Coinfections are an important part of comprehensive lyme treatment. The most important coinfections are usually bartonella and babesia, and usually I see mostly bartonella. Viruses are very common, and parasites are important in some patients as well. Most commonly, Epstein Barr virus seems to be a reactivated infection that has escaped the immune system because of the immune system dysregulation that happens in chronic lyme. In some cases, particularly when fatigue is the most prevalent symptom, testing for and addressing the EBV infection is very important.
There are many chronic viral infections - warts, herpes simplex, herpes zoster, and Epstein Barr virus should be treated no differently. The majority of people have been exposed to EBV by adulthood, and in some cases they were aware of the original infection because they were diagnosed with "mono". Many have been exposed, mounted an immune response, may have been very mildly ill, but then never become ill from it again. A subset of my lyme patients have this infection reactivated and chronic. Often, they had been diagnosed as having chronic fatigue syndrome, and as part of the work up of their fatigue had a variety of tests done by doctors prior to seeing me. Often this would include testing for mono, or for EBV. However, the testing for EBV was usually for the Epstein Barr Virus viral capsid antigen, which unless an IgM type antibody is positive, does not tell you anything. The IgG antibody against this viral capsid antigen only shows past exposure. The Epstein Barr virus nuclear antigen can be of use, but the main test needed is the EBV-EA D (Epstein Barr virus early antigen).
I predominantly run this test in my chronic lyme patients if treatment with an antiviral (drugs and herbs) might be useful for their fatigue. Dr Martin Lerner et al has published on this. One study, published in "In Vivo" in 2007 detailed treatment with valacyclovir in a subset of patients who were diagnosed with CFS (chronic fatigue syndrome) and who were EBV EA positive. Fatigue, rapid heart rate, and cardiac muscle function improved in treated patients compared to placebo.
If positive, then often I will treat with either valacyclovir or famciclovir, alongside high dose astragalus. Occasionally chinese herbs can be useful. Ozone and IV vitamin C can be useful as trials as well.
Other viral infections may be important as well. Enteroviruses have been shown to be higher in intestinal biopsies of CFS patients compared to controls (82% vs 20%). If there are oral ulcerations, monthly recurrent flares, this should be considered as well. This was published in BMJ in 2008...
Usually, while studies have shown that medications like valacyclovir can be used for infections involved in a CFS-like presentation, it takes a few months for effects to be had. I and others have clinically found that some respond beautifully, and usually these are the patients that have a response after 2-4 weeks. Natural treatments that are useful again include ozone therapy (see treatments section of this website), transfer factors, AV tincture from Byron White, Astragalus, and other herbals. Ozone therapy in particular is a particular good solution. Usually patients will have a trial of 3-4 treatments over two weeks. If there is a partial response, then the treatment is continued.
In conclusion, when fatigue is a large part of the picture in a patient seeking treatment for chronic lyme, then an evaluation for chronic, reactivated viral infections is in order. Some patients respond very quickly to either valacyclovir or to ozone therapy, and for others, it is one of the components of treatment that needs to be addressed alongside lyme treatment.