is highly sensitive to tetracyclines. Thus, oral doxycycline is the recommended treatment, at the same dose used for Ehrlichia infections: 200 mg/day in two divided doses. The usual treatment duration is 5-10 days, which is extended if there is suspected coinfection with B. burgdorferi, the agent of Lyme disease. In any case, treatment should continue for at least three days after the patient’s fever resolves. Response to treatment is usually rapid; if the patient remains febrile more than two or three days after initiation of doxycycline therapy, the diagnosis should be revisited. As with Ehrlichia infections, rifampin is used in cases where doxycycline is contraindicated, such as pregnancy or allergy.
The CDC recommends a lower dosage. Lyme literate doctors know that some people need higher dosages. This is an important issue that has kept some from getting better. Consider and discuss with your practitioner.
https://madisonarealymesupportgroup.com/2016/01/16/babesia-treatment/
Please see article for various treatments. Dr. Horowitz states that Babesia is one of the most tenacious coinfections he deals with. He recommends treatment of 9-12 months. Studies have also shown that mono therapies like the singular use of Mepron to be ineffective as the pathogens develop resistance to it. Lyme literate doctors typically utilize an overlapping treatment with numerous modalities to prevent this from happening. I’ve heard many professionals state that once you start treating Babesia you need to see it through to completion. So don’t start until you mean business and then stick it out. Treatment is typically 3 weeks on, one week off. In this article I state the treatment that worked for both my husband and I.
FYI: Two weeks of treatment is hardly ever sufficient.
https://igenex.com/tick-talk/symptom-checker (Go here for Symptom Checker)
If you’ve been sick and aren’t getting better, use this IGeneX symptom checker to determine your likelihood of having Lyme disease or other associated tick-borne illnesses.
The Lyme and Tick-Borne Disease Symptom Checker is for informational purposes only and should not be considered, or used as a substitute for, medical advice, diagnosis, or treatment. By using this website and the Symptom Checker, you agree that this website and the Symptom Checker is not intended to and does not replace the advice of your own physician or other medical professional and that this website does not constitute the practice of any medical or other professional healthcare advice, diagnosis, or treatment. You are solely responsible for your own health care decisions regarding the use of this website and the Lyme and Tick-Borne Disease Symptom Checker and your use is entirely at your own risk. You should consult a medical professional for all questions or concerns you may have relating to your health. If this is an emergency in the United States, call 911.
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**Comment**
A very helpful online quiz. You can also read about common symptoms for Lyme disease, Babesia, Tick-borne Relapsing Fever, Bartonella, Ehrlichiosis, Anaplasmosis, and Rickettsiosis.
My only caution is that there are other symptoms omitted from this quiz. My own case is a perfect example.
All my initial symptoms were gynecological and I believe strongly were my first signs of Lyme/MSIDS infection, obtained from my husband who is also infected. You can read about that here: https://madisonarealymesupportgroup.com/2017/02/24/pcos-lyme-my-story/
It is quite common to have an initial 90 minute appointment with these ILADS trained doctors as you fill out medical history forms going back to infancy. The doctor then discusses these with you to further ascertain the potential of early infection (perhaps in utero). Often, many health issues can be traced back to infancy if you were infected congenitally. For more: https://madisonarealymesupportgroup.com/2018/06/19/33-years-of-documentation-of-maternal-child-transmission-of-lyme-disease-and-congenital-lyme-borreliosis-a-review/
While sexual transmission of Lyme/MSIDS has not been admitted to by ‘authorities,’ congenital transmission recently has been: https://madisonarealymesupportgroup.com/2020/02/01/cdc-website-updated-today-possibility-of-mother-to-fetus-transmission-of-lyme-disease/
It is also quite common for ‘authorities’ to first admit something is ‘rare’ only to have to admit later it’s more common than first thought. This is their modus operandi. For years I’ve watched them state Lyme doesn’t exist in certain geographical locations because the ticks that transmit it aren’t there, only to have to update that information later on. This has happened repeatedly. But before the information gets updated, infected patients are told “it’s all in their heads,” left to rot, and are denied treatment. These patients only go on to worsen, making their cases far more difficult to treat: https://madisonarealymesupportgroup.com/2017/09/21/its-all-in-your-head-until-finally-a-lyme-diagnosis/
This must end. Using entomology maps to diagnose has hurt patients. While maps are interesting, they should never keep patients from getting diagnosed.
For the Horowitz symptom questionnaire, which has been validated: https://madisonarealymesupportgroup.com/wp-content/uploads/2016/01/symptomlist.pdf Print, fill out, and tally up the points.
Just remember that while these checklists are helpful, and in fact probably far better than current testing, they are not perfect. Lyme/MSIDS is wiley – with waxing and waning symptoms. Your best hope of correct diagnosis and treatment remain in the hands of an experienced Lyme literate doctor, although nothing replaces learning all you can to be a helpful partner in your own healing.
https://vineyardgazette.com/news/2020/10/07/lone-star-ticks-swarm-aquinnah
Tick biologist Richard Johnson said the best way to reduce the tick population is to reduce the deer population. Credit: Tim Johnson
Lone star ticks – and thousands of their larvae — have overrun the town of Aquinnah, biologist and tick expert Richard Johnson told Aquinnah selectmen at their meeting Wednesday, following reports that showed a high incidence of tick-borne disease in the town this year.
In a letter that went out last week, the town board of health reported 13 new cases of tick-borne illnesses since April of this year, including cases of Lyme disease, ehrlichiosis, babeosis and Rocky Mountain spotted fever. At the meeting, Mr. Johnson said he was in Aquinnah on Tuesday surveying yards for ticks and found lone star larvae in every location he visited.
