Archive for the ‘research’ Category

Pandas & Lyme in a 7-Year Old

https://danielcameronmd.com/pandas-and-lyme-disease-in-a-7-year-old-child/

PANDAS AND LYME DISEASE IN A 7-YEAR-OLD CHILD

PANDAS-Lyme-disease

Hello, and welcome to another Inside Lyme Podcast. I am your host Dr. Daniel Cameron. In this podcast, I will be discussing the case of a 7-year-old child who was initially diagnosed with PANDAS and later, Lyme disease.

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The article by Cross et al. entitled “Case Report: PANDAS and Persistent Lyme disease with Neuropsychiatric Symptoms: Treatment, Resolution and Recovery” was published in Frontiers in Psychiatry. [1]

The 7-year-old girl developed multiple physical and neuropsychiatric symptoms six months after travelling to a tick endemic region of the U.S. During this period, she was treated for 3 separate strep infections and was subsequently diagnosed with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). PANDAS was considered based on classic symptoms and a history of strep, a positive ASO titer and a slightly elevated DNase B titer.

However, despite treatment, the patient’s symptoms continued to worsen. Additional testing revealed that she was also positive by CDC’s criteria for Lyme disease. The Lyme EIA and western blot IgM were positive (with 2 of 3 bands). The western blot IgG was positive for 3 of 10 bands at the IGeneX lab. Her B. henselae IgG was positive at Quest labs. Her IgG Mycoplasma and IgG Babesia duncani antibodies were positive at IGeneX.

Dr. Charles Ray Jones, co-author and treating physician, describes the patient’s broad range of symptoms.

Neuropsychiatric symptoms

On her first visit, “the patient presented with crying, anxiety, headache, joint pain, decreased cognitive functioning, fatigue, nighttime awakening and an extreme fear of sleeping alone.”

The patient’s symptoms were extensive, Jones explains, and included:

• Obsessions, compulsions
• ADHD-like behavior
• Decline in school work
• Separation anxiety
• Panic attacks
• Muscle and joint pain
• Mood lability
• Aggressive behavior
• Fatigue
• Headaches
• Difficulty sleeping
• Word selection problems
• Cognitive decline
• Irrational fears (would not sleep alone)

Functional decline 

The young girl was considered a gifted child and excelled in academics. But cognitive symptoms emerged. She reportedly told her mother, “Mom, something happened to my brain.”

“The patient regressed from being a year ahead of her class in math, to being unable to add beyond the number 10. She began having trouble comprehending more difficult reading,” the authors explain.

“During a ride home with her mother, the patient asked, ‘Who are you? What’s your name again?’ And ‘I know you are mommy but what’s your name?’”

Lyme disease, PANDAS and PANS

PANDAS may be diagnosed when a strep infection triggers multiple neurologic and psychiatric symptoms. PANS or Pediatric Acute-Onset Neuropsychiatric Syndrome, on the other hand, may be triggered by other bacterial, viral or fungal infections. Researchers believe that Borrelia burgdorferi, the bacteria that causes Lyme disease can trigger PANS in some patients.

Lyme disease, PANS and PANDAS can present with similar symptoms. Dr. Bransfield, a psychiatrist who specializes in tick-borne diseases, describes a broad range of neuropsychiatric symptoms that he has seen in his Lyme disease patients. [2]

These include: behaviors associated with developmental disorders or autism spectrum disorder, schizoaffective disorders, bipolar disorder, depression, anxiety disorders (panic disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, intrusive symptoms), eating disorder, decreased libido, sleep disorder, addiction, opioid addiction, cognitive impairments, dementia, seizure disorders, suicide, violence, anhedonia, depersonalization, dissociative episodes, derealization and other impairments.”

Treatment

According to the authors, the child was treated with multiple courses of oral and IV antibiotics including: intravenous ceftriaxone, Omnicef 300 mg BID, Zithromax 250 mg BID, 500 mg BID and Tindamax 250 mg QD (Saturdays and Sundays only), Bactrim and Mepron. Despite this, her symptoms continued and the Cunningham Panel™ of tests was ordered.

