Lyme Disease and Bartonella Coinfections
Updated: Nov 4, 2020
I was recently interviewed on Lyme Basics. Click here to read the full interview.
How do you differentiate between what clinical symptoms are caused by Lyme disease and Bartonella? What are some of the more typical symptoms of a chronic Bartonella infection?
It can be difficult to differentiate between Lyme disease and Bartonellosis based on clinical symptoms alone. There is certainly an overlap of symptoms found in both, such as headaches, fatigue, brain fog and cognitive dysfunction, mood disorders, and joint pain. Bartonella can cause additional signs and symptoms that are more specific for it, but still does not rule out the possibility of another infection or even another disease state.
For instance, Bartonella can cause a linear rash, now known as Bart-tracks, that can have an appearance similar to stretch marks. While this seems to be very specific for Bartonella, there is now some data based on skin biopsies to suggest that Borrelia burgdorferi (the bacteria that causes Lyme disease) can also be found in the same location as Bartonella in the skin. In addition, there are some patients who truly have stretch marks, or striae, due to collagen disorders, and these patients can have some symptoms that overlap with Bartonella.
How do you treat a chronic Bartonella infection?
There are various treatment regimens that have been used in Bartonella infections. There doesn’t seem to be a one size fits all option for all patients. Sometimes herbal protocols can be helpful alone or combined with a variety of other therapeutic interventions, like dietary changes, immune support, efforts to heal the gut, detoxification, and electromagnetic frequency machines.
Sometimes antibiotics are necessary and research suggests that multiple antibiotics are often needed at the same time due to the high rate of resistance that develops in the bartonella organisms.
The case reports that are published by Mozayeni and Breitschwerdt show that Bartonella infection can cause a very broad range of disease manifestations, but what is more problematic is showing the causal relationship between a chronic infection with a Bartonella species and the clinical condition. What are your thoughts about that? And how can physicians in the trenches treating this disease help and collaborate with scientists?
This was a powerful case report that was published linking Bartonella infection with Ehlers-Danlos Syndrome and Mast Cell Activation Syndrome. The case exemplifies what we already know about Bartonella, that it can exist alter the quality of connective tissue in many parts of the body. Physicians in the trenches often don’t have the time to write papers on their cases but they might have very interesting findings that could help scientists who are studying this condition. I would encourage these physicians to reach out to the ILADS organization and connect with other doctors treating Lyme and tick-borne infections. There may be physicians and scientists out there who could help get the information into publication.
I have learned that antibiotic resistance is not an issue with Lyme disease, however it persists despite being susceptible to the used antibiotic because it creates morphological forms that are able to survive lethal doses of antibiotics.
This is not correct information. Borrelia burgdorferi can absolutely develop antibiotic resistance which can lead to the development of persister bacteria.
Here is a quote from Dr. Horowitz’s publication in 2016, The Use of Dapsone as a Novel “Persister” Drug in the Treatment of Chronic Lyme Disease/Post Treatment Lyme Disease Syndrome:
Johns Hopkins researchers in 2015, as well as researchers from Northeastern University (Kim Lewis and colleagues) demonstrated that that Borrelia burgdorferi can form persister cells. Persisters are a small fraction of quiescent bacterial cells that survive lethal antibiotics but can regrow leading to post-treatment relapse. Examples include mycobacterium, syphilis, endocarditis, and biofilm infections.
Does antibiotic resistance play a role in Bartonella infections?
Yes, antibiotic resistance plays a significant role in Bartonella infections. In the April 2019 issue of Antibiotics, research on antibiotic resistance from Johns Hopkins was published in the article “Identification of FDA-Approved Drugs with Activity against Stationary Phase Bartonella henselae.” What they found was that a number of drugs that were not routinely used for Bartonellosis and without previous evidence for antibacterial activity did in fact completely eradicate the stationary phase B. henselae after 3 days in culture. They also found that the drugs currently used to treat Bartonellosis such as rifampin, azithromycin, and ciprofloxacin had poor activity against the stationary phase B. henselae. This is consistent with what we are seeing in clinical practice. Many patients are being treated with conventional antibiotics and not getting better and this is causing other doctors to question the diagnosis of the infection in these patients. These patients can have a chronic infection with Bartonella and yet not respond to treatment.
Many infectious disease doctors think Bartonella is a harmless infection and the reason why Lyme patients have antibodies against Bartonella is because it is a common infection. If antibody-tests are not helpful in all cases what tests are there that can differentiate between an active/chronic or past infection with Bartonella?
