Archive for the ‘Treatment’ Category

Endocarditis Caused by Bartonella Quintana, A Rare Case in the U.S.

. 2019; 17: e00533.
Published online 2019 Apr 6. doi: 10.1016/j.idcr.2019.e00533
PMCID: PMC6667705
PMID: 31384552

Endocarditis caused by Bartonella Quintana, a rare case in the United States


Bartonella quintana is a relatively rare cause of endocarditis in the United States (USA). Historically it was linked with trench fever, but cardiac involvement seems to be more prevalent recently. There are some known risk factors associated with Bartonella quintana endocarditis such as human immunodeficiency virus (HIV) infection, alcoholism, homelessness and poor hygiene. We report a case of 37-year-old African man, with culture negative endocarditis, emboli and rising B. quintana and B. henselae IgG titers. B. quintana DNA was subsequently detected from the mitral valve sample with 16S rRNA gene and ribC primer sets. Eventually, blood culture for B. quintana was positive after 21 days. Patient was successfully treated with doxycycline and gentamicin. There have been a few cases of B. quintana endocarditis in the USA and most of them were associated with HIV infection, homelessness or alcoholism. The case reported here highlights the importance of high clinical suspicious for Bartonella species in blood culture negative endocarditis in the USA in appropriate setting and will help to increase awareness among physicians for early diagnosis and treatment.



A few points of interest:

  • Patient’s chief complaints:  progressive shortness of breath, chest painoccasional non-drenching night sweats, fatigue, unintentional ten pound weight loss, and intermittent sharp chest pain radiating to the neck
  • Past medical history significant for latent tuberculosis infection and treatment completed 3 months prior to the presentation
  • While living in the Democratic Republic of Congo before migrating to Indiana, patient had a cow at his home and used to drink raw cow’s milk
  • Had Janeway Lesions on hands & feet

Janeway lesion Pictures, Definition, Symptoms, Causes, Treatment

Janeway lesion Pictures, Definition, Symptoms, Causes, Treatment

  • Was considered immunocompetent 

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GLA Response to Proposed IDSA/AAN/ACR 2019 Draft Lyme Disease Guidelines


The Infectious Diseases Society of America (IDSA), along with the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR), recently published a public request for comments on the “2019 Draft Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease.” Below is the official response from Global Lyme Alliance (GLA).

The 100-page guidelines document attempts to cover various aspects of Lyme disease, including prevention, acute Lyme disease, neurological Lyme disease, co-infections, and more. GLA purposefully focused on seven (7) specific areas of the Draft Lyme Disease Guidelines to comment on. The 7 areas are handpicked for two key reasons: they represent the most glaring oversights and omissions in the guidelines and there is strong scientific evidence to refute them.

GLA focused its comments on 1) the overall misses of the guidelines, 2) Lyme disease diagnostics, 3) tick bites and prophylactic treatment, 4) neurological Lyme disease, 5) post-treatment Lyme disease, 6) treatment for persisting Lyme infections, and 7) chronic Lyme disease.


General comments on entire draft, pages 2-69, lines 45-1605: Throughout the 2019 draft revised guidelines, an overriding concern is the generation of false positive diagnoses and misattribution of symptoms to Lyme disease. In contrast, there is little, or no concern voiced about the possibility of false negative diagnoses and misattribution of Lyme disease symptoms to other etiologies. Obviously, all patients, whatever their ailment, should be accurately diagnosed in a timely manner. Testing methods more sensitive and reliable than the CDC standard two-tier test (STTT), as concluded by 40 Lyme disease academic and government specialists attending a Banbury Conference at Cold Spring Harbor Laboratory, and a year later by the Tick-Borne Disease Working Group, are desperately needed to differentiate between those who do and those do not have Lyme disease. Individuals suffering from Lyme and other tick-borne diseases (TBDs) who are not promptly diagnosed are likely contributing, at least in part, to the accumulation of patients suffering from post-treatment Lyme disease syndrome(PTLDS). Because of the severe consequences of missed or delayed diagnosis of Lyme disease, it is extremely important to minimize false negative diagnoses as well. Specific guidance on how best to avoid false negative diagnoses would be invaluable to medical care providers.


