are we now? lyme & chronic diseases: where · medical history (anamnesis) of the patient,...

Lyme & chronic diseases: where are we now?

Lyme & Co-infections:diagnostic and treatment protocols

Presentation, Diagnosis and Treatment

London, September 23rd 2017Dr. Carsten Nicolaus, MD PhD

BCA-clinic Augsburg86159 Augsburg, Morellstrasse 33

[email protected]

Diagnostic is based on:

1. Medical history (anamnesis) of the patient, including special anamnesis types

2. Traditional Diagnostic Tests

=> Laboratory testings => Physical and Technical examinations (ECG, ultrasound, etc.) => MRI, SPECT (single photon emission computerized tomography)

Extended Anamnesis Checklist (Questionnaire 15 pages)

Checklist for Co-Infections

Risk Assessment Questionnaire for Chronic Inflammation

Diagnostics/Laboratory Testings

The following lab tests are available for Lyme Disease:

▪ Borrelia IgG and IgM EIA ▪ Borrelia IgG and IgM Blot▪ Elispot /Lymespot Borellia▪ CD 57+ NKcells Test▪ Borrelia-DNA-PCR▪ Cultivation▪ C6 peptide ELISA

„Two Tier Testing“


Plus:⇒ Checking for possible bacterial co-infections

▪ Ehrlichia ▪ Bartonella▪ Rickettsia▪ Chlamydia▪ Mycoplasma▪ Yersinia


Plus:⇒ Checking for parasites:

▪ Babesiosis ▪ other Piroplasma Infections

Checking for worm disease:Helminths ( tapeworms, roundworms)e.g. Toxocara canis or Ascaris suum ( only the larvae)*

* Regarding Prof. Dr. Herbert Auer, Medizinische Parasitologie, Medizinische Universität Wien


And/Or:

⇒ Checking for possible viral co-infections

▪ EBV▪ CMV▪ HSV▪ Coxsackie▪ Toxoplasma▪ Parvo B19


Plus:⇒ Checking for Differential Diagnosis

▪ Rheumatic Diseases ( RF, Anti-CCP )

▪ Autoimmune Diseases ( ANA, ENA, p-ANCA, c-ANCA )

▪ Inflammation ( IL-1, IL-6, TNF-α, Interferon gamma)

▪ Toxicity ( Multiple Chemical Sensitivity, Heavy Metals, Environmental Illness, Mold )

▪ Endocrine dysfunktions ( Thyroid, Pituitary, Adrenals, Sex Hormones, Vit D )

Diagnostics - Physical and Technical Examinations

The following basic examinations are necessary in terms of traditional diagnostics:

▪ Physical examination ▪ Electrocardiogram (ECG)▪ Ultrasound of abdominal organs

Lyme Disease: Specific Symptoms

▪ Acute Stage: Erythema migrans

▪ Chronic Stage: Acrodermatitis chronica atrophicans (ACA)

▪ Only Erythema migrans or ACA are accepted as safe clinicical signs of Lyme Disease

Unspecific General Symptoms

significant loss of energy (work/house work/sports) > 90%

exhaustion > 90%

fatigue > 90%

flu-like infection with fever: In the early stages this means that Borrelia are present in the blood (20%)

≈ 20%

neck pain 78%shoulder pain 76%temporary headache / dizziness 76%changing/“moving” joint pain 68%changing/“moving” muscle pain / “rheumatism”, overall weakness

62%

Unspecific General Symptoms

dysuria, irritated bladder / urge to urinate 19%coughing 5%chest pain / heart palpitations / heart rhythm dysfunction

4%

ear pain / tinnitus 4%diarrhoea 2%

bad temper / mental instability / depression 62%back pain, often sciatic pain 58%problems sleeping “through” the night with night sweating / urge to urinate between 2 a.m. and 4 a.m.

