the lyme enigma complexity and controversy. lyme life cycle lyme disease is caused by a tick-borne...

Download The Lyme Enigma Complexity and Controversy. Lyme Life Cycle Lyme disease is caused by a tick-borne spirochete, Borrelia burgdorferi. Humans are an incidental

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  • Slide 1
  • The Lyme Enigma Complexity and Controversy
  • Slide 2
  • Lyme Life Cycle Lyme disease is caused by a tick-borne spirochete, Borrelia burgdorferi. Humans are an incidental host The lifecycle of the spirochete is predominantly between mice, deer and the deer tick. In CA ixodes pacificus is the vector and in the east coast it is ixodes scapularis The nymph deer tick is the most likely to transmit Lyme, and they are generally feeding in the spring and summer, adults feed in the fall
  • Slide 3
  • 3 A closer look Borrelia burgdorferi is found in NA. But also B miyamotoi Borrelia garinii and afzelii are found in Europe. Or American patients returned from Europe. Ticks are not the only way to get Lyme: sexual and placental transmission
  • Slide 4
  • Early signs and symptoms of Lyme Erythema Migrans onset 7-14 days after bite Sore throat, myalgias, arthralgias, fever, chills, and headache within days to 2 weeks after infection If symptoms are severe and high fever is present consider co-infection with human granulocytic anaplasmosis(HGA) and Babesia. Babesia microti/duncani in the East and babesia duncani in CA
  • Slide 5
  • Early disseminated Lyme Arthralgias, Neurologic symptoms, headaches, cranial neuropathy, diffuse or focal mononeuropathy multiplex, lymphocytic meningitis, plexopathy, Radiculoneuropathy (Bannwarth syndrome) Cardiac symptoms syncope, dyspnea, chest pain, palpitations, A-V block Skin involvement-secondary erythema migrans, acrodermatitis chronicum atrophicans
  • Slide 6
  • Late Lyme disease Occurs months to years after infection and often a period of latency Joint and neurologic symptoms most common Sub acute encephalopathies, axonal neuropathies and peripheral neuropathy Bannwarth syndrome Neuropsychiatric symptoms
  • Slide 7
  • Diagnosis antibodies, antigen, PCR, T-cell response, culture
  • Slide 8
  • Direct testing PCR Lyme antigen Coyles research
  • Slide 9
  • Antibodies Initial lag time to seroconversion Conversion of IgM to IgG sensitivity of ELISA sensitivity of WB WB comparison C6LPE afzelii and garinii Coyles research
  • Slide 10
  • T-cell response aka iSpot
  • Slide 11
  • Lyme culture fussy bug: long incubation, preferred media, preferred surfaces
  • Slide 12
  • Associated Lab Findings low CD57, low WBC possibly low IgG3 or slightly elevated ANA normal ESR, CRP first-degree heart block
  • Slide 13
  • Co-infections Babesia, Bartonella, Ehrlichia, Anaplasmosis...
  • Slide 14
  • Treatments antibiotics, herbs, oxidative therapies, silver
  • Slide 15
  • IDSA Treatment of early Lyme disease without significant neurological or cardiac symptoms Doxycycline 200mg bid Amoxicillin 500mg tid Cefuroxime 500mg bid All the above are given for 14-21 days
  • Slide 16
  • ILADS treatment of Erythema Migrans without other symptoms Doxycycline 100mg qid or 200mg bid with food Cefuroxime 1g bid Amoxicillin 1g tid with probenicid 500mg tid if pregnant dose Amoxicillin q6h Treat for 21 days If pregnant treat for 6 weeks and test for Babesia, HGA, and Bartonella
  • Slide 17
  • IDSA treatment of Lyme carditis Ceftriaxone 2gm qd for 10-28 days Doxycycline 100-200mg po bid for 10-28 days For AV block or myopericarditis use either of above regimes with appropriate inpatient monitoring. With resolution of heart block patient may be discharged home on po meds
  • Slide 18
  • ILADS Early disseminated Lyme Milder symptoms present for less than one year with multiple Erythems Migrans lesions, constitutional symptoms, and lymphadenopathy, Treat with oral therapy until no active disease for 4 weeks (46 months typical) using same antibiotic doses as outlined for Erythema Migrans Pregnancy: As in Erythema Migrans, but duration as above. Treat throughout pregnancy, and do not breast feed.
  • Slide 19
  • IDSA treatment of late Lyme disease arthritis Doxycycline 100mg bid Amoxicillin 500mg tid Cefuroxime 500mg bid Treat for 28 days If persistent or recurrent joint swelling retreat with another 28 days of above antibiotics or 2-4 weeks of IV ceftriaxone
  • Slide 20
  • IDSA late neurologic Lyme disease This includes encephalopathy's and radiculopathies, Bannwarth syndrome Treat with ceftriaxone 2 gm qd for 2-4 weeks Response to treatment is usually slow and may be incomplete Re-treatment is not recommended unless relapse is shown by reliable objective measures
  • Slide 21
  • ILADS Late Disseminated/ Chronic Lyme Symptoms present greater than one year, more severely ill patients, and those with prior significant steroid therapy or any other cause of impaired immunity: Treat adults and pregnant woman with 10 or more weeks of IV therapy, then oral or IM till asymptomatic for 6-8 weeks Children: IV therapy for 6 or more weeks, then oral or IM follow up as above.
  • Slide 22
  • IDSA treatment of late Lyme disease arthritis Doxycycline 100mg bid Amoxicillin 500mg tid Cefuroxime 500mg bid Treat for 28 days If persistent or recurrent joint swelling retreat with another 28 days of above antibiotics or 2-4 weeks of IV ceftriaxone
  • Slide 23
  • IDSA late neurologic Lyme disease This includes encephalopathy's and radiculopathies, Bannwarth syndrome Treat with ceftriaxone 2 gm qd for 2-4 weeks Response to treatment is usually slow and may be incomplete Re-treatment is not recommended unless relapse is shown by reliable objective measures
  • Slide 24
  • IDSA Post Lyme disease syndrome proposed definition Onset of the following symptoms within 6 months of a documented case of Lyme that has been treated by IDSA guidelines Fatigue Widespread musculoskeletal pain Complaints of cognitive difficulties Exclusion of any diagnosable disease
  • Slide 25
  • 25 Why antibiotic treatments dont work three forms of lyme (spirochete, L-form, cyst) biofilm tissue sequestration patients intolerance to treatment: toxicity, gastritis, mycosis, mitochondrial fatigue co-infections evolution of bacteria, i.e. resistance targeted vs comprehensive treatment strategy 25
  • Slide 26
  • 26 Why treatments dont work Immune evasion Using proteins that look like ours (ID badges), avoid recognition and therefore destruction by complement pathway. Mutate surface proteins. Encysting. Using proteins that look like ours (feeding misinformation), activate the immune system non-productively
  • Slide 27
  • Immune Evasion Modulation of its surface antigens, OspA and OspC Evades complement pathway: OspC, CD59-like complement inhibiting protein OspA potent neutrophil stimulator and inducer of IL-1b, TNF-a, and IL-6 Induces IL-10 initially to downregulate immune response Delayed conversion of IgM to IgG
  • Slide 28
  • 28 Comprehensive Support anti-inflammatory: diet, herbs, proteolytic enzymes lymphatics: walking, skin brushing, massage gastro-intestinal: probiotics, regularity liver support: phase I and II brain/nerves: B12, herbals methylation, glutathione emotional/spiritual

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