Diagnostic Testing for Lyme disease, page 10, lines 228-229: It states that “IgG seronegativity in a patient with prolonged symptoms (months to years) essentially rules out the diagnosis of Lyme disease…”. This is only true if the patient with prolonged symptoms has no history of other objective, clinical measures of Lyme disease. Also, it is noteworthy that research has shown that seroreactivity to Borrelia burgdorferi antigens varies between individuals and during the course of disease within an individual. Therefore, a static test at one point in a dynamic disease process is a poor diagnostic tool. The IDSA/CDC criteria requiring that five of 10 IgG bands be present for positive diagnosis does not make sense immunologically as it suggests that a patient with only four bands does not have Lyme disease. How does one then explain away the presence of four distinct antibodies highly specific in their ability to recognize B. burgdorferi antigens? Furthermore, work published by researchers at Northeastern University and Johns Hopkins University have shown in vitro and in vivo (in a mouse model of Lyme borreliosis), respectively, that at different stages of growth B. burgdorferi expresses a distinct repertoire of antigens and degrees of antibiotic tolerance. While in vivo studies are ongoing to identify these persister forms in patients, it is premature to dismiss the possibility that persisters expressing variant antigens, and the antibodies they elicit, exist in PTLDS patients. Therefore, the Western immunoblot of the CDC standard two-tier test (STTT) may not include the full repertoire of antigens recognized by patients with prolonged symptoms. Their absence from the STTT could result in late stage patients failing to meet the “five of 10 IgG bands” criterion for a positive diagnosis. As the field transitions from use of the STTT to a modified two-tier test (MTTT) this same concern about whether the ‘correct’ antigens are targeted remains.

Another factor to consider is that continued B. burgdorferi-specific IgM reactivity has been observed in IgG seronegative patients. This scenario is confusing, because it can lead to a false positive Lyme diagnosis. However, there also are IgM-positive/IgG-negative patients who were previously diagnosed with Lyme disease, based upon presentation of erythema migrans or other CDC criteria. The Johns Hopkins University SLICE studies suggest that a diversity serological profiles exist in PTLDS patients; these include those who are IgM-positive/IgG-negative when tested months after cessation of treatment. In an initial case series of 60 patients, while 43% were IgG-positive, 11% were IgM-negative. Among these IgM-negative patients, most were IgG-negative as well. In short, the lack of B. burgdorferi-specific IgG does not necessarily preclude continued disease just as the continued presence of B. burgdorferi-specific IgM and/or IgG is not always indicative of active infection. Acknowledgement of these important, albeit nuanced, facts is absent from the revised guidelines.


Tick bites, prevention, and prophylaxis of Lyme disease – What diagnostic tests should be used following tick bite?, pages 19-20, lines 453-467: It states, “We recommend against testing for B. burgdorferi in an Ixodes tick following a bite”. While true that the presence of a pathogen does not reliably predict the likelihood of clinical infection, there still is valuable information to be gained by testing ticks. Primary care physicians, even in Lyme-endemic areas, are not always familiar with the tick species common to a given location or the pathogen(s) they may carry. The stated rationale for the recommendation not to test is that “Even in areas that are highly endemic for Lyme disease, patients presenting with an Ixodes tick bite have a low probability of developing Lyme disease…”. This statement is not referenced and is unsupported by the fact that in highly endemic areas, in the northeastern U.S. in particular, the carriage rate for B. burgdorferi can be 50% or greater and such high carriage rates correlate with a higher incidence of Lyme disease. Tick removal and sending it for testing is a relatively rare event and thus should not contribute significantly to unnecessary antibiotic prescriptions. A major benefit to tick testing is that if no pathogens are found, this information would put the patient’s mind at ease.  If instead, the tick tests positive for one or more pathogens, this will focus the physician’s and patient’s attention on what symptoms to look for and better inform a treatment strategy if such symptoms arise.

The guidelines also suggest that “Anticipatory guidance is recommended so that a prompt diagnosis of Lyme disease (as well as other Ixodes tick transmitted infections) can be made should a patient develop symptoms”. However, given the inadequate familiarity most physicians have regarding ticks and tick-borne agents in their area, let alone in an area(s) to which a patient may have traveled and been bitten, there is no basis for thinking such anticipatory guidance can be provided. It is hard to rationalize why the guidelines would advocate for physicians and patients to make decisions having less rather than more information in hand, especially when the benefits of a prophylactic single dose of Doxycycline are substantial and the risks negligible.