Cunningham Panel™ and IVIG

“The Cunningham Panel was ordered to assess the presence of antineuronal antibodies against specific neuronal receptors,” the authors write. “If the Cunningham Panel is positive or strongly positive, that would be an indication that one has an autoimmune problem that needs to be treated with IVIG, as well as antibiotics,” explains Jones.

READ MORE: Highlights from the case report

Panel results indicated the patient had elevated levels for 3 out of 4 autoantibodies: Dopamine D1 Receptor (DRD1), Dopamine D2L Receptor (DRD2L), and Tubulin (TUB).

“Based upon the patient’s Cunningham Panel tests results, the decision was made to prescribe IVIG,” the authors write.

“Over a span of 31 consecutive months of treatment with various antimicrobials and 3 courses of IVIG she experienced complete remission and remains symptom free at the time of this publication.”

Outcome

“Currently this patient appears to be fully recovered and has been discharged from the care of the pediatric Lyme disease specialist. She is asymptomatic and performing academically at the “top” of her class according to her mother,” the authors write.

According to Jones, “multiple concomitant infections may be involved and require treatment to effectively resolve symptoms. Improvement in neuropsychiatric symptoms does not typically occur unless all co-infections are addressed and resolved.”

This podcast addresses the following questions:

  1. What is Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)?
  2. What are the typical symptoms of PANDAS?
  3. What are the similarities between Lyme disease, PANS and PANDAS?
  4. Why was Lyme disease and other tick-borne illnesses considered?
  5. Why was the name Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) introduced?
  6. What is the Cunningham Panel™ of tests and why was it ordered?
  7. What tests did the girl have that supported the diagnosis of a tick-borne illness?
  8. Can you discuss the range of symptoms this patient experienced?
  9. Can you discuss the girl’s treatment for PANS?
  10. Can you discuss the girl’s treatment for Lyme disease, Bartonella, and Babesia duncani?
    Thanks for listening to another Inside Lyme Podcast. You can read more about these cases in my show notes and on my website @DanielCameronMD.com. As always, it is your likes, comments, reviews, and shares that help spread the word about Lyme disease. Until next time on Inside Lyme.

Please remember that the advice given is general and not intended as specific advice as to any particular patient. If you require specific advice, then please seek that advice from an experienced professional.

Inside Lyme Podcast Series

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.

References:
  1. Case Report: PANDAS and Persistent Lyme Disease With Neuropsychiatric Symptoms: Treatment, Resolution, and Recovery. Cross A., Bouboulis D., Shimasaki C., Jones C.R. Front. Psychiatry, 02 February 2021
  2. Bransfield RC. Suicide and Lyme and associated diseases. Neuropsychiatr Dis Treat. 2017;13:1575-1587. Published 2017 Jun 16. doi:10.2147/NDT.S136137.

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For more:  

Category:

Lyme, PANS, research, Uncategorized

Case Report: Delayed Onset Babesia

https://danielcameronmd.com/case-report-delayed-onset-babesia/

CASE REPORT: DELAYED ONSET BABESIA

delayed-onset-babesia

Hello, and welcome to another Inside Lyme Podcast. I am your host Dr. Daniel Cameron. In this podcast, I will be discussing an unusual case of delayed onset Babesia.

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Podcast:  https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5idXp6c3Byb3V0LmNvbS83NzIx

The case, involving a 19-year-old Hispanic man, was published in the Italian Journal of Pediatrics.1

Ten weeks after travelling to New York, the patient was diagnosed with the tick-borne illness Babesia. Initially, he presented with a 4-day history of fever, generalized weakness, and flu-like symptoms.

His fever was 104.8 F. His hemoglobin dropped from 9.3g/dL to 6.7g/dL within 5 hours. He was diagnosed with hemolysis and transfused with 2 units of packed red blood cells. A peripheral blood smear revealed a Maltese cross typically seen in Babesia.

