Archive for the ‘Treatment’ Category

Will Two Pills of Doxy Prevent Lyme?

Created by Lyme Action Network

Only one study in 2001 tested this hypothesis at one hospital in New York.

For the study, the bullseye rash was the diagnostic criteria to determine if doxy prevented LD. The study actually showed that people bitten by nymphs were more likely to develop a bullseye rash and therefore diagnosed with LD in comparison with those bitten by an adult tick. None of those bitten by adult ticks developed a bullseye rash.

The Bullseye is a poor indicator of LD.

Only 50% with LD got any kind of rash and only 9% developed a bullseye.

Two pills used at the time of tick bite by a nymph prevented people from getting the bullseye – so they were not diagnosed as having LD and were excluded from the study.

So, will 2 pills of doxy prevent Lyme?

No.

Category:

Lyme, research, Testing, Ticks, Treatment

Controversies in Chronic LD

http://www.nursingcenter.com/journalarticle?Article_ID=3874121&Journal_ID=237151&Issue_ID=3874037

Journal of Infusion Nursing Volume 39, Number 6, Nov/Dec 2016

Elizabeth L. Maloney, MD

ABSTRACT
The Centers for Disease Control and Prevention estimates that more than 300, 000 new cases of Lyme disease occur each year in the United States and that 10% to 20% of these patients will remain symptomatic despite receiving appropriate antibiotictherapy. Many elements of the disease are poorly understood and have generated considerable controversy. This paper discusses the medical controversies related to posttreatment manifestations and their potential impact on infusion nurses.

An executive summary of the article

In an article to infusion nurses, Dr. Maloney points out that less than 20% of all EM rashes have the “classic” bullseye pattern. Infection often involves several tissue types or systems and there is a wide variety of nonspecific disease manifestations. Dissemination can happen quickly but signs may not appear for weeks, months, or even years, and it is not unusual for patients to initially present with Late-stage disease.

In other words, it is quite illogical to think you can quickly pin this thing down & tie a pink ribbon on it.

The article goes on to delineate the existing controversies in Chronic Lyme Disease.

Controversy #1 – Lack of universally understood terminology

Maloney states that initially the word “Chronic” was neutrally used to simply mean that the disease could be long-standing, but that this term over time was denoted by the Infectious Diseases Society of America (IDSA) to a negative connotation when they dismissed the very idea of chronic infection with Lyme Disease and came up with the term Post-Lyme disease syndrome (PLDS), also endorsed by the CDC. Maloney states that their assumption of PLDS lacks proof as there are no tests of cure for Lyme or biomarkers that can identify PLDS.

Controversy #2 – Validity of persistent manifestations being attributable to LD

The bulk of evidence supports the idea that persistent symptoms are related to an active infection or Lyme-induced immune dysregulation, yet again the IDSA and CDC discount this. Maloney sites study after study, particularly recent evidence clearly showing distinct differences in cerebral spinal fluid proteins of patients with chronic LD and those with chronic fatigue, and a longitudinal study of positive EM patients which found that only 1% developed fibromyalgia, which is lower than the general population.

Controversy #3 Significance of LD Persistence

Maloney states the evidence is clear: the physical, social, and economic costs of chronic LD is substantial and is a burden for the whole country. LD patients in study after study had significant physical impairments that interfered with functioning including abnormal sensory ability and motor deficits with pain levels matching post surgical patients, fatigue similar to MS patients, and physical functioning similar to patients with congestive heart failure. In one study, 39% spent at least $5,000 out of pocket for treatment and had to stop working, while another 28% reduced their hours at work.

Controversy #4 Testing in Chronic Lyme

Evidence shows that there are no tests to determine if a patient has an ongoing infection, yet some doctors use serology to decide if a person has chronic Lyme. Current testing DOES NOT identify the bacterium, but rather looks for antibodies to the bacterium. Elevated levels indicate exposure; however, levels in the body change over time. Positive serology in treated patients doesn’t necessarily mean they have an active infection just as negative results are not indicative of cure.

Controversy #5 Uncertain causation of Chronic Lyme

Several causes for chronic Lyme have been suggested but supporting evidence is lacking and include:
1) Other infections
2) Post infectious state
3) Permanent or temporary tissue damage
4) Secondary conditions triggered by initial infection and persisting despite Bb eradication
5) Immune dysfunction either to autoantibodies or unregulated inflammation                       6) Persistent Bb infection

Many doctors acknowledge all of these potential causes except persistent infection despite much evidence to the contrary including an NIH sponsored study demonstrating documented uninfected ticks becoming infected after feeding on a chronically infected patient who had been treated for LD over a year earlier. Also, evidence for 1 cause of persistence does not rule out all others as well as it may be numerous mechanisms working together.

Controversy #6 Antibiotic Usage

The CDC and IDSA propagate the idea that antibiotic treatment is risky and doesn’t help patients, while others disagree. According to Maloney the evidence supports the selective use of antibiotics for chronic Lyme. She also states that the trials by Klempner et al should not be used to prove that antibiotics are not helpful as the study was biased and of poor design. She also points out that findings demonstrating effective retreatment that improved patient outcomes as well as complete recovery in some, has received little notice and that most doctors are not going to even know about them. She also wisely mentions that immune modulators may be useful but persistent infection needs to be ruled out because lowering the immune response risks triggering an active infection.

Maloney clearly admonishes infusion nurses that the science of chronic Lyme is constantly changing but that many doctors have wrongly entrenched themselves in a biased opinion despite the reasoned opinions of colleagues and that due to this they will probably find themselves in the thick of the argument. She says nurses can and should influence treatment decisions by advocating for the patient and by staying abreast of current science and giving accurate information that offers options to create a dialog between care giver and care receiver.

Author Affiliation: Partnership for Healing and Health, Wyoming, Minnesota.
Elizabeth L. Maloney, MD, is the president of Partnership for Health and Health, Ltd. She develops educational materials on tick borne illnesses, including accredited continuing medical education courses for physicians and nurses, and has published papers and letters on Lyme disease in peer-reviewed journals. The author has no conflicts of interest to disclose. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
Corresponding Author: Elizabeth L. Maloney, MD, President, Partnership for Health and Health Ltd, PO Box 84, Wyoming, MN 55092 ( md@phhmd.com ). Elizabeth L. Maloney , MD DOI: 10.1097/NAN.0000000000000195

Category:

research, Treatment

Probable Transfusion-Transmission of Babesiosis

The Brief case: Probable transfusion-transmitted babesiosis in a transplant recipient

Kitt E, Keaton AA, Graf EH.
Journal of Clinical Microbiology 54:2632–2634.

http://dx.doi.org/10.1128/JCM.00981-16

Case

A 3-year-old immunocompromised male who had been hospitalized for 7 months in the cardiac intensive care unit developed fever and tachycardia in December. He was prenatally diagnosed with hypoplastic left heart syndrome and received right ventricle to pulmonary artery conduit surgery days after delivery. Due to worsening right ventricular function, after a hemi-Fontan procedure, he received an orthotopic heart transplant at the beginning of his 3rd year of life.

His posttransplant course was complicated by multiple episodes of rejection, cytomegalovirus (CMV) pneumonitis, and several central-line-associated bloodstream infections. As a result of the rejection, necessitating plasmapheresis as well as frequent blood draws for management, which led to anemia, he received 36 packed red blood cell transfusions over the course of 7 months posttransplantation. These transfusions were evenly spaced, and he remained hospitalized during the 7 months.

At the time of the febrile episode, he was on caspofungin, trimethoprim-sulfamethoxazole, and ganciclovir. The subsequent diagnostic workup included multiple sets of blood cultures, a urine culture, and a CMV viral load analysis. He was started on vancomycin and cefepime while awaiting microbiologic results. Other pertinent test results included a complete blood count (CBC) with differential showing pancytopenia and an aspartate transaminase (AST) level of 200 U/liter (reference range, 20 to 60 U/liter), an alanine aminotransferase (ALT) level of 84 U/liter (reference range, 5 to 45 U/liter), and a C-reactive protein level of 3.1 mg/dl (reference range, 0 to 0.9 mg/dl), which increased to 7.1 mg/dl over 4 days.

On the 5th day of fever, another CBC with differential was ordered and was noted by the hematopathologist to contain intraerythrocytic parasites. Immediately, a blood smear with Giemsa stain (Harleco Giemsa stain; EMD Millipore, Billerica, MA, USA) was performed by the microbiology laboratory, yielding the definitive diagnosis. Babesia species with a parasitemia level of 18% was reported to the clinical team. Real-time PCR testing, performed by a reference laboratory, provided the species-level identity of Babesia microti. All other infectious workups were negative. The patient was started on azithromycin plus atovaquone due to the contraindications against treatment with quinidine (QT interval prolongation in a heart transplant recipient with declining heart function).

Three days later, clindamycin was added when his parasitemia level did not decline. He was also given an exchange transfusion on day 4 after diagnosis in an attempt to reduce his parasitemia. After 14 days of therapy, his parasitemia became undetectable and he completed 6 full weeks of therapy, at which time he remained aparasitemic. Since transfusion was the child’s only known risk factor for Babesia infection, a complete investigation into the blood products used was conducted, but the infectious unit/donor could not be definitively identified. Banked products from the organ donor were also tested, and it was determined that the heart transplant was not the source of the Babesia infection.

Category:

Babesia, research, Treatment

Lyme Disease: A Bioethical Morass

http://www.omicsonline.org/clinical-research-bioethics-abstract.php?abstract_id=81033

Abstract
“Primum non nocere”, “first do no harm” is a medical dictum based in antiquity. Yet, in nearly everything related to Lyme disease, it seems almost entirely disregarded. How ethical is it that we follow the guidelines of the CDC regarding diagnosis when those guidelines require erythema migrans that is clearly recognizable only in one (“bullseye rash”) of its multiple presentations? Further, how ethical is it that we are held to guidelines regarding a positive serology that is positive (at best) only 40% of the time? Another questionable ethical situation is the use of a bacteriostatic antibiotic that barely meets the MIC for Borrelia burgdorferi in its ordinarily prescribed regimen. It is also dependent on compliance which is a huge issue because of the gastrointestinal side effects. This antibiotic may clear the rash, but seemingly does little to prevent late findings of the disease. The sub lethal antibiotic dose can be important in the subsequent development of biofilms that lead to a chronic disease state. Lastly, how ethical is it that we have nearly abandoned our patient advocacy and permitted the insurance companies to dictate allowable treatment? And, in as much as Borrelia organisms were found in the brains of Alzheimer’s disease patients over 25 yrs ago and those spirochetes have recently been shown to produce biofilms, how ethical is it that we ignore research underpinning the pathogenesis of this disease? The intent of this work is to discuss how all aspects of Lyme disease (LD) are bioethically challenged. We include Alzheimer’s disease (AD) in the discussion because Lyme spirochetes have been found in, and cultured from, the brains of AD. This makes LD, in its presentation as AD, the equivalent of tertiary neurosyphilis with the only difference being a different spirochete.

 

Category:

Lyme, Testing, Treatment

News Story on Researcher Kim Lewis and Chronic Lyme

Published on Oct 25, 2016 by Sharon Crowley Fox News

Each year about 300,000 people in the United States will get Lyme disease, a tick-borne illness. The majority — about 90-percent — of those who get Lyme disease will take a short round of antibiotics and within a few weeks feel better. But doctors say 10 percent will develop long-term health problems known as post-treatment Lyme disease syndrome, or PTLDS.

Dr. Kim Lewis leads a Lyme disease research team at Northeastern University’s Anti-Microbial Discovery Center in Boston. He says doctors do not know what the difference between those people who will and will not develop PTLDS. The symptoms of PTLDS, also known as chronic Lyme disease, can be debilitating.

PTLDS brought Dr. Lewis and other researchers from all fields of science, medicine, and the environment together at conference in New York City at the Icahn School of Medicine at Mount Sinai. These experts are sharing what they are learning about fighting Lyme disease and its long-term side effects.

Dr. Lewis and his team of researchers in Boston are trying to solve problems on several fronts. He also hopes within the next year or two there will be a blood test available to determine if you get Lyme disease if you will be among the 10 percent likely to develop long-term problems. Knowing that would help doctors immediately prescribe a more aggressive antibiotic treatment.

Dr. Lewis says he and his team are testing a mixture of drugs already on the market being used for something else they believe will also work on solving the long-term effects of Lyme disease.

Category:

Lyme, Treatment