Neurological Lyme disease – For which neurological presentations should patients be tested for Lyme disease?, page 36, lines 840-841: It states that “In patients with cognitive decline the guidelines recommend against routine testing for Lyme disease.” Global Lyme Alliance vehemently disagrees with this statement because it does not take into consideration the extensive evidence in peer-reviewed medical journals describing the cognitive decline experienced by Lyme neuroborreliosis patients. Such studies include patients with PTLDS, as defined by the IDSA-proposed case definition, who experience cognitive decline as well as PTLDS patients with neuropsychiatric symptoms linked to neuroimmune responses. This latter reference also argues against the guidelines’ claim that “No studies suggest a convincing causal association between Lyme disease and any specific psychiatric conditions”. If patients present with otherwise unattributable cognitive decline, and they live in a Lyme-endemic area, why should a physician not consider Lyme disease in their differential diagnosis? To not do so risks a missed/delayed diagnosis, and it is well-established that the earlier the treatment for Lyme disease is initiated the more positive the prognosis for recovery and cure. It also is recognized that cognitive symptoms can vary depending on a patient’s age, so a “one size fits all” statement that patients with (otherwise) unexplained cognitive decline should not be tested for Lyme disease seems at odds with a careful process of differential diagnosis and best-practice medical care.


Prolonged symptoms following treatment of Lyme disease, page 61, lines 1412-1419: Reference is made to studies of “patients appropriately diagnosed and treated for Lyme disease” who describe either “persisting or recurrent fatigue, musculoskeletal pain, neurocognitive and other non-specific subjective symptoms”.  These are in fact patients clinically defined by Rebman et al. as having PTLDS and yet reference to this seminal study and specific mention of this PTLDS patient population is missing and should be included in the body and bibliography of the guidelines. In this same section it states that long-term “symptoms appear to subside over time…”. For patients suffering from PTLDS, most continue to have debilitating symptoms. In fact, a Dutch study found an average of 1.7 disability-adjusted life years lost due to persisting symptoms attributable to Lyme, and even longer for some patients.


Prolonged symptoms following treatment of Lyme disease – Should patients with persistent symptoms following standard treatment of Lyme disease receive additional antibiotics?, pages 62-63, lines 1445-1449 and 1464-1468: Four randomized, controlled trials are cited as evidence against repeated antibiotic treatment (references #317, 321, 319). A careful statistical analysis of the trials and their design calls into question the conclusion that repeated antibiotic treatment has no benefit. DeLong et al. showed that two trials conducted by Klempner (reference #317) had sample sizes too small to detect true minimum clinically-important differences, particularly in SF-36 scores. The guidelines state that in study by Fallon et al. (reference #321) “A cognitive index score at week 24 did not differ between treatment and control groups.” While true that objective measures such as cognitive test results did not show differences between PTLDS patients and controls, it is important to note that PTLDS patients in the study had to invest considerably more effort to achieve the same test scores. This would argue against the notion “that this phenomenon, in whole or in part, represents anchoring bias…”. Additionally, the authors did note a positive effect on fatigue, similar to that observed in the Krupp trial (reference #319), and Fallon and co-authors highlighted the need for further study. In reviewing these clinical studies, DeLong et al. concluded that “primary outcomes originally reported as statistically insignificant were likely underpowered.” At the very least, DeLong’s analysis should be cited in the IDSA guidelines as evidence that further study of repeated antibiotic use should be very carefully designed, executed, and interpreted.

Regarding continued or repeated antibiotic treatment for persistent symptoms, the guidelines state that “A body of literature conducted in animal models has raised hypotheses of microbiological persistence”. While correct, this statement is wholly disingenuous as it fails to reference any of the studies and, worse, neglects to acknowledge that experimental results are presented that support the hypotheses put forward. It also is stated that “Moreover, animal models cannot reproduce the human experiences of fatigue and pain, and it is unlikely that any animal study can give reliable insight into the biology of humans experiencing such symptoms following treatment of Lyme disease.” Again, this statement neglects a significant body of literature describing animal models of human fatigue and chronic pain.  Such studies have been instrumental in advancing our understanding of the pathogenesis of these human conditions and have spurred the development of novel treatments. This statement also fundamentally misrepresents the intent of the diverse animal studies conducted that provide evidence of persistence of spirochetes post-antibiotic treatment of infected animals. The purpose of using animal models as articulated by Monica Embers, Ph.D. (Division of Bacteriology and Parasitology, Tulane National Primate Research Center, Tulane University Health Sciences Center) is “to understand the etiology of post-treatment Lyme disease syndrome (PTLDS), namely whether or not the spirochetes persist post-treatment and could thus contribute to chronic symptoms.” Symptoms experienced by PTLDS patients are not restricted to fatigue and pain, so one cannot reasonably discount the results of animal findings supporting spirochetal persistence because they are purported not to recapitulate all the symptoms experienced by humans.