Babesia is more likely to be symptomatic in individuals with a history of a splenectomy. This young man had a history of a splenectomy for hereditary spherocytosis when he was 3 years old.

Early in the disease, Babesia is more likely to be diagnosed with a thick blood smear under the microscope. But later in the course of the disease, a polymerase chain reaction (PCR) or antibody test can confirm the infection.

Babesia is more likely to be contracted in the Northeastern region of the United States. This young man had returned from a trip to New York. The disease is less likely to be contracted in Florida where the young man presented to an emergency room.

The patient was prescribed Quinine, but it was stopped due to headache, tinnitus, and blurred vision. Instead, he was successfully treated with Atovaquone, clindamycin, and azithromycin.

Two newborns with delayed onset Babesia 

During their third trimester, two mothers were treated for Lyme disease with amoxicillin. Both babies were born and discharged home. But several weeks later, the babies became ill with Babesia.²

The following questions are addressed in this Inside Lyme Podcast.

  1. What is Babesia and where are you more likely to contract the disease?
  2. How is Babesia diagnosed and treated?
  3. Can Babesia be transmitted through blood transfusions?
  4. What are the most common symptoms of Babesia?
  5. Is treatment different from Lyme disease?
  6. How frequently does Babesia co-occur with Lyme disease?
  7. Do patients with Babesia and Lyme disease present differently?
  8. Could Babesia explain why some Lyme disease patients relapse after initially improving with treatment?
  9. What is a Maltese cross?
  10. What is the importance of a splenectomy?
  11. Why is delayed onset Babesia important?

Editor’s note:  Delayed onset Babesia in two newborns is discussed in another Inside Lyme podcast.

    Thanks for listening to another Inside Lyme Podcast. You can read more about these cases in my show notes and on my website @DanielCameronMD.com. As always, it is your likes, comments, reviews, and shares that help spread the word about Lyme disease. Until next time on Inside Lyme.

Please remember that the advice given is general and not intended as specific advice as to any particular patient. If you require specific advice, then please seek that advice from an experienced professional.

Inside Lyme Podcast Series

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.

References:
  1. Patel JK, Tirumalasetty K, Zeidan B, Jr., Desai P, Frunzi J. A Case Report of Babesiosis Seen Outside of its Endemic Area and Incubation Period. Cureus. Dec 5 2020;12(12):e11926. doi:10.7759/cureus.11926
  2. Saetre K, Godhwani N, Maria M, et al. Congenital Babesiosis After Maternal Infection With Borrelia burgdorferi and Babesia microti. J Pediatric Infect Dis Soc. Feb 19 2018;7(1):e1-e5. doi:10.1093/jpids/pix074

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For more:  https://madisonarealymesupportgroup.com/2016/01/16/babesia-treatment/

https://madisonarealymesupportgroup.com/2020/07/31/cipro-derivatives-show-promise-against-babesia-in-vitro/

https://madisonarealymesupportgroup.com/2020/07/21/babesia-in-dogs-implications-for-people/

https://madisonarealymesupportgroup.com/2021/01/08/rising-geriatric-babesia-cases-may-require-longer-treatment/

Category:

Babesia, research, Treatment

Study Finds ‘No Significant Beneficial Effect’ of Restrictive Lockdowns

https://onlinelibrary.wiley.com/doi/epdf/10.1111/eci.13484

Abstract
Background and Aims: The most restrictive non-pharmaceutical interventions (NPIs) for controlling
the spread of COVID-19 are mandatory stay-at-home and business closures. Given the consequences
of these policies, it is important to assess their effects. We evaluate the effects on epidemic case
growth of more restrictive NPIs (mrNPIs), above and beyond those of less restrictive NPIs (lrNPIs).
Methods: We first estimate COVID-19 case growth in relation to any NPI implementation in
subnational regions of 10 countries:
  • England
  • France
  • Germany
  • Iran
  • Italy
  • Netherlands
  • Spain
  • South Korea
  • Sweden
  • US

Using first-difference models with fixed effects, we isolate the effects of mrNPIs by subtracting the combined effects of lrNPIs and epidemic dynamics from all NPIs. We use case growth in Sweden and South Korea, two countries that did not implement mandatory stay-at-home and business closures, as comparison countries for the other 8 countries (16 total comparisons).

