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Diagnosis and Therapy of Chronic Systemic Co-Infections in Lyme Disease and Other Tick-Borne Infectious Diseases
GARTH L. NICOLSON, Ph.D
The Institute of Molecular Medicine, Huntington Beach, CA USA
*The author have no financial interest in the products discussed in this contribution.
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.
Lyme Disease (LD) is the most common tick-borne disease in North America and has
been reported in 48 U.S. 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 and other
co-infections.1Borrelia b. and its co-infections has 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 Borrelia
b. 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. 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 BURGDORFI 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 3-30
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 that 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) and
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,5causing
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
Similar to 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 Borrelia b. 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 imunoblot. 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 Borrelia b. antigens, show cross-reactivity with other
microorganisms and in some cases are only useful 4-6 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.
Other tests that are offered for LD have been criticized. For example, diagnosis
of LD based
on culture of B. burgdorferi is completely unreliable.7 One laboratory offers a
one-step Lyme antigen urine test (LUAT), but some researchers have criticized
this test for its high rate of false-positive tests.8 Similarly, some IFA tests
are suspect because they are almost universally positive. Most consider a
patient positive if Borrelia b. antigens (EIA plus Western Blot analysis) are
present in blood serum in more than one test, or the patient is PCR-positive for
Borrelia b.
DIAGNOSIS OF TICK-BORNE CO-INFECTIONS: MYCOPLASMA, BABESIA, EHRLICHIA AND
OTHERS
Co-infections complicate the diagnosis and signs/symptoms of LD. These
infections can also occur in various combinations. For example, another
tick-borne infection is caused by the intracellular protozoan Babesia spp.,
first described in domestic animals in Romania.9 There are over 100 species of
the genus Babesia, but most infections in humans in North America are caused by
Babesia microti and in Europe by Babesia divergens and Babesia bovis. About
20-40% of cases of LD show Babesia co-infections. When both infections are
present, the number of signs/symptoms, their severity and duration of illness
can be greater in the early stages of disease,9including high fever, chills,
generalized weakness, gastrointestinal symptoms (anorexia, nausea, abdominal
pain, vomiting, diarrhea, among others), anemia, muscle and joint pain,
respiratory problems and dark urine. This combination of
infections can be lethal in some patients (about 7% of patients can have
disseminated intravascular coagulation, acute respiratory distress syndrome and
heart failure), but the majority of patients with Babesia spp. have the chronic
form of the infection. In Babesia infections patients can show mild to severe
hemolytic anemia (probably correlating with the protozoan colonization of
erythrocytes, which can be seen by experienced individuals in blood smears) and
a normal to slightly depressed leukocyte count.9 However, this is usually not
seen in patients who have progressed to the chronic phase of the disease.
We and others10 have found that the most common co-infection with Borrelia b.
are various
species of Mycoplasma. Approximately 60-75% of LD patients also have mycoplasmal
co-infections (Mycoplasma fermentans > Mycoplasma hominis > Mycoplasma
pneumoniae, M. genitalium, M. penetrans, other species). In some cases multiple
mycoplasmal infections are present in LD patients. The presence of
mycoplasmal infections complicates the diagnosis and treatment of LD, and some
of the generalized signs/symptoms found in Borrelia-positive patients are also
found in mycoplasma-positive patients.5,6
Like the Borrelia b. spirochete, mycoplasmas are found at intracellular
locations in various
tissues and are only rarely found free in the blood. This can make detection
difficult, and in some patients the appearance of Borrelia b. and various
mycoplasmas in their white blood cells can be cyclic. We recommend testing for
mycoplasmal infections in LD using the most sensitive PCR procedures to detect
DNA in white blood cells.5,6,11 In addition to LD, mycoplasmal infections have
been found at high incidence (40-60%) in CFS, Fibromyalgia Syndrome, Rheumatoid
Arthritis, Gulf War Illness and neurodegenerative diseases.5,6,11,12 These are
emerging infections, and the medical community is just beginning to respect the
involvement of this type of co-infection in many clinical conditions.