Recent human evidence that continued bacterial presence may contribute to long-term symptoms was published by Jutras et al. in a 2019 PNAS article. They found that B. burgdorferi peptidoglycan, a component of the cell wall, was recovered from 94% of synovial fluid samples from Lyme arthritis patients, with specific IgG responses. Many of these patients had previously been treated with antibiotics. As peptidoglycan is shed from actively growing live bacteria, it’s at least plausible and worth further inquiry to study whether bacteria persist in these patients. If not, one is left with a less plausible explanation that foreign bacterial antigens must remain in inflamed tissues for weeks, months, or even years after (presumed) effective antibiotic-mediated killing of B. burgdorferi. With such intriguing findings at least hinting at the possibility of persistent organisms in Lyme disease patients, the authors of the revised guidelines should consider specifically referencing these animal and human studies rather than covering the entire topic by citing one publication (reference #320) and summarily discounting the results presented in so many other peer-reviewed scientific journals.


Prolonged symptoms following treatment of Lyme disease – Chronic Lyme disease, page 64, lines 1474-1479: It states that “The term ‘chronic Lyme disease’ as currently used lacks an accepted definition for either clinical use or scientific study, and it has not been widely accepted by the medical or scientific community”. Although this statement is correct with respect to the lack of an accepted clinical definition, at least 68 publications in peer-reviewed scientific and medical journals spanning 1985 to 2019 describe the chronic infectious and persistent nature of Lyme disease. While treatment of patients with Doxycycline or other standard-of-care antibiotics is quite effective when provided within the first few weeks of infection, no clinical studies have demonstrated complete clearance of spirochetes; just elimination of symptoms for some, but not all patients (i.e., PTLDS patients). When early treatment is ineffective or initial diagnosis is delayed, B. burgdorferi can avoid pharmaceutical and/or immune clearance and spirochetes have an opportunity to disseminate and cause persistent disease. Literally a dozen or more bacterial pathogens are capable of establishing persistent infection and associated chronic disease. It would be truly remarkable if B. burgdorferi were unable to do the same. To our knowledge, there is no scientific or medical evidence to suggest they are incapable.

Whether persistent disease is synonymous with persistent infection is an important scientific question worthy of objective consideration and further careful investigation, rather than recrimination, disparagement and dismissal. The revised guidelines would stand on firmer scientific/medical footing were it to acknowledge that the question of persistent disease vs. infection is still an open question, rather than suggesting the latter has no evidentiary support whatsoever.

To conclude, the content and bibliography of the 2019 revised IDSA guidelines fails to acknowledge evidence or reference published scientific and medical studies that could and should convey a more nuanced understanding of the complexities of Lyme disease diagnosis, symptomatology, treatment, and treatment failure. A more inclusive, open-minded, and informed approach to conveying information can only benefit the Lyme disease physician and patient community, as it will better serve to enhance co-operation, reduce controversies that divide the IDSA and ILADS ‘camps’, and ultimately reduce the likelihood of false negative and false positive diagnoses.

Learn more about important GLA-funded peer-reviewed Lyme disease research, ranging from basic science, treatment, to chronic Lyme disease.



I all I can say is a hearty AMEN!

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Illinois Expands Insurance Coverage For Those With Tick-borne Diseases And Children Requiring EpiPens

Illinois expands insurance coverage for those with tick-borne diseases and children requiring EpiPens

SPRINGFIELD, IL (WGEM) — Governor JB Pritzker signed two new laws expanding insurance coverage for children whose allergies require life-saving EpiPens and Illinoisans suffering from Lyme disease.

“This legislation takes a big step forward in protecting our children and families,” said Pritzker. “Both of these new laws fulfill a core principle of this administration: state government ought to be standing up for working families. Lowering the cost of prescription drugs and expanding health care coverage is one important way to help lower costs and build a higher standard of living for all Illinoisans.”