47%

sore throat / prone to infections / herpes-EBV-infections 39%

burning eyes / watering eyes / blurred vision 28%

Local Infection(Stage I)

Dermato-Borreliosis- Erythema migrans - (around 50%!)- Lymphadenosis benigna cutis

-„Summer Flu“

=> After a few days

The Stages of Lyme Disease

Acute Organ Manifestation(Stage II)

Neuro-Borreliosis- Meningitis- Meningoradiculoneuritis- cerebrovascular forms- Affecting brain nerves

Internal Manifestations: - Carditis- Hepatitis

Ophthalmo-Borreliosis: - Retinitis etc.

-Myositis-Arthritis

=> After weeks or months

Chronic Organ Manifestation (Stage III)

Neuro-Borreliosis- Mono- Poly- Neuritis - cerebrovascular forms- Progressing Encephalomyelitis- PNP

Internal Manifestations: -Cardiomyopathy

-Dermato-Borreliose- Acrodermatitis chron. athrophicans - Lymphadenosis cutis ben.

=> After months of years

Erythema migrans / “Bull‘s Eye Rash“ (Stage I)

Erythema migrans Erythema multiforme

Erythema migrans and Erythema multiforme

Erythema migrans / “Bull‘s Eye Rash“ (Stage I)

Cutaneous Lymphoid Hyperplasia (Borrelial Lymphocytoma)

Stage II Neuro-Borreliosis: Facial Paresis

Stage III: Acrodermatitis chronica athrophicans (ACA)

Stage II / III: Lyme-Arthritis

Columns of Integrative Treatment - Traditional

Antibiotics:

▪ Eliminate Borrelia as well as potential coinfections

▪ Considering the different polymorphism forms of Borrelia (“bleb´s, roundbodies, Biofilm formations, intracellular forms) and co-infections for the right selection of antibiotics

▪ Length of treatment. If required longterm treatment (considering the life cycles of Borrelia and co-infections).

Lyme Disease: Treatment

spirochete

BFL

round bodies

blebs

Treatment for Borrelia burgdorferi (CLD)

Cell Wall „Roundbodies“ former Cystic Forms

Intracellular

Betalactams: Artemisin Macrolides:Amoxicillin Hydroxychloroquin AzithromycinPenicillin G benzathine Atovaquon ClarithromycinCephalosporins: ClindamycinCeftriaxon i.v. Metronidazole Quinolones:Cefotaxim i.v. Tinidazole CiprofloxacinCefuroxim LevofloxacinCefdinir MoxifloxacinCefpodoxime Rifampicin

Tetracyclines:DoxycyclineMinocycline

Lyme disease: treatment recommendation (ILADS)

Stage I (acute stage)Oral treatment (Duration: minimum / taking until disappearance of “bull’s eye rash” respectively of lymphocytic infiltration).

Doxycycline (from age of 8 years): 200 mg/d for 28 days

Cefuroxim* 2x0,5 g/d for 28 days

Amoxicillin * ** 3x0,5 g/d for 28 days

Clarithromycine* 2x0,5 g/d for 28 days

Azithromycin * ** 500mg pulsed for 28 days

(* for children under 8 years and for **pregnant women)

Lyme Disease: Treatment Recommendation

Stage II (acute organ manifestation)

➢If possible IV/oral antimicrobial treatment:e.g. Ceftriaxon, Cefotaxim, Azithromycine 4-6 weeks. Mostly if possible a second antibiotic additionally ( e.g. Ceftriaxon/Azithromycin; Ceftriaxon/Minocyclin; Azithromycin/Doxycyclin).

Stage III (chronic organ manifestation)

➢Oral/ IV antimicrobial treatment:Ceftriaxone, Cefotaxim, Azithromycin, Doxycycline and others for a minmum 8 weeks, even longer if needed ( mostly between 2-6 month).

Treatment according to the international guidelines of ILADS and the German Borreliosis Society (Deutsche Borreliose Gesellschaft e.V.)

