Diagnosis and therapy of chronic systemic co-infections in Lyme disease and other tick-borne infectious diseases

Townsend Letter for Doctors and Patients, April, 2007 by Garth L. Nicolson

Abstract

Often Lyme disease (LD) patients are initially diagnosed with other illnesses, such as Chronic Fatigue Syndrome. The diagnosis of LD should be based on clinical and laboratory data as well as the likelihood of exposure to the LD spirochete. Virtually all LD patients have multiple co-infections. In addition to the Borrelia burgdorferi, the majority of LD patients are also infected with tick-borne mycoplasma, rickettsia, and/or protozoa. There are a number of considerations when undergoing therapy for the multiple infections found in chronic LD, including whether to use traditional antimicrobial as well as integrative nutraceutical approaches. Chronic LD requires long-term therapy, including antibiotic/antiprotozoan therapies and dietary supplements to restore immune and gastrointestinal systems as well as mitochondrial function.

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Lyme disease is the most common tick-borne disease in North America and has been reported in 48 US states and in Eastern Canada. First described in Old Lyme, Connecticut in 1975, the infection is caused by a tick bite and the entry of the spiral-shaped spriochete Borrelia burgdorferi (Bb) and other co-infections. (1) Bb and its co-infections have been carried into new habitats by a variety of ticks, such as the deer, black-legged, lone-star, and bear ticks, and their vectors, such as birds, deer, rodents, and other mammals. After incubation for a few days to a month, the LD spriochete and co-infections migrate through the subcutaneous tissues into the lymph and blood where they can travel to near and distant host sites. (2) Transplacental transmission of Bb and co-infections can occur in pregnant animals, including humans, and blood-borne transmission in humans by blood transfusion is likely but unproven. The tick-borne LD co-infections can and usually do appear clinically at the same time.

Often LD patients are diagnosed with other illnesses, such as chronic fatigue syndrome (CFS) or rheumatoid arthritis (RA). Since the signs and symptoms of LD overlap with other chronic conditions, this is not unusual. However, many patients with LD have not received an adequate diagnosis for years, and during this period, ineffective treatments may have contributed to the refractory nature of the disease.

Clinical and Laboratory Diagnosis of Tick-Borne Borrelia burgdorferi Infections

About one-third of LD cases start with the appearance of a round, red, bulls-eye skin rash (erythema migrans) at the site of the tick bite, usually within three to 30 days. (2) Within days to weeks, mild flu-like symptoms can occur that include shaking chills, intermittent fevers, and local lymph node swelling. After this localized phase, which can last weeks to months, the infection(s) can spread to other sites (disseminated disease), and patients then show malaise, fatigue, fever and chills, headaches, stiff neck, facial nerve palsies (Bell's palsy), muscle and joint pain, and other signs/symptoms.

LD can eventually become persistent or chronic and involve the central and peripheral nervous systems as well as ophthalmic, cardiac, musculoskeletal, and internal organ invasion. At this late chronic stage, rheumatoid arthritis, neurological impairment with memory and cognitive loss, cardiac problems (mycocarditis, endocarditis causing palpitations, pain, bradycardia, etc.), and severe chronic fatigue are often apparent. (2-4) As mentioned above, the signs/symptoms in the late chronic phase of the disease usually overlap with other chronic conditions, such as CFS, fibromyalgia syndrome, rheumatoid arthritis, among others, (5) causing confusion in the diagnosis and treatment of the chronic phase in LD patients. Some contend that this late phase is not even related to LD, resulting in failure to successfully identify and treat the chronic condition. The involvement of co-infections, such as Mycoplasma species and other co-infections, in causing chronic signs/symptoms in patients has not been carefully investigated; however, such infections on their own have been shown to produce comparable signs/symptoms. (6)

As with many chronic illnesses, diagnostic laboratory testing for LD at various clinical stages is, unfortunately, not full-proof, and experts often stress the need to diagnose LD with a checklist of signs and symptoms and potential exposures, along with multiple laboratory tests. (2,7) The laboratory tests used for LD diagnosis include detection of Bb surface antigens by enzyme-linked immunoassay (EIA), immunofluorescent assay (IFA), and Western immunoblot of Borrelia proteins. Alternatively, polymerase chain reaction (PCR) for Borrelia DNA has been used to detect the DNA of the intact organism in blood.

A true-positive test result usually consists of more than one positive test from the above list, usually EIA followed by Western immunoblot. The problem with these tests is that they are blood tests requiring the presence of antibodies or Borrelia proteins in the blood, or they are dependent on the spirochete and thus its DNA being present in the blood (PCR). Some of the tests, such as serology testing for antibodies against Bb antigens, show cross-reactivity with other microorganisms and, in some cases, are only useful four to six weeks after onset of signs/symptoms; thus, the quality of the tests can vary. The most sensitive type of test (PCR) requires that the spirochete be released into the blood where its DNA can be detected, and this only occurs occasionally, such as within the first week of antibiotic administration.