The new laws include House Bill 889 and 3435.

House Bill 889

The Governor’s office stated that House Bill 889 requires insurance companies to cover office visits, testing and treatment for tick-borne diseases like Lyme disease. The new law aims to support farmers throughout the state who have struggled to afford continuing treatments. From 2004 to 2016, tick-borne diseases have risen dramatically according to the Centers for Disease Control.

“The ability to receive treatment when you have previously been insufficiently treated is life changing,” said Rep. Daniel Swanson (R-Woodhull). “By mandating insurance coverage of long-term antibiotic treatment needed for patients, we are putting another piece of the puzzle into place for some patients and removing one additional hassle on their path to recovery.”

House Bill 3435

Officials stated that House Bill 3435 requires insurance companies to cover EpiPens, for children with severe allergies. The cost of an EpiPen has skyrocketed over the last decade, rising by more than 400% for the two-pen injector pack. Without insurance, these EpiPens can cost a family nearly $700 and typically have a shelf life of a little more than a year before the medicine needs to be restocked in stores.

“With steady increases in food allergies and other serious allergic conditions, families are relying on EpiPens more than ever before,” said Sen. Julie Morrison (D-Deerfield). “We should be doing everything we can to expand access to affordable lifesaving drugs and medicines. No child with a serious allergy should be without an epinephrine injector because they cannot afford one.”

House Bill 889 takes effect immediately.

House Bill 3435 takes effect on January 1, 2020.

While legislators attempt to help Lyme patients by proposing bills such as these, the CDC Lyme Corps goes into every state and undermines them:  Excerpts: 
To be clear, the CDC is using Lyme Corps to tell health practitioners the only valid treatment for Lyme, chronic Lyme and complications from coinfections are found in the 2006 IDSA Lyme Guidelines.  However, key science institutions and federal agencies would not support this objective….
The CDC Lyme Corps was initiated in 2013 prior to the NGC delisting of the IDSA Lyme Guidelines. Nevertheless, as of July 4, 2016, the IDSA and the CDC Lyme policy and programs, including Lyme Corps continue to promote these outdated notions and noncompliant Guidelines.
The IDSA has also taken numerous actions against Lyme patients’ and practitioners’ protections.  One such IDSA website post  State-Level Lyme Disease Advocacy Efforts  openly admits to undermining Lyme patient rights in: California, Connecticut, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Texas, Vermont, Virginia, West Virginia and Wisconsin. [xvi]  Another such IDSA web announcement is the IDSA’s Lyme Disease Advocacy Efforts[xvii] The ‘anti-protections’ advocacy letters are detailed.

A breach of public trust by the CDC Directors responsible for protecting the public health and welfare against Lyme epidemic – all these CDC officials are members of IDSA and there are no non-IDSA members among the Directors responsible for CDC’s Lyme policy and programs.  [xxviii]

This group of CDC officials show continuous and singular “preferential treatment” for the ‘Lyme product’ of a private medical society, the IDSA. The product is the IDSA Lyme Guidelines; these Guidelines have failed federal criteria for evidence-based medicine.

The promotion of these federally noncompliant IDSA Guidelines make waste of tax dollars and misinform the public. Such actions run contrary to protecting the health and welfare of the public against the Lyme epidemic and they show a strong a lack of “honest effort in the performance of their duties.

Unfortunately, due to this undermining, I do not expect these well meaning bills to do anything of substance to truly help patients.
Regarding “doctor protection” bills, I’ve heard from doctors that they are under more scrutiny than before they had these supposed “protections.”
And regarding states that have adopted bills requiring doctors to tell patients they could still be infected even if the test is negative, I’ve heard many doctors aren’t complying.