There are a number of tests such as PCR and FISH that can be done to help understand whether Bartonella infection is active. Unfortunately, these tests don’t always confirm the diagnosis. A diagnosis of Bartonellosis should still be considered in a patient who is negative on PCR and/or FISH , especially in the setting of clinical signs and symptoms and very elevated antibodies to one or more Bartonella species.
Some physicians say to patients with complex illnesses that they suffer from depression, anxiety, OCD or a range of other psychiatric disorders. From my own experience it can be a symptom of Lyme disease and/or Bartonella infection. How do you differentiate between a classic psychiatric disorder and an infection induced one? And how do you treat it if an infection is the trigger?
These are very complicated questions. Patients with psychiatric manifestations should always be ruled out for underlying systemic medical conditions, including infections and immune dysregulation, first. Conventional medicine, however, often does the opposite. The assumption is that the psychiatric illness is primary and even if there is an underlying medical issue it is unrelated to the psychiatric issue. This does a tremendous disservice to patients and limits their ability to get better.
Having said that, it is not always easy to differentiate between a psychiatric disorder and an infection induced one. All patients with psychiatric issues should, in my opinion, undergo genetic testing to identify their risks for psychiatric illness as well as to identify treatment options that are best for the patient based on their genetic profile. In addition, a full lab panel should be performed to rule out underlying medical conditions that can cause or contribute to psychiatric illness, such as thyroid and/or adrenal dysfunction, vitamin and mineral deficiencies, immunodeficiencies, toxicities such as increased levels of heavy metals, and mast cell activation syndrome, to name a few. A clinical history suggestive of exposure to cats and dogs and/or insect/tick bites should warrant investigation for Bartonella, Lyme and other vector-borne infections.
Since the advancement of laboratory technology, the interest for these more difficult to grow organisms like Bartonella has gotten more interest from scientists, especially those in the field of veterinary medicine. Science doesn’t have all the answers with regards to how Bartonella causes disease and where it resides and evades antibiotics in the host – bone marrow – red blood cells – endothelium – skin. As a treating physician, what are some of the questions on your mind concerning Bartonella that you would like scientific research to answer in the coming decade?
Can we develop better diagnostic tools?
How can we prevent transmission of the organism from animals to humans, from animals to insects and from insects to animals or humans?
What exact treatment regimen will achieve cure in these patients?
VECTOR BORNE DISEASES: BARTONELLA
What are the differences between acute Lyme and chronic Lyme (PTLDS)?
Acute Lyme disease occurs right after a tick bite. However, not everyone finds the tick or remembers being bitten. Symptoms can set in days to weeks after the tick transfers the Borrelia burgdorferi bacteria from its saliva into the person it has bit. If the infection is treated within the first few weeks, it can sometimes be cured. Of course, there are cases of patients treated early who go on to develop chronic Lyme disease.
In some of these patients, it is the presence of the co-infections that were not treated adequately that continue to cause illness and not just the Lyme disease. The term PTLDS stands for Post Treatment Lyme Disease Syndrome and refers to symptoms that patients who have completed standard Lyme disease treatment continue to suffer from. The terminology implies that it is not the Lyme disease itself that is causing continued symptoms but rather some sort of after effects from the Lyme that should go away with time. Unfortunately, for many patients, the lingering symptoms we call Chronic Lyme, truly represents persistent infection that did not fully respond to treatment.
Do you consider early localized Lyme (1-4 weeks), early disseminated Lyme (1-4 months), and late disseminated Lyme (4+ months), to be easily resolved with standard treatment? If not, what is your approach to resolving symptoms in patients in these stages?
Early localized Lyme disease is the stage when a bull’s eye rash can appear or patients can develop flu-like symptoms. Some patients don’t have any symptoms at this stage. If appropriate antibiotic treatment is started as soon as possible and treated for at least 28 days (although longer courses are sometimes necessary), resolution of symptoms and Lyme disease is definitely possible.
Once early disseminated Lyme sets in, around 1-4 months, the symptoms can be more severe indicating the infection has likely infiltrated the joints, nervous system, and other parts of the body. It is critical that the infection be treated no later than this point, as this increases the likelihood of the development of chronic Lyme disease. Prolonged, multi-drug antibiotic courses may be needed at this stage.