Evidence-Based Guidelines for the Management of Lyme Disease▪ Since there is currently no definitive test for Lyme disease, laboratory

results should not be used to exclude an individual from treatment.

▪ Lyme disease is a clinical diagnosis and tests should be used to support rather than supersede the physician’s judgment.

▪ The early use of antibiotics can prevent persistent, recurrent and refractory Lyme disease.

▪ The duration of therapy should be guided by clinical response, rather than by an arbitrary (i.e., 14 - 30 day) treatment course.

▪ The practice of stopping antibiotics to allow for delayed recovery is not recommended for persistent Lyme disease. In these cases, it is reasonable to continue treatment for several months after clinical and laboratory abnormalities have begun to resolve and symptoms have disappeared.

▪ Expert Rev Antiinfect Ther 2004;2(1 Suppl):S1-13

The Role of Co-Infections in CLD:

• CLD is a multisystemic illness. Not only the nerve system, joints or skin could be targeted. One could find Borrelia and co-infections nearly in all organ systems after a while.

• CLD is most often connected to a wide range of different co-infections. These co-infections could be based on viral, protozoal and other bacterial infectious diseases.

• CLD and co-infections could suppress the host immune system and / or cause a non-specific stimulation of the immune system, leading to inflammation, immune dysfunction, hormonal dysfunction and ANS dysregulation. (Krause et al. JAMA 1996: LD & Babesiosis)

• CLD and many co-infections persist despite seemingly adequate courses of antibiotics, and may be transmitted transplacentally (Breitschwerdt et al. Jnl of Clin Microbiol Apr 2010)

• Most often patients with CLD suffer from chronic fatigue, myalgias, arthralgias, neuropathic, and neuropsychiatric abnormalities. These patients have multiple overlapping etiologies responsible for their symptoms

The Role of Co-Infections in CLD:

• Chronic Lyme Disease is a Multisystemic Illness. In presence of additional co-infections it should be better defined as a

• „Multiple Chronic Infectious Disease Syndrome“ ( MCIDS).

This term goes back to Dr. Richard Horowitz, who has used it a few years ago for the first time

Co-Infections transmitted by ticks or other biting insects (tick or mosquito borne infections):

• Ehrlichia / Anaplasma infections• Rickettsial infections• Bartonella• Babesia• Tularemia ( Francisella tularensis)• Vector-Borne Viral Infections ( TBE, Omsk Hemorrhagic Fever,

Congo-Crimean Hemorrhagic Fever (CCHF)

Co-Infections transmitted by air, ingestion (unsterilized milk or meal), sexual contact, transplacental and others

These co-infections are mostly based on a weak immune system supressed by CLD: •Chlamydia pneumoniae and trachomatis•Mykoplasma pneumoniae and fermentans•Yersinia•Brucellosis•Q fever (Coxiella burnetii) Feces of Dermacentor ticks•Virus infections: EBV, Cytomegalie, HHV-6, Coxsackie, etc.

Vector-Borne Viral Infections in Lyme-MSIDS

• Mosquito borne: dengue fever, Japanese encephalitis, Eastern and Western equine encephalitis

(EEE, WEE) and West Nile virus. The new “tiger mosquito” which is spreading across the US and Europe (Munich) is also containing over 20 different viruses and pathogens

• Tick borne:tick-borne encephalitis (TBE), Omsk Hemorrhagic Fever, Kyasanur Forest Disease

(KFD), Congo-Crimean Hemorrhagic Fever (CCHF), Heartland virus, and Powassan encephalitis.

• Reactivation of latent Viral infections: EBV, HHV6, CMV….

Differential Diagnosis I :When to suspect co-infections with these organisms

• Lyme Disease: fatigue, headache, arthralgias, cognitive difficulties. Clue - migratory arthralgias, symptoms

tend to come and go, including intermittent paraesthesias. Women flare before-during-after menstrual cycle.

• Babesia: malarial like illness: fever, chills, day sweats, night sweats, persists despite Lyme treatment.