An Unexpected Case of Bartonella Alsatica Prosthetic Vascular Graft Infection

An unexpected case of Bartonella alsatica prosthetic vascular graft infection

Authors Puges M, Ménard A, Berard X, Geneviève M, Pinaquy JB, Edouard S, Pereyre S, Cazanave C

Published 7 August 2019 Volume 2019:12 Pages 2453—2456


Abstract: Bartonella alsatica is a wild rabbit pathogen causing bacteremia rarely reported in humans, with only three cases published so far, including one lymphadenitis and two endocarditis cases. Here, we report the case of a 66-year-old man who suffered from acute renal failure due to a membranoproliferative glomerulonephritis. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) showed diffuse FDG uptake around the aortobifemoral graft with no indication of infection. A white blood cell scan showed an accumulation of labeled neutrophils on the left femoral part of the graft. The patient underwent surgery and an abscess around the left iliac part of the graft was found intraoperatively. Intraoperative samples were all negative, but 16S rRNA gene-based PCR was positive, and the sequence was positioned among the Bartonella species cluster. Specific PCRs targeting groEL/hsp60, rpoB and gltA genes were performed and led to the identification of B. alsatica. Accordingly, indirect immunofluorescence serological analyses were positive for Bartonella henselae and Bartonella quintana. The patient had a history of regularly hunting wild rabbits. He was treated with 100 mg of doxycycline twice a day for six months and his renal function significantly improved with no sign of persistent infection. This case highlights the contribution of serology assays and molecular-based methods in prosthetic vascular graft infection diagnosis.________________

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The Tell-Tale Sign Of Lyme Disease: Mother Shares Photo Of Her ‘Bullseye’ Rash After She Caught The Infection While Walking Her Dog in the Park

The tell-tale sign of Lyme disease: Mother shares photo of her ‘bullseye’ rash after she caught the infection while walking her dog in the park

  • Kate Allen got tick bites on a summer’s day and three days later a rash appeared
  • She had 15 circular rashes, some which reached 12 inches (30cm) across
  • Other early symptoms of memory loss and fever led to a diagnosis of Lyme
  • Left untreated, the infection can spread to the organs and be deadly
  • Ms Allen was treated with antibiotics, but fears the infection remains 

A mother has shared a photo of the ‘bullseye’ rash that proved to be a sign of her Lyme disease.

Kate Allen, 28, from Leicester, spotted raised bumps on her skin after walking her dog through long grass in the park in 30°C.

Three days later, she had expanding circular red areas on both legs with a clear centre forming a pattern, some reaching 12 inches (30 cm) across.

Feeling feverish, lethargic, and more forgetful, a doctor diagnosed a mild form of Lyme disease – an infection spread by ticks.

Ms Allen had circular red areas on both legs with a clear centre forming a pattern - also known as a 'bullseye' rash (pictured). She shared her photo on social media to raise awareness


The doctor prescribed Ms Allen a 21-day course of antibiotics (pictured) to treat a mild form of Lyme disease and stop it from spreading

Christine Jennings, 57, was just 32 when the bug latched onto her skin while she was playing with her young daughters.

Over the next week, the former interior designer and artist developed what she thought was a virus, with migraines, a rash and swollen joints.

However, it was just the beginning of a 25-year battle with Lyme disease, in which her health has deteriorated to the point of being bed-ridden.

A spokeswoman from Lyme Disease Action said: ‘Humid weather brings the ticks above ground looking for a meal and walkers and campers need to be aware of the risk of tick bites in shaded areas and long grass.

‘The majority of UK ticks are not infected with Lyme disease, and the risk of disease can be minimised by prompt removal of the tick, without squashing the body.

‘Awareness is key, and ticks should not deter people from enjoying the outside, with all the benefits it brings.’

According to the NHS, it is recommended to cover skin while walking outdoors and use insect repellent on clothes and skin.


Lyme disease is caused by a bacteria that is transmitted to humans through the bite of infected black-legged ticks.

The most common symptoms of the disease are fever, headache, fatigue and a skin rash called erythema migrans.

The disease can typically be treated by several weeks of oral antibiotics.

But if left untreated, the infection can spread to the joints, heart and nervous symptoms and be deadly.


During the first three to 30 days of infection, these symptoms may occur:

  • Fever
  • Chills
  • Headache
  • Fatigue
  • Muscle and joint aches
  • Swollen lymph nodes
  • Erythema migrans (EM) rash

The rash occurs in approximately 80 per cent of infected people.

It can expand to up to 12 inches (30 cm), eventually clearing and giving off the appearance of a target or a ‘bull’s-eye’.

Later symptoms of Lyme disease include:

  • Severe headaches and neck stiffness
  • Additional rashes
  • Arthritis with joint pain and swelling
  • Facial or Bell’s palsy
  • Heart palpitations
  • Problems with short-term memory
  • Nerve pain

Source: CDC



Please remember that while a “bullseye” rash is indicative of Lyme disease, you can still be infected with Lyme without the rash. 