(See link for article)
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**Comment**
OK – this here should alarm us – an entomologist getting a daily call from folks discovering clusters of lone star ticks.
Although not known to carry Lyme, they can cause ehrlichiosis, Rocky Mountain spotted fever, as well as a red meat and or dairy allergy.
“I hope this isn’t the new normal but I fear that they’re exploding in numbers.” Richard Johnson
Johnson also points out that unlike deer ticks, lone star larvae stay in groups of 2,000-8,000 until they are nymphs which means those who brush up against a cluster could have hundreds to thousands attaching simultaneously.
The article mentions controlled burns for changing the habitat which could eradicate the ticks. Please see: https://madisonarealymesupportgroup.com/2019/07/18/frequent-prescribed-fires-can-reduce-risk-of-tick-borne-diseases Burning works but it must be done repeatedly.
The article mentions using various birds to eat them, but the ticks also travel and feed on birds.
Johnson stated that the number one thing they can do is reduce the deer population.
Rapid Response:
Re: Tick bite
Dear Editor
Razai et al, in their consultation on tick bite, missed an important message to learners (1).
The most common infectious agents transmitted by Ixodes species ticks in North America that have the potential for co-infection with B burgdorferi are Anaplasma phagocytophilum, Babesia species, deer tick (Powassan) virus, Borrelia miyamotoi, and the Ehrlichia muris–like agent (2).
A phagocytophilum is transmitted by the same Ixodes ticks as B burgdorferi in the United States and causes fever, chills, headache, myalgia, and fatigue arising 1 to 3 weeks following tick exposure. Most cases are mild and self-limited. However, severe manifestations may include respiratory failure, adult respiratory distress syndrome, peripheral neuropathy, rhabdomyolysis, acute renal failure, pancreatitis, and coagulopathies.
It has been found that in Wisconsin, approximately 3% of I scapularis ticks examined were co-infected with B burgdorferi and A phagocytophilum (3). A similar study in 11,000 ticks in public parks of New York State’s Hudson Valley Region found that co-infection rates of nymphs and adults were 0.5% and 6.3%, respectively (4).
The frequency of humans with Lyme disease simultaneously co-infected with A phagocytophilum from various studies ranges from 2% to 10% (5,6). Similirly, Babesiosis is transmitted through the bite of infected I scapularis and I pacificus ticks. Most patients are asymptomatic or have mild, self-limited disease but may be complicated by renal failure, acute respiratory distress, and shock.
In a study of patients with Lyme disease from southern New England, approximately 10% were co-infected with babesiosis (7).
Unlike Lyme disease and Anaplasmosis, doxycycline is not an effective treatment of babesiosis and requires atovaquone and azithromycin or combination of clindamycin with quinine, making it imperitive to consider this diagnosis in mind in patients with tick bite.
Of the 3 species of Ehrlichia in United States, only E muris–like (EML) agent is transmitted by I scapularis is the vector of this emerging pathogen(8).
Possible co-infections should be considered in any patients who are diagnosed with tick bite or Lyme disease, especially those who have unexplained leukopenia, thrombocytopenia, or anemia, or who fail to respond to treatment for Lyme’s disease.
References:
1- Razai MS, Doerholt K, Galiza E, Oakeshott P. Tick bite. BMJ 2020;370:m3029
2- Caulfield AJ, Pritt BS. Lyme disease Coinfections in the United States. Clin Lab Med 2015;35:827–846.
3- Lee, X, Coyle DR, Johnson DK, et al. Prevalence of Borrelia burgdorferi and Anaplasma phagocytophilum in Ixodes scapularis (Acari: Ixodidae) nymphs collected in managed red pine forests in Wisconsin. J Med Entomol 2014;51:694-701.
4- Prusinski MA, Kokas JE, Hukey KT, et al. Prevalence of Borrelia burgdorferi (Spoirochets: Spirochaetaceae), Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae), and Babesia microti (Piroplasmida: Babesiidae) in Ixodes scapularis (Acari: Ixodidae) collected from recreational lands in the Hudson Valley Region, New York State. J Med Entomol 2014;51:226-36.
5- Horowitz HW, Aguero-Rosenfeld ME, Holmgren D, et al. Lyme disease and human granulocytic anaplasmosis coinfection: impact of case definition on coinfection rates and illness severity. Clin Infect Dis 2013;56;93-9.
6- Steere AC, McHugh G, Suarez C, et al. Prospective study of coinfection in patients with erythema migrans. Clin Infect Dis 2003;36:1078-81.
7- Krause PJ, Telford SR, Spielman A, et al. Concurrent Lyme disease and babesiosis – evidence for increased severity and duration of illness. JAMA 1996;275:1657-60.
8- Pritt BS, McFadden JD, Stromdah E, et al. Emergence of a novel Ehrlichia sp. agent
pathogenic for humans in the Midwestern United States. 6th International Meeting
on Rickettsiae and Rickettsial Diseases. Heraklion (Greece), June 5–7, 2011.
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**Comment**
This important letter to the editor highlights many contentious issues Lyme/MSIDS patients have to muddle through. From where I sit, I disagree with the author’s statements that these infections are ‘mild and self-limited’, but I deal with sick people – not healthy. If there’s one thing I DO know, it’s that these infections have been downplayed for far too long, and it’s been a real problem. Patients haven’t been taken seriously for over 40 years!
The consideration of coinfections; unfortunately, is not common in mainstream medicine regarding Lyme/MSIDS. They still treat this as a one germ disease with doxycycline curing it, when nothing could be further from the truth: https://madisonarealymesupportgroup.com/2018/10/30/study-shows-lyme-msids-patients-infected-with-many-pathogens-and-explains-why-we-are-so-sick/