• Severity of illness - co-infected patients are the most severely ill. (JAMA 1996 Krause et.al.: Patients co-infected with Lyme Disease and Babesiosis had evidence for increased severity and duration of illness) • Ehrlichia:

High fevers, low WBC counts and platelet counts, elevated liver functions. (also seen with RMSF, Heartland virus)

Differential Diagnosis II :When to suspect co-infections with these organisms

• Bartonella: ongoing symptoms despite prior courses of antibiotics (fatigue, headache, resistant

arthritis) especially, resistant encephalopathy and cognitive difficulties, new onset of a seizure disorder or history of a seizure disorder. Opthalmological manifestations: visual loss, neuro retinitis; Significant lymphadenopathy. ? GI symptoms.

• Mycoplasma / Chlamydia: Heart rhythm disturbances, rapid and irregular heart beat, “airhunger”, cough,

sinusitis like symptoms,….

• Viruses: ? Underlying role with resistant symptoms. Severe Fatigue

• Candida/Yeast Syndrome: hx BCP & prolonged AB’s , unresponsive to AB treatment or worsening of symptoms

w/ abdominal bloating, thrush, vaginitis..

1. Naturopathic anti-infective Remedies

➢ Herbal antimicrobials could eliminate Borrelia spirochets (destruction, to prevent further dissemination, etc.) and potential co-infections

➢ Herbal remedies support the body in accomplishing this task

➢ Regulation of the body's immune reaction

➢ Promotion of damaged tissue repair

Columns of Holistic Treatment

Integrative/Alternative Protocols

Many different herbal protocols are available:

• USA: - Buhner Protocol- Beyonced Balance Formulas Susan McCamish - Cowden Protocol- Byron White Formulas- Zhang Protocol

• Europe:

- „Lyme plus Protocol“ (Austria)- „M1-M7“ Protocols (Germany)

Integrative/Alternative Protocols

Pros:

All of the mentioned herbal protocols have shown good effectiveness and tolerance. They seem to be always good alternatives in case of e.g. non-tolerance of antibiotics or other reasons.

Cons:

• A big problem is that none of the american protocols are officially listed in Europe. According national laws and rules of medical boards in most of the european countries prescriptions or selling by doctors are not allowed.

• Actual only the „Lyme plus - protocol“ from Austria and the herbal tinctures M1- M7 from Germany based on the „Deutsches Arzneimittelbuch“ are officially listed.

Lyme plus Protocol

Lyme plus Protocol

• „TBB capsules“ Basic Treatment for Lyme Disease including Co-Infections

• TBB Plus ®:– Polyporus umbellatus– Andrographis paniculata– Artemisia annua– Red Grape Seed (OPC)– Grapefruit seed– Garlic

DTC plus

• Chlorella pyrenoidosa

• Nettle

• Bilberry

• Cranberry

• Ligonberry

• Artichoke

• Sage

• Bear’s Garlic

• Turmeric (Curcuma)

Lyme plus Protocol

APP plus• Artemisia annua• Monolaurin• Rosmary• Black Pepper

APP plus study:

Lyme plus Protocol

The M-Protocol – Dr. Carsten Nicolaus –

Conclusions

➢ Naturopathic treatment protocols are a good alternative in treating Lyme Borreliosis and other tick-borne diseases, particularly if a classical antibiotic treatment cannot be prescribed due to various reasons.

➢ The length of treatment is in mostly 2-3 times longer.

➢ The treatment is usually best tolerated by patients and has very few side effects.

➢ A naturopathic treatment over 12 – 18 months has shown almost similar results compared to a 6 months antibiotic treatment in our clinic.

Thank you for your attention!

Carsten Nicolaus, MD, PhDMedical and Executive Director

BCA-clinic AugsburgMorellstrasse 3386159 Augsburg

GermanyTel. +49 (821) 455471-0

[email protected]

are we now? lyme & chronic diseases: where · medical history (anamnesis) of the patient,...

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