The article states, “The first signs are a distinctive circular rash.”  NOT TRUE. Many NEVER get the rash. The CDC information at the end of the article stating that 80% get the rash is WRONG. The ranges of those getting the rash are 25-80%hardly a sure thing.

The spokesperson from Lyme Disease Action is not helping anyone when they state, The Majority of UK ticks are not infected with Lyme Disease…”

It only takes ONE infected tick to make you ill.  ONE. Prudence would err on the side of caution. Do not take this lightly.  Do not be lazy.

Look at each tick as a monster from hell that can suck the very life out of you.

Perhaps this spokesperson didn’t know Lyme is three times higher than estimated in the UK:

While this article hones in on Lyme, please remember that ticks are filled with numerous pathogens and Lyme is often one of many. Each of these pathogens requires different testing and different medication. This is often NOT a one pathogen illness:  Excerpt:

For the first time, Garg et al. show a 85% probability for multiple infections including not only tick-borne pathogens but also opportunistic microbes such as EBV and other viruses.

I’m thankful they included Bartonella as that one is often omitted but definitely a player.  I’m also thankful for the mention of viruses as they too are in the mix.  The mention of the persister form must be recognized as well as many out there deny its existence.

Key Quote:  Our findings recognize that microbial infections in patients suffering from TBDs do not follow the one microbe, one disease Germ Theory as 65% of the TBD patients produce immune responses to various microbes.”

But there is another important point.

According to this review, 83% of all commercial tests focus only on Lyme (borrelia), despite the fact we are infected with more than one microbe.  The review also states it takes 11 different visits to 11 different doctors, utilizing 11 different tests to be properly diagnosed.

And lastly, please remember that this 21 days of doxycycline is what mainstream medicine is going to give patients even when they admit freely that later symptoms of Lyme disease can involve the heart, brain, cause arthritis, neurological and cognitive issues, and nerve pain, and kill you. If you go onto develop those symptoms, they will tell you, “it’s all in your head, here’s an antidepressant, go home and be well.”  A doctor told her she was, “too pretty to be sick.”

EM: Course & Outcome in Patients Treated With Rituximab

. 2019 Jul; 6(7): ofz292.
Published online 2019 Jun 19. doi: 10.1093/ofid/ofz292
PMCID: PMC6634433
PMID: 31334301

Erythema Migrans: Course and Outcome in Patients Treated With Rituximab



Information on Lyme borreliosis (LB) in patients treated with rituximab is limited to individual case reports.


We reviewed data on adult patients diagnosed with typical erythema migrans (EM) at the LB outpatient clinic of the University Medical Center Ljubljana, Slovenia, in the 10-year period 2008–2017. For all patients, clinical and laboratory information was acquired prospectively using a standardized questionnaire.


Among 4230 adult patients with a diagnosis of EM, 7 patients (0.17%), 5 women and 2 men with a median age of 65 years (range, 55–66 years), were receiving rituximab for an underlying medical condition. In these 7 patients, signs of disseminated LB (43%) and the isolation rates of borreliae from blood before antibiotic treatment (40%) were unusually high compared with corresponding findings in immunocompetent patients who had EM diagnosed at the same institution (8% vs <2%, respectively). The rates of LB-associated constitutional symptoms and borrelial antibodies in serum were lower than expected (14% and 29%, respectively, in patients receiving rituximab vs 25% and 65% in immunocompetent patients). One of the 7 patients (14%) experienced treatment failure; nevertheless, the outcome of early LB 1 year after antibiotic treatment, as used for immunocompetent patients with EM, was excellent in all 7 patients.


Findings in 7 patients with EM who were receiving rituximab for underlying disease suggest that although early LB in these patients is more often disseminated than in immunocompetent patients, the outcome 1 year after antibiotic treatment, as used for immunocompetent patients, is excellent.



There should be followed up done on these patients. A one year outcome, if you understand Lyme disease at all, is a short period of time.