Another co-infection found in some LD patients is a rickettsial infection caused
by Ehrlichia
species.2,3 These small, gram-negative, pleomorphic, obligate intracellular
infections are similar to mycoplasmas in their structures, intracellular
locations and resulting signs/symptoms. Commonly found species are E.
chaffeensis and E. phagocytophila, and these microorganisms can cause
signs/symptoms within 1-3 weeks of exposure, such as fever, shaking chills,
headache and muscle pain and tenderness and less commonly nausea, vomiting,
abdominal pain, diarrhea, cough and confusion.3 Laboratory features include mild
to moderate transient hemolytic anemia, decreases in white blood cell count
(leucopenia, thrombocytopenia) and elevated erythrocyte sedimentation rate, and
sometimes
increases in liver enzymes and less often increases in blood urea nitrogen and
creatinine. Serology is usually only positive after 1-2 weeks with the
limitations discussed above. Since culturing the microorganism is not practical,
antibody and PCR testing have been used for confirmation of the
infection.3
LD patients are at risk for a variety of other opportunistic infections,
including other bacterial
infections as well as viral and fungal infections. These can complicate
diagnosis and treatment, but they may be principally a problem in the late,
chronic phase of the disease. Late stage patients with neurological
manifestations, meningitis, encephalitis, peripheral neuropathy and other
signs/symptoms may have complicated co-infections that are not recognized
or treated by their physicians.
TREATMENT OF LD BORRELIA AND CO-INFECTIONS
Most LD patients do well on combinations of antibiotics plus nutritional and
nutraceutical support. Experts agree that LD is much easier to treat in the
earlier phases, but some of the co-infections can be difficult to treat,
especially if the disease is in the late chronic stage. The most common
recommendations for the treatment of LD Borrelia and co-infections involve
antibiotics that can effectively suppress early localized or early disseminated
LD Borrelia.2-4 A variety of antibiotics in 2- week regimens show good activity
against early-stage Borrelia infections, such as combinations of doxycycline
plus amoxicillin, doxycycline plus penicillin V and amoxicillin or pencillin V
plus cefuroxime axetil, in that order, in terms of effectiveness and
expense,2,13 although some reports indicate that the latter antibiotics are just
as effective as the doxycycline combinations.14,15 Also, doxycycline also shows
good activity against most species of Mycoplasma and Ehrlichia, and it also
shows good penetration into the central nervous system (CNS). Doxycycline should
not be used in
children under the age of 8 years, but some have suggested that short duration
treatments (2 weeks) at pediatric doses are very useful.13 Alternatives include
the use of erythromycin, but most experts do not consider this a first line
treatment for LD Borrelia.2,13
A major problem in the treatment of LD is finding effective treatments of the
late chronic stage, especially when they involve the CNS. The table below (Table
1) shows the antibiotics useful for treating LD based on the clinical
situation.13-15 Since with time (late stage) Borrelia b. infections occur
intracellularly as cystic or persistent forms, Plaquenil, Falgyl or Tinidazole
should be added along with a macrolide (azithromycin, Biaxin or Dynabac)
and/or fluoroquinolones (ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin).13-17
With antibiotic treatment, Herxheimer reactions (or ‘die-off’ reactions
involving chills, fever, night sweats, muscle aches, joint pain, short term
memory loss and fatigue or a general worsening of symptoms) usually occur for
days to weeks due to release of bacterial cell wall
degradation products and stimulation of interleukins or chemical messengers that
cause worsening of some signs/symptoms.16,17
To overcome Herxheimer reactions or other adverse responses i.v. antibiotics
