More difficult to pick up that your malaria-like acute cases, babesia coinfection usually can make treatment for lyme more resistant unless it is addressed.
Babesia coinfection treatment in lyme
At the recent ILADS conference in Toronto in 2011, there was an excellent talk by Dr Horowitz on treatment of chronic babesia / babesiosis as a coinfection in lyme.
There has always been the debate that my patients discuss with me in whether coinfections need to be treated first or if lyme has to be treated first. There are some lyme doctors who as a rule treat lyme first, and other lyme doctors who again as a rule insist that coinfections need to be addressed before lyme otherwise no progress will be made. At another lecture there was discussion by the presenter that treatment should start from th elarge organisms down to the small; eg from parasites, to yeast, to bacteria, etc right down to viruses. Unfortunately there was no real rationale to that order.
What I have always discussed when I treat my chronic lyme patients is that everything in naturopathic medicine is patient specific. If a patient is presenting with largely lyme symptoms, then my focus is giving chronic lyme treatment while we of course address any co-morbid or contributing factors. These factors have been discussed on my page on COMPREHENSIVE LYME TREATMENT, but basically includes looking at sleep, hormones, mood, nutritional dependencies, and heavy metal /chemical toxicities. If the patient has definite lyme exposure, possibly evidence of antibodies in the blood specific against lyme, but their symptoms that are most troubling point to coinfections, then these coinfections are addressed first.
LYME COINFECTION SYMPTOMS
There are many coinfections in tick-borne infections, but the ones that I and most lyme doctors find important are Babesia, Bartonella, Ehrlichia, the new protozoan FL1953, and maybe mycoplasma.
The hints I have found most useful for coinfection symptoms include:
- drenching night sweats
- malarial like symptoms of chills and fever sensations
- oxygen hunger
- dry cough with normal chest x ray, pulmonary function tests
- dizziness, balance issues
- dysautonomia, postural orthostatic tachycardic syndrome or POTS, or dizziness and lightheadedness when changing positions or standing for extending periods
- major depression with severe fatigue
- sore soles especially on waking, feel like walking on pebbles
- gastric symptoms, including dyspepsia, reflux, H pylori like symptoms but negative H pylori breath test
- subcutaneous nodules that may indicate low grade blood vessel inflammation / vasculitis
- symptoms mimicking neurological lyme, including severe brain fog, hyper-excitability; a "twitchiness" to the patient
Often times chronic lyme patients of mine will have clear lyme symptoms as well as clear coinfection symptoms (usually babesia) - I have often started with lyme treatment as the medications are often better tolerated. Most patients do improve.
At the ILADS presentation mentioned above, the presenter (along with other presenters at other parts of the meeting) generally agreed that if a patient is resistant to lyme treatment, or who's lyme symptoms seem to be particularly severe, then chronic babesia treatment should be considered. This sometimes can be in the absence of major babesia type symptoms, and in the absence of lab evidence of illness. In fact, often times after starting treatment for babesia, the labs will then go positive as more babesia is then exposed to the immune system to mount antibodies to (which we detect in some of the tests).
There are a few chronic babesia tests available. The usual convention test is a regular smear, which misses likely all chronic cases. The smear is basically a quick visual scan to see if there are loads of babesia in the blood, something that only happens in close proximity to exposure and in acute, severe illness.
Babesia coinfection tests:
- antibodies against Babesia microti and Babesia duncani
- limitations are that the immune system has to actually see enough babesia to mount a response
- a further limitation is that only two species can be detected vs likely many more, and we do not know if the antibodies cross react with these other species (they likely do not)
- an advantage is that the level or titres of reaction can sometimes be used to follow progress
- FISH smear at Igenex
- stains RNA specific for Babesia microti and duncani and then visual examination for fluorescence under a microscopee
- PCR to check for DNA of Babesia in the blood
- may be most useful during a flare, or when a fever is present since the usual yield is quite low
Chronic Babesia treatment
The usual approach by lyme doctors in the treatment of chronic babesia as a lyme coinfection is to use either a combination of atovaquone (Mepron) and azithromycin (or similar macrolide antibiotic) or to use a combination of clindamycin and quinine. The latter is not really well tolerated, since quinine can have a lot of side effects.
What was really interesting at the lyme disease meeting was information presented on how a lot of babesia is becoming resistant to the mepron combination above. The usual doses of 1 tsp twice a day with the antibiotics does not seem to work in many cases, and some doctors have had to increase to 2 tsp twice a day or more. The medication is already quite expensive at the 1 tsp twice a day and at double or triple doses can be prohibitively so.
Clindamycin and quinine may still be effective, but such large doses of quinine are hard to tolerate in even the most ambitious chronic lyme patients.
Dr Horowitz described data in approaches to overcome the resistance of chronic babesia coinfection to the above treatments, which I have already implemented.
One measure for patients already on mepron and a macrolide antibiotic included adding in Bactrim (or septra, another brand name) - basically the commonly known "sulfa" drugs - in high dose on top of the mepron. The dose was quite high though, and my notes state 1 bactrim DS tab 4 times a day. The usual dose is half that. With increasing dose of bactrim I do worry about the ever so rare but very serious reaction / allergy called Stevens-Johnsons syndrome.
Clindamycin could be added on top of mepron/macrolide for chronic babesia treatment.
Another combination that may be useful is azithtromycin and bactrim (the sulfa drug).
One very interesting option was instead of using clindamycin and quinine, was to use clindamycin and a macrolide antibiotic (like biaxin, azithromycin, etc). This is one I like as it gives very good coverage for lyme as well. I have found a lot of lyme patients who are resistant to the usual chronic lyme antibiotic treatments do respond to clindamycin. I tried this after hearing about Dr Jemsek using this as well in his patients.
Coartem was an interesting one as it is only given for 3 days, and seems to do very well for some patients.
Alternative and natural chronic babesia coinfection treatment
Cryptolepis root was one of the most promising treatments presented. It is a herb used in Africa to treat malaria. A few case studies of this were presented in patients who previously responded to other chronic babesia treatments but who kept on relapsing. I am looking into this herb as it is harder to find.
Ozone/UV autohemotherapy was also discussed, but not in the lecture on chronic babesia treatment. It was discussed in a round table as a treatment that holds a lot of promise, and one doctor who was presenting described his daughter using this treatment over a year to great success. I have found that this treatment helps tremendously in chronic babesia treatment, maybe because babesia lives in the red blood cells, which are sensitive to the lipid peroxides produced and infused in the treatment.
At any rate, the big take home of this presentation was that chronic babesia coinfection may be responsible for either the most severe lyme patients, and the most resistant to usual lyme treatment patients. The past treatments of mepron and azithromycin are no longer reliable, and often different combination therapies may be needed, some of which I have described above.