Results: Implementing any NPIs was associated with significant reductions in case growth in 9 out of
10 study countries, including South Korea and Sweden that implemented only lrNPIs (Spain had a
non-significant effect). After subtracting the epidemic and lrNPI effects, we find no clear, significant
beneficial effect of mrNPIs on case growth in any country. In France, e.g., the effect of mrNPIs was
+7% (95CI -5%-19%) when compared with Sweden, and +13% (-12%-38%) when compared with
South Korea (positive means pro-contagion). The 95% confidence intervals excluded 30% declines in
all 16 comparisons and 15% declines in 11/16 comparisons.
Conclusions: While small benefits cannot be excluded, we do not find significant benefits on case
growth of more restrictive NPIs. Similar reductions in case growth may be achievable with less
restrictive interventions.
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**Comment**
We can be very thankful Sweden and South Korea stood up to the concerted bullying or there would have been no control group to compare lockdowns to!

Category:

Activism, research, Viruses

Spatial and Temporal Patterns of Borrelia Miyamotoi in NY Deer Ticks

https://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-020-04569-2

Spatial and temporal patterns of the emerging tick-borne pathogen Borrelia miyamotoi in blacklegged ticks (Ixodes scapularis) in New York

Parasites & Vectors volume 14, Article number: 51 (2021) Cite this article

Abstract

Borrelia miyamotoi, a bacterium that causes relapsing fever, is found in ixodid ticks throughout the northern hemisphere. The first cases of human infection with B. miyamotoi were identified in 2011. In the eastern USA, blacklegged ticks (Ixodes scapularis) become infected by feeding on an infected vertebrate host, or through transovarial transmission. We surveyed B. miyamotoi prevalence in ticks within forested habitats in Dutchess County, New York, and identified possible reservoir hosts. To assess spatial variation in infection, we collected questing nymphal ticks at > 150 sites. To assess temporal variation in infection, we collected questing nymphs for 8 years at a single study site. We collected questing larval ticks from nine plots to estimate the amount of transovarial transmission. To evaluate potential reservoir hosts, we captured 14 species of mammal and bird hosts naturally infested with larval blacklegged ticks and held these hosts in the laboratory until ticks fed to repletion and molted to nymphs. We determined infection for all ticks using quantitative polymerase chain reaction.

  • The overall infection prevalence of questing nymphal ticks across all sites was ~ 1%, but prevalence at individual sites was as high as 9.1%.
  • We detected no significant increase in infection through time.
  • Only 0.4% of questing larval ticks were infected.
  • Ticks having fed as larvae from short-tailed shrews, red squirrels, and opossums tended to have higher infection prevalence than did ticks having fed on other hosts.

Further studies of the role of hosts in transmission are warranted. The locally high prevalence of B. miyamotoi in the New York/New England landscape suggests the importance of vigilance by health practitioners and the public.

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**Comment**

A perfect example of how there can be high infection rates in humans but low infection rates in ticks.

Category:

Borrelia Miyamotoi (Relapsing Fever Group), research, Testing, Ticks

Herxheimer Reaction in 13 Year Old Boy With Lyme Disease

https://danielcameronmd.com/herxheimer-reaction-lyme-disease/

HERXHEIMER REACTION IN A 13-YEAR-OLD BOY WITH LYME DISEASE

herxheimer reaction in boy with lyme disease

A Jarisch-Herxheimer reaction (JHR), also referred to as a Herxheimer reaction, was first described after initiating treatment for syphilis. This reaction is associated with the onset of new symptoms or a worsening of existing symptoms in patients receiving antibiotic treatment. The Herxheimer reaction has also been described in patients treated for leptospirosis, relapsing fever, and Lyme disease.