have been used
for a few weeks—then oral. Oral Benadryl (diphenhydramine, 50 mg) taken at least
30 min before antibiotics, and lemon/olive drink (1 blended whole lemon, 1 cup
fruit juice, 1 tbs olive oil—strain and drink liquid) have proved useful.16 This
period usually passes within a few weeks and differs from allergic reactions
that can cause immediate rashes, itching, swelling, dizziness, trouble breathing
and other problems. For LD the dosing for pediatric use has been worked out.2
ANTIBIOTIC THERAPY FOR CO-INFECTIONS OF BORRELIA, MYCOPLASMA, BABESIA AND
OTHERS,
Patients with co-infections of Borrelia plus Mycoplasma species the therapy
should be the same as in Table 1 (with doxycycline) but the duration of therapy
must be increased. The reason for this is that slow-growing mycoplasmal
infections are not readily susceptible to antibiotics, and thus the therapy must
be more gradual.6,16,17 Some patients with mycoplasma co-infections may benefit
from combinations of antibiotics other than those listed in the table, such as
adding additionally azithromycin or a floxacin, especially if there are limited
responses.16 These can be worked into the regimen slowly over weeks, if
necessary. The protocol for infections involving Borrelia plus Mycoplasma
species should be continued for at least 6 months.17
When Babesia infections are present as
co-infections with Borrelia, patients can be treated with quinine (Quinamm) and
clindamycin (cleocin).9 For co-infections with Mycoplasma or Ehrlichia species
doxycycline should be added to the antibiotic regimen.3 Dr. Richard Horowitz has
presented a scheme for treating co-infections in LD,19 and I have added advice
on Mycoplasma/Ehrlichia co-infections (Table 2). If Chlamydia pneumoniae is also
present, then two penetrating antibiotics active against these microorganisms
should be considered, such as doxycycline plus a fluoroquinolone (levofloxacin,
ofloxacin or gatifloxacin).
GENERAL NUTRITIONAL CONSIDERATIONS WHEN UNDERGOING THERAPY
LD patients are often immunosuppressed and susceptible to opportunistic
infections, so proper nutrition is imperative.17 Patients should not smoke or
drink alcohol or caffeinated products. Fresh fluids, lots of juices (such as
Juice Plus) or pure water are best. It is important that patients avoid high
sugar and fat foods, such as military (MRE) or other fast foods and acid
forming, allergen-prone and system stressing foods or high sugar/fat junk foods.
Increase intake of fresh vegetables, fruits and grains, and decrease intake of
fats and simple or refined sugars that can be immunosuppressive. Cruciferous
vegetables, soluble fiber foods, fish and whole grains are useful. In some
patients exclusive use of 'organic' foods has been beneficial. For heavy
metal removal, Garlic Plus (Longevity) has been proposed, and we find the use of
Detoxamin suppositories useful. For help with bowel bacteria and bladder
infections, many recommend D-mannose (Biotech). This natural sugar inhibits
binding of bacteria to biological membranes.
Chronic illness patients are often depleted
in vitamins (especially B complex, C, E, CoQ-10)
and certain minerals.16 These illnesses often result in poor absorption.
Therefore, high doses of some vitamins are useful; others, such as vitamin B
complex, cannot be easily absorbed so sublingual natural B-complex vitamins
should be substituted. General vitamins plus extra C, E, CoQ-10, beta-carotene,
folic acid, bioflavoids and biotin appear to be best, and L-cysteine,
L-tyrosine, L-glutamine,L-carnitine, malic acid and flaxseed or fish oils have
been used as supplements. Certain minerals aredepleted in chronic illness
patients, such as zinc, magnesium, chromium and selenium. Thus extra vitamins
and minerals have been used, especially if patients are removing heavy metals
with chelating agents. Vitamins and minerals must not be taken at the same time
of day as antibiotics (or oxygen therapy), because they can affect absorption.