Rituximab, a cancer medicine that interferes with the growth and spread of cancer cells, is used alone or in combination with other medicines to treat the following conditions in adults:

Rituximab may cause a serious brain infection that can lead to disability or death, as well as severe skin problems. You are supposed to tell your doctor if you have any of the following before using the drug:

  • liver disease or hepatitis (or if you are a carrier of hepatitis B)
  • kidney disease
  • lung disease or a breathing disorder
  • a weak immune system (caused by disease or by using certain medicines)
  • an active infection, including herpes, shingles, cytomegalovirus, chickenpox, parvovirus, West Nile virus, or hepatitis B or C
  • heart disease, angina (chest pain), or heart rhythm disorder
  • if you have used rituximab in the past
  • pregnancy – it can harm the unborn baby

According to this, Rituximab suppresses the immune system:

Biological drugs are becoming more popular as a treatment for rheumatoid arthritis (RA). Rituximab is one such drug that works by blocking the activity of immune cells. This then reduces the high level of inflammation seen in the joints of RA patients. Longer courses of treatment are needed for rituximab to be completely effective.

This prolonged treatment can weaken a patient’s immune response and can lead to a condition called hypogammaglobulinemia. This is an immune disorder where the body’s antibody levels are severely reduced, which increases the risk of serious infections.

LLMD’s typically do not recommend immune suppressants for Lyme/MSIDS patients unless they are on antibiotics in tandem. This research study shows why – those in Rituximab had more disseminated Lyme and more borrelia isolated from the blood.  By suppressing the immune system the infection has a greater ability to take over. The fact they had fewer constitutional symptoms and borrelia antibodies in serum means little.  Given time, this could change in a heart-beat. I suspect there were more treatment failures if they followed up on these patients up over years of time.

Patients in the study with solitary EM were prescribed oral antibiotics:

  • doxycycline (100 mg twice daily for 14 days)
  • cefuroxime axetil (500 mg twice daily for 15 days)
  • azithromycin (500 mg twice daily on the first day followed by 500 mg once daily for 4 subsequent days)
  • patients with multiple EM were treated with ceftriaxone (2 g once daily intravenously for 14 days)

For this study, treatment failure was defined as

  1. the occurrence of objective extracutaneous manifestations of LB within 1 year after the start of antibiotic treatment
  2. the appearance/persistence of subjective symptoms or their increased intensity (at the 1-year follow-up visit) that could not be attributed to other causes
  3. persistence of a skin lesion (ie, still visible EM) at a follow-up visit 2–3 months after commencement of treatment
  4. demonstration of borreliae by skin culture at the site of previous EM 2–3 months after the start of treatment (only patients with isolation of borreliae from skin before antibiotic treatment underwent repeated biopsy)

Patients with treatment failure were treated again with an alternative antibiotic.

By looking at the drugs listed, we can see right away that doxy has been shown to throw the spirochete into the non-cell wall form to reemerge later:

The emphasis on external lesions is a mistake. Research has shown that antibiotics clear the EM but won’t clear a systemic infection:

And something must be said about antibiotic levels as well.  In this timely video, Dr. Burrascano explains how some patients need higher drug levels to kill pathogens:

A one sized approach for Lyme/MSIDS is another mistake.

Sadly, the authors conclude that after one year everyone’s dandy, when nothing could be further from the truth.






ILADS Scientific Conference – Registration Now Open

20th Annual ILADS Scientific Conference
Join us in Boston – Registration is Now Open!

We invite you to join us at the 20th Annual International Lyme and Associated Diseases (ILADS) Scientific Conference in Boston from October 31 – November 3, 2019. This year’s conference showcases best practices in the clinical care of patients with Lyme disease and related infections, presents the latest research and trends in treating tick-borne diseases and explores major themes including:

  • How persistent infections and host responses interact to cause chronic disease
  • An introduction to novel antimicrobial strategies in Lyme treatment
  • The role of Big Data in the future of patient care

Conference Highlights:

  • Choose one of two day-long, pre-conference tracks:  Lyme Fundamentals or Exploratory Treatments for Tick-Borne Diseases
  • Daily breakfast chats or networking breakfasts
  • Morning plenary sessions
  • Poster viewing and awards presentation
  • Friday and Saturday afternoon Practical Skills Expansion (PSE) breakout sessions
  • Exhibits by more than 50 vendors showcasing products and services relevant to medical professionals who treat tick-borne diseases

For additional information and a more detailed agenda, please visit

Register before September 7 to receive our early registration discount. We look forward to seeing you at this exciting event!

Register here: