Approaches to Herxheimer Reactions in Chronic Infections
/Introduction
Herxheimer reaction’s are often spoken about by those who are undergoing treatment for chronic infections. It is something that many practitioners have experienced with their patients although it is not as commonly reported in the literature for conditions such as chronic Lyme, there is quite a bit of data on Herxheimer reactions in other conditions such as syphilis and relapsing fever.
The majority of the patients that I see are well past the acute infection stage. Sometimes their symptoms have been ongoing for years. In such a situation, post infectious sequela become very important and often the primary focus of treatment. Part of the sequelae can include neurological and immunological imbalances that persist.
Likely, a combination of immune system dysregulation and overreaction of the nervous system contributes to Herxheimer type reactions in those that do experience this with anti-microbial treatment.
Definition and background of Herxheimer reaction
Herxheimer reaction is usually an intensification of symptoms that happen subsequent to starting anti-microbial treatment. If it is truly a Herxheimer reaction, it may provide good clinical evidence that there is still at least some degree of ongoing infection. Importantly, we have to distinguish between true Herxheimer reactions and adverse reactions to whatever medication or herbal we are using.
Herxheimer reactions are thought to be mediated by a release of either endotoxin, lipopolysaccharide, or some metabolic product that is contributing to immune system dysregulation.
Very importantly, herxheimer reactions are not a necessarily good thing to have, and they definitely are not to be sought after while treating these infections. Sometimes they are unavoidable.
Relationship between chronic infections, such as chronic Lyme disease, and Herxheimer reactions
Herxheimer reactions have traditionally been described in syphilis. Some people believe that Lyme treatment causes many frequent Herxheimer reaction as well, since they are both spirochetes. This is likely true, but there are other factors in play. Usually the immune system dysregulation, especially the nervous system hypersensitivity seem to make Herxheimer reaction more likely in lyme.
Importance of addressing and managing Herxheimer reactions
Managing these reactions is very important for both patient tolerance as well as long-term outcomes. Again while they are unavoidable, in some cases, treatment should not be generally stacked to become more and more aggressive in order to “kill off” more lyme. Rather, herxheimer reactions can sometimes perpetuate the cycle of central nervous system hypersensitivity.
Thus, discussing with your doctor ways to manage these reactions and reduce treatment if it is feasible, is usually the best approach in a nonacute, chronic case.
Mechanisms underlying Herxheimer reactions
Managing Herxheimer reactions often comes down to one of these three reactions:
- Immune response activation
- Central nervous system hypersensitivity
- Release of pro-inflammatory cytokines
- Toxicity from microbial cell components
Clinical manifestations of Herxheimer reactions
- Flu-like symptoms (e.g., fever, fatigue, muscle aches)
- Worsening of existing symptoms
- New or increased neurological symptoms
Importantly, new symptoms shouldn’t be interpreted as a Herxheimer reaction initially. Discussion with your practitioner about whether or not an adverse effect might be at play is important, and in some cases, sometimes if adverse effects are ruled out and it is a new symptom, it may be progression of the illness or uncovering of another infection.
Managing Herxheimer Reactions
Pre-treatment strategies
- Comprehensive patient evaluation and assessment: if there is a history of intensification of symptoms, after antimicrobial treatment, starting treatment slowly (if this is not an acute case), as well as full identification of current and past infection or exposures may be helpful.
- Identifying potential risk factors for severe reactions: individual patients might have a tendency to have a profound immunological reaction. Sometimes this is seen in conditions such as mast cell over activation, even if it is transient. This can lead to strong allergic type reactions. Other patients might have a strong psychiatric history that is related to the condition and should be monitored closely.
- Individualized treatment plans based on patient characteristics: gentle treatment is often the best approach if this is not an acute case. My instructions to patients are usually that if there is an intensification of symptoms, that is more than 50% of their baseline, typically we stop treatment for at least a few days and then consider restarting after discussion.
During-treatment approaches
- Monitoring and adjusting treatment protocols: this may include lowering of dosages, or number of supplements, antibiotics, herbal medications that have an anti-microbial effect.
- Use of adjunctive therapies to support detoxification and symptom relief: this may include detoxification support, binders, and often mast cell stabilization approaches. Some patients seem to benefit most from herbal supportive formulations, that help the kidney, liver, and lymphatics. Other patients seem to benefit most from stabilization of mast cell type inflammation, including antihistamines.
- Ensuring adequate hydration and electrolyte balance: often times patients will hear about using Alka-Seltzer gold, which active ingredient is basically ENO salts. It is thought that the alkalization helps the Herxheimer type reaction. This can be overdone as well, so should be monitored by the practitioner.
- Addressing nutritional deficiencies and optimizing diet: at times, mineral deficiencies, often exacerbate Herxheimer type reactions. Some patients seem to respond to Epsom salt baths; this may be related to either the heat and relaxation, magnesium, or sulfate. Some patient seem to have a molybdenum deficiency and correction of this maybe tried.
Post-treatment considerations
Herxheimer reactions almost always resolve on their own. Usually a discontinuation of treatment for 3 to 4 days alleviates most of the symptoms. Discussion with your practitioner with regards to whether or not the treatment dosage or type should be modified should be done during that time.
Conclusion
Herxheimer reactions are an exacerbation of original symptoms in response to an anti-microbial treatment. Often times, we see these reactions more in sensitive patients and it is a sign that we need to treat the immune dysregulation and nervous system hypersensitivity in addition to going more slowly with the treatment.
In chronic cases, they are not always available, but should be minimized if possible.