Late disseminated Lyme disease may lead to reversible or even irreversible damage to the heart, joints, or other body parts depending on the patient. Treatment should be aggressive, but length of treatment and which regimen is best for this stage is unclear. Whether the infection can be fully cleared at this stage is also unclear. I have seen many patients treated for late disseminated Lyme with IV antibiotics, for instance, who several years later go on to develop other late stage manifestations. Persistent infection despite antibiotic treatment is real and has been shown repeatedly in the lab.
What would you say is the stage most patients are in by the time they arrive to your office to be seen as a patient?
Most of the patients who seek my help have been sick for a long time and are searching for answers. Some know that Lyme disease is the root cause of their prolonged illness but some don’t. Through my extensive workup, I often find chronic infections in patients who come to me with other diagnoses, such as ME/CFS (myalgic encephalomyalgia/chronic fatigue syndrome), neuropathy, fibromyalgia, and autoimmune disorders.
However, because of the endemic area of the country that I practice in, I have patients who I have followed for years for other issues (and who never had Lyme disease) who develop acute Lyme disease while under my care. This is a good scenario if I can find it early and start treatment as soon as possible.
How do you determine when a Lyme patient is resolved of symptoms?
Patients know their bodies well and I rely on them to tell me if their symptoms persist or have resolved. However, it is important to note that patients without persistent symptoms could still have hidden borrelia in their cells; they just may not be active or causing any issues.
Is there a way to test patients to be sure they are free of the Borrelia burgdorferi following standard treatment in each stage of disease?
There is no reliable way to test patients to confirm that they are free of the Borrelia bacteria at any stage of disease. The majority of the testing available uses antibodies, which can be helpful in indicating acute infection or past exposure, but is not a good measure of whether the infection is cured or whether it persists in the body. It can also miss early infection within the first few weeks.
What are the different testing methods for Lyme and how reliable are these tests?
The Elisa screening test is the most common test ordered and unfortunately, it is really the worst one out there. If doctors only rely on the Elisa and it is negative, they could miss up to 50% of cases. The Lyme Western Blot test looks at acute and chronic antibodies and is a better test to run than just the Elisa alone. However, the commercially available western blot tests only test for one strain of borrelia burgdorferi (B31) and there are multiple strains known to exist in the United States and around the world so it will miss many of these.
Igenex does a similar type of test, called the Immunoblot, and uses the B31 strain as well as 297, which increases the sensitivity of the test. If these tests are run too early, for instance right after a tick bite, they may be falsely negative, as it takes time for the immune response to kick in. Igenex also does PCR testing, that detects the DNA of the borrelia bacteria, which can help confirm the diagnosis when it is positive. There are other tests being developed by other labs, but it is too soon to tell how reliable they are. It is also critical that the co-infections get tested in any patient that Lyme disease is being considered in. We know that ticks can harbor multiple bugs, including parasites, viruses and other bacteria.
Is there evidence to suggest that Lyme bacteria can persist after treatment?
We have good studies that have confirmed that Borrelia can persist even after aggressive antibiotic treatment. For instance, at Johns Hopkins, they found that doxycycline and even two-antibiotic regimens were not enough to eradicate borrelia. They have identified certain drugs and protocols that seem to be more effective against persister infection.
What is your professional opinion on whether chronic/persisting Lyme infection exists?
Chronic/persistent Lyme disease does certainly exist and it can lead to a number of long-term consequences.
Have you come across the need to consult with a patient regarding blood donation eligibility in your practice?
It comes up every once in a while that a patient wants to donate blood. However, typically my patients are quite ill and are not well enough to do so.
What do patients who have ever been diagnosed with Lyme disease need to consider before donating blood if deemed eligible by standard criteria?
Patients should consider when the last time they had any symptoms and whether it is possible that they have persistent infection. If they have ever had Babesia, they should never donate blood.
Based on your experience and available research, do you think it is safe for a donor with PTLDS or chronic to donate blood? Is it safe for the donor recipient to receive blood from someone who has PTLDS or chronic Lyme?
In my expert opinion, any patient who has suffered from PTLDS/chronic Lyme or co-infections (including Bartonella and Babesia) should not donate blood. It is clear from recent research that persistent infection is a real possibility, particularly in patients with continued symptoms. As we don’t have commercial testing for persistent infection, we have to make assumptions in the case of donating blood, that any symptom in someone with a history of Lyme or co-infections, could represent persistent infection.
In addition, anyone with a history of Babesia can never donate blood. Unfortunately, donor recipients are not given any information about who their donor is or what their medical history is so there is no way for them to have any input about whether the blood has come from someone with chronic Lyme or other tick-borne infection.