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In a recently published paper, Nykytyuk and colleagues describe the case of a 13-year-old boy with Lyme arthritis, a common manifestation of Lyme disease, who developed a Herxheimer reaction when treated with doxycycline. [1]

“A 13-year-old boy was admitted to the regional hospital with complaints of left knee swelling, hip, ankle and cervical spine pain,” the authors write. The first signs of left knee arthritis began 6 months prior to his hospitalization.

The doctors assumed the boy suffered from post-traumatic arthritis and prescribed non-steroidal anti-inflammatory drugs (NSAIDs) which were only minimally effective.

Six months later, a rheumatologist diagnosed Lyme disease, in part, due to a reported tick bite which occurred 3 months before the onset of the left knee arthritis. The patient did not have a erythema migrans (EM) rash.

Laboratory tests were consistent with the diagnosis of Lyme arthritis and doctors prescribed doxycycline.

On day 7 of antibiotic treatment, the boy developed a Herxheimer reaction. “On the 7th day of doxycycline treatment the patient’s condition deteriorated: a low-grade fever occurred, and severe arthralgias with intense hip, ankle and cervical spine pain and myalgias developed,” the authors explain.

The boy also had elevated CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate). Steroids were prescribed.

There was no evidence of neurologic involvement and a spinal tap was normal. Nevertheless, doctors prescribed 4 weeks of intravenous ceftriaxone which led to a resolution of the joint swelling and less arthralgias.

Herxheimer reactions in Lyme disease patients

Jarisch-Herxheimer reactions have been described in the literature with a combination of symptoms occurring including fever, severe polyarthralgias, and myalgias, according to the authors.

Other Jarisch-Herxheimer reactions have also been described. The list includes “chills, high temperature, hypotension, nonpruritic, nonpalpable rash, tachycardia, nausea, headache, strengthening of existing or occurrence of new symptoms of the underlying disease,” the authors write.

Some studies have found that Herxheimer reactions were milder in patients with Lyme disease when compared to other diseases, without organ dysfunction or need for hospitalization, Nykytyuk  writes.

However, another case report by Haney et al., describes a more severe Herxheimer reaction in response to doxycycline in a patient with chronic Lyme disease. The patient developed “a low-grade fever, sore throat, sinus congestion, watery diarrhea, headache, stabbing pain in the upper back muscles, increased fasciculations and fatigue.” [2]

Physician education needed

The exact cause of Jarisch-Herxheimer reactions is still unknown.

“At first, the role of an endotoxin in the development of JHR was suggested, but later experimental studies showed that spirochetes do not have biologically active endotoxins,” the authors explain.

Nykytyuk and colleagues emphasize the importance in educating physicians about the Herxheimer reaction, as there appears to be a “low awareness.” For example, “JHR is often mistaken for an allergic reaction.”

Editor’s note: It is not uncommon for Lyme disease patients to have flare-ups with or without antibiotics. Some patients refer to these reactions as “Herxing,” in the absence of a more descriptive word. The mechanisms of these reactions are uncertain.  I typically avoid prescribing steroids to manage these reactions, as I do not want to suppress a patient’s immune system.

References:
  1. Nykytyuk S, Boyarchuk O, Klymnyuk S, Levenets S. The Jarisch-Herxheimer reaction associated with doxycycline in a patient with Lyme arthritis. Reumatologia. 2020;58(5):335-338. doi:10.5114/reum.2020.99143
  2. Haney C, Nahata MC. Unique expression of chronic Lyme disease and Jarisch-Herxheimer reaction to doxycycline therapy in a young adult. BMJ Case Rep 2016; 2016: bcr2013009433,
    DOI: 10.1136/bcr-2013-009433.

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For more:  

Category:

Detoxing, Lyme, research