Enzymes and biofilm -

Systemic enzymes can be an important part of treatment as well. These are enzymes such as serratio peptidase, lumbrokinase (boluoke), wobenzym etc. We don't use these enzymes to assist with digestion but rather to help the body with breaking down suspected biofilm.

Biofilm is basically "slime" - an area of usually lipid which is secreted and sequestered by communities of organisms as a result of secretion of quorum sensing molecules. In effect, the bugs talk to each other. The slime community prevents adequate infiltration by the immune system, and prevents the antibiotics often from working well.

The enzymes work to break down this biofilm so that the immune system can affect the infection, as can the medications. But... if done quickly or aggressively again often the symptoms can get worse as the bugs are being released.

Herxheimer reactions - physical as well as mental...

Herxheimer reactions are situations in which a chronic infection patient, usually with a spirochete infection such as lyme disease, have a temporary worsening of their symptoms after initiating antimicrobial treatment. This could be with antibiotics or herbs. These are not drug side effects, like the common nausea, or diarrhea, but rather a worsening of the original symptoms such as joint pain or swelling. In joint pain and stiffness, it is obvious and easy to see the intensification of symptoms, but this can also occur in the mental health realm.

Some patients may complain of simply impaired cognition or "brain fog" - and this can markedly worsen as well. But depressive symptoms, anxiety and panic symptoms are also very common. Such "emotional" or "mental" herxes can go with time, and sometimes can also be managed and treated well with symptomatic treatment such as prescription medications or herbal options as well. Importantly, the central nervous system can become "hypersensitive" and amplify both pain signals as well as have an inability to filter to stimulation - ie. light and sounds become painful.

Such herxheimer reactions are usually temporary, lasting about a week, and then some degree is improvement is seen until the next reaction occurs, which is often at the 4 week point. These monthly cycles can often be seen in lyme as the bacteria has a life cycle in which it increases its growth rate at certain times.

Useful measures for emotional / mental herxheimer reactions include drugs such as antidepressants, tricyclics especially for pain, modafinil for "brain fog", quercetin and theracumin for pain / inflammation, lavender and passionflower for anxiety.

Two other common components of fatigue to work up:

In patients with a presentation of fatigue, who are thinking of lyme or other infection as contributing, often we have to consider viral reactivation previously discussed here as well as looking at some specific aspects of thyroid function. 

Usually there has already been comprehensive work up from the family doctor for things like anemia, hypothyroidism, pulmonary disease, iron deficiency etc. The thyroid is the harder part: the usual test is a TSH level which stands for thyroid stimulation hormone. This comes from the brain to act upon the thyroid to release T4 - which is levothyroxine, the most commonly prescribed thyroid replacement. 

In many lyme patients and some myalgic encephalitis patients, it is important to consider the conversion of T4 into T3, which is the much more active hormone. In some, this level is low. In others, it is normal, but we also need to consider reverse T3, or the hormone that blocks free T3. In effect, we need to account for the ratio as some patients have much more reverse T3 than usual for their amount of T3.

Dessicated thyroid has T3 and T4, and is often useful. In cases where the reverse T3 ratio is quite abnormal, any extra T4 may not be useful and I will use T3 alone in these patients to help with their brain fog and fatigue.

"Adrenal fatigue"

Often times we need to identify and address the body's response to a stressor; be it a mental emotional stressor that we are all accustomed to or a physical stressor such as inflammation and infection that has gone on for too long.

The adrenals respond to this stress with an output of cortisol, which is balanced with DHEA. Sometimes this response is an increased cortisol, which is fine, and other times it is too low - which is not fine. The symptoms associated are a persisting "fight or flight" response, anxiety, and almost always fatigue in the morning and mid afternoon.

In the image attached we have done a salivary analysis and find that the DHEA is low. Cortisol is normal, but there is quite a rapid drop from the morning to mid afternoon. In such a case, licorice is often used as the glycyrrhizin component slows the break down of cortisol - it extends the half life. Our goal in therapy here is to attenuate the fatigue associated, and to monitor for licorice induced hypertension, all while trying to treat the reason why the adrenals are starting to show signs of "stress".

Mast cell reactivity - two examples

I often describe some post-treatment lyme effects to patients in that certain components of the immune system have developed a "habit" of inflammation that needs to be re-educated and forgotten, if possible. Not really an autoimmune disease per se, but rather symptoms that could be attributed to inflammation that improve when we find the right control.

A complex example is mast cell activation, which sometimes fits the criteria of mast cell activation disorder, and sometimes does not. It rarely fits the criteria for mastocytosis, an increase in the actual number of mast cells versus their activity.

Mast cells are an immune cell that release a host of mediators, including allergic type mediators such as histamine, and flu-sensation mediators like various cytokines. 

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I had one patient who responded very well to IV ceftriaxone (an antibiotic) alongside concurrent treatment for bartonella (with oral antibiotics). However, she developed a reactivity of the immune cells that caused mottling rashes, abdominal cramping, and respiratory distress at different times. There was no significant history of "allergies" prior to the lyme treatment (which was quite effective for pain) and it was not a simple post-treatment candida type situation. This responded very well to treatment for mast cell activation syndrome, in this case managed with antihistamines and mast cell stabilizers.

Another patient was from another province and had seen some very good physicians in the states for treatment of lyme. Unfortunately, she had not responded to IV antibiotics nor oral antibiotics for lyme and had sought another opinion from myself. She was a very difficult case, trying in her earnest to get well, but had not responded to months, near a year of various antibiotic treatment. I had worked up her adrenal glands, thyroid hormones, heavy metals, mycotoxins - all the usual "roadblocks" to getting well - but nothing was significant. The only significant hint was a severe facial rash, whenever her cognitive fog would flare alongside other symptoms.

As her rash worsened as we waited for investigations, we trialled cromolyn sodium to stabilize the mast cells alongside loratadine and famotidine. At follow up after 4 weeks - the patient was conversing again with her parents, and starting to even become more social as her brain fog and energy improved, alongside her rash. I was quite surprised at this as previously, anthistamines did not change her rash at all.

Both cases showcase how often there can be a persisting immune system activation, but not really autoimmune disease, that occurs after lyme. It can persist and respond after what appears to be successful treatment for lyme, and also after treatment that has not been effective for lyme. 

EMF sensitivity - seen a handful of times.

Perhaps the first EMF sensitivity patient I saw was years back, whom I had treated briefly for suspected lyme-like infection based on low cd57 count, multiple positive bands on western blot, and monthly worsening of symptoms after a flu-like illness while camping. At that time - the main complaints were a terrible headache that would be daily but made much worse by working with heavy cameras (worked in the film industry), cell phone use, and wifi.

We treated with a basic combination of doxycycline and metronidazole, and had discussions of how there were many theories about EMF sensitivity, including nitric oxide aberrations, oxidative stress, mycotoxin exposure, psychiatric illness, voltage-gated calcium channel problems in the cells, and lyme exposure as a trigger. 

I spent most of the discussion speaking about the possibilities of calcium channel blockers and nutritional interventions for voltage gated receptors as well as oxidative stress respectively, but we started with lyme treatment.

I didn't hear from him after the initial follow up for about 3 years - in which he had consulted on mainly "fatigue persisting after treatment, headaches and EMF sensitivity was gone after 3 months treatment." Strangely, his EMF and headaches were near cured with a simple treatment, and I say strangely because usually it is multifactorial and takes much longer.

Another patient recently has had good benefit from an initial lyme antibiotic doxycycline treatment, and then mainly adrenal support, sleep support, and especially "grounding and earthing techniques" as described by many including Dr Stephen Sinatra MD 

 

While still sensitive, overall daily activity and the common "sense of overwhelm" with stimulation, both electrical / energetic as well as overstimulation with the mind has been much improved. I would anticipate a full recovery with longer term immune support (things similar to low dose naltrexone) and further stress reduction and adrenal support.

simple treatment sometimes

I had a conversation with a patient this week where our decision was to watch and wait. He had a bulls eye rash in late summer, and was very early on treated with first cephalexin for suspected skin infection, then doxycycline 200 mg twice a day (higher dose) for lyme. This was early treatment. The patient was symptomatic with headaches, blurred vision, stiff neck, flu like symptoms.

There were still symptoms at the end of 3 weeks, and the family MD after a week off antibiotics extended for 6 weeks. The patient was still symptomatic despite early treatment.

He then came to see me for a second opinion, as he had already started on 3 months of clarithromycin and hydroxychloroquine. To our delight, after 3 months the patient was mostly symptom free.

The interesting thing about this case is that there was very early treatment, which was not successful. Despite that, relatively simple treatment, which was probiotics and antibiotics, was able to finally clear the symptoms. Often if simple treatment with doxycycline is not effective, we have to consider more aggressive treatment that covers for all forms or morphologies of lyme is needed, or a lot of supportive measures for hormones, detoxification, nutrition is needed. In this case, switching classes of medication and adding in something for the cyst form of lyme seemed to be most useful.

 

A classic progression of symptoms during treatment...

I had a patient come in for follow up after we have been on treatment for lyme disease for 3 months. At first, I was in doubt of the diagnosis, and thought that the more likely condition was something related to stress, or adrenal fatigue. However, testing subsequently showed a very likely at least exposure to lyme, if not being absolutely clear for current infection. A cautious watch and wait, treat the stress approach was started, with no change.

We decided to start on antibiotic treatment with the most basic - doxycycline. After 2 months, there was significant improvement in target symptoms of dizziness, palpitations, fatigue, and cognitive impairment. We started on metronidazole to address the cystic and persister forms of lyme.

Notably, on starting the metronidazole, there was a significant flare in symptoms. All of them. There was a mild nausea that we could attribute to a drug side effect as well. We pulsed the metronidazole 7 days on 7 days off, and on the week off, symptoms again improved. On the second round of metronidazole, all symptoms flared again, but to a much lesser extent.

The patient was worried that she was regressing, as she did not feel as well as she did compared to the first 2 months. However, this was not the case.

Usually, on first starting treatment, some patients experience the typical die-off symptoms which we call a herxheimer reaction. This is theoretically from a killing of susceptible lyme, and the subsequent inflammatory response that follows. Imagine the lyme as a mixed bunch of balloons - letting off a small amount of faint gas that causes symptoms. The treatement initially pops a great number of these balloons, and symptoms get worse. Then they improve.

When we add another medication, particularly flagyl, we provoke more symptoms since we target different balloons, or different morphologies of lyme. And... the flares tend to get less with each subsequent round since there are less of these balloons to pop.

Testing is not the be all and end all.

Last week I spoke with a prospective patient who was calling from Alberta. They had a negative elispot test, which is a T-cell assay for an inflammatory response specific to lyme, and was then told that based on this they absolutely did not have lyme. However, in briefly speaking with the patient, they were interested in seeking a second opinion because they had many of the symptoms, across multiple systems, which were migratory and intermittently severe.

No lab has a 100% sensitivity or likelihood of catching lyme disease. Coinfections could be at play, different strains or species of lyme, or the patient may just not have a very robust immune response against lyme, as the usual lyme testing is an indirect test, aimed at detecting the immune response. Further, for tests like the western blot, the CDC interpretation may be negative, but other published criteria might be positive for lyme, or at least hint that retesting or treating and then retesting would be a suitable course.

Often, if a western blot is equivocal or has some bands that are positive but not many, then after a discussion of the risks and possible benefits of treatment we might start on a course of treatment if the clinical picture matches lyme or a related condition. If there is no clear clinical response, then sometimes retesting the lyme western blot can be informative, looking for an increase in the bands seen.

last week three patients stopping treatment...

I had used the same example for three of my patients this last week. One patient had started seeing me around October of last year and had been on a combination of antibiotics, cefixime, then doxycyline and azithromycin, and had had about 60-75% improvement after about 3 months. We ran into unfortunate side effects with the gut, and decided to discontinue antibiotics for 2 weeks. 

I then had an email that the patient did not want to go back on the treatments since she had felt about 90% back to normal after discontinuing the antibiotics. This is absolutely the best choice - when feeling well, stay off and evaluate for if and when there is a recurrence.

Sometimes there is a recurrence after a 4 week honeymoon type cycle - due to the biology of lyme. There seems to be an increase in growth rate every 4 weeks or so after a significant change, so often we can do well until then. Often times, even if there is residual lyme (for example, if cyst forms and biofilm communities were not treated) the burden is low enough that there is no clinical recurrence.

Another patient had started with the Marshall Protocol with another practitioner and most recently we had finished clindamycin and quinine for suspected babesia-like infection with chills, sweats, air hunger, cough. These symptoms had improved, and previous things like joint pains had improved as well. She was still very fatigued, but again, we want to see if the drugs themselves are causing the fatigue, and whether or not hormone supportive and immune supportive measures can keep the previous symptoms of joint pain, headache, neck stiffness, away. We are not likely done treatment with this patient, but sometimes stopping therapy allows for us to see what the new baseline truly is, and if in fact symptoms come back we remember that it is still advantageous that we had stopped since the medications almost universally work only when the organisms are metabolically active. Stopping the medications allows the more dormant forms to become active again, and then susceptible to treatment.

first post - hopefully for easier updates

Since changing the website from a very dated design approximately 4 years ago, there has not been an update to the basic pages of the site in quite some time. Hopefully this format might make it easier to note some questions or events that happen during the week which might be worth sharing. 

I'll start with a positive. A long time patient of mine described a term that I never had heard of or thought of before, naming a "post-lyme bucket list." This came up because the patient had come into the office to talk about options for treatment if she had a relapse when snow-birding for the winter - something she hadn't been healthy enough to do for some time. I thought it was great that throughout the struggles of treatment, she had a positive mentality to keep a post lyme bucket list and thought it was even more great she could actually do it.

--- this particular breakthrough was quite interesting. Instead of systemic treatment, it came from localized treatment of MARCONS after systemic lyme treatment.