YEAST/FUNGAL OVERGROWTH WHILE ON ANTIBIOTICS
Yeast overgrowth can occur, especially in females (especially vaginal
infections) during antibiotic therapy. Gynecologists recommend Nizoral, Diflucan,
Mycelex, or anti-yeast creams. Metronidazole (Flagyl, Prostat) has been
used to prevent fungal or parasite overgrowth or other antifungals (Nystatin,Amphotericin
B, Fluconazole, Diflucan or Pau d’ arco, 7 capsules/2X/day) have been
administered for fungal infections that can occur while on antibiotics. Some
patients have as their principal problem systemic fungal infections that can be
seen using dark field microscopy of blood smears. For superficial fungal
infections, such as fungal nail, a topical mixture of Laminsil in 17% DMSO
2X/day is effective. As mentioned above, L. acidophilus mixtures are used to
restore gut flora. Bacterial
overgrowth can also occur, for example, in between cycles of antibiotics or
after antibiotics have been stopped.16
Nutraceutical approaches to controlling
yeast infections include: Pau d’ arco, grapefruit extract, olive leaf, caprylic
acid, garlic extract and oregano oil. Diet is especially important in
controlling yeast overgrowth, and the dietary instructions above should be
followed, such as the elimination of most simple sugars from the diet.16-18
OXIDATIVE THERAPY FOR CHRONIC LYME DISEASE CO-INFECTIONS
Borrelia, Mycoplasma, Ehrlichia and other infections are mostly intracellular
and should be considered borderline anaerobic infections that grow and survive
better in low oxygen environments. Oxidative therapy can be useful in
suppressing a variety of anaerobic infections, but this approach should be
considered experimental and only palliative. We recommend several weeks to
months of Hyperbaric Oxygen (1.5-2.0 ATM, 60 min) treatments, because these are
well tolerated by most patients with chronic infections.16 Alternatively,
American Biologics Dioxychlor, i.v. ozone or hydrogen peroxide might be useful
but should only be undertaken with experienced physicians. Some patients have
used
peroxide baths with 2 cups of Epsom salt in a hot bath or Jacuzzi. After 5 min,
2-4 bottles 16 oz. of 3% hydrogen peroxide are added. This is repeated 2-3 times
per week; but no vitamins must be taken 4 hr before the bath. The hydrogen
peroxide is added after skin pores open. This appears to have some benefit to
patients, especially those with skin/muscle problems.
Hydrogen peroxide can also be directly applied to skin after a work-out or hot
shower/tub. In
this case the hydrogen peroxide is left on for 5 min, and then washed off. For
oral irrigation, 1 part 3% hydrogen peroxide with 2 parts water can be used like
a mouth wash three times per day.16 Most chronic illness patients have
periodontal problems, and oral infections and bone cavitation infections are
common.
REPLACEMENT OF GUT FLORA, IMMUNE MODULATORS AND NATURAL REMEDIES
Patients undergoing treatment with antibiotics and other substances risk
destruction of normal gut flora, and this can result in over-growth of less
desirable bacteria. To supplement bacteria in the gastrointestinal system live
Lactobacillus acidophilus in capsules or powder have been strongly recommended.
Mixtures of Lactobacillus acidophillus, L. bifidus, B. bifidum, L. bulgaricus
and fructoologosaccharides to promote growth of these probiotics in the gut have
also been used. L. acidophillus mixtures (above 2.5-3 billion live organisms)
should be taken three-times per day. For irritable bowel, the nutraceutical Calm
Colon (Samra) has proven to be very effective in clinical trials. A very
good probiotic mixture is Theralac (www.theralac.com). In addition, to improve
digestion and especially absorption enzyme mixtures have proved useful. The best
known of these is Wobenzym.
A number of natural remedies, such as ginseng root, herbal teas, lemon/olive
drink, olive leaf
extract with antioxidants are sometimes useful, especially during or after
antibiotic therapy. More important examples are immune modulators, such as
bioactive whey protein (ImuPlus,
www.imuplus.com; Immunocal, ImmunoPro), transfer factor (4-Life Transfer Factor,
Immuni-T) or MGN3. Some additional remedies are: olive leaf extract (many
sources), NSC-100 and Laktoferrin. These products have been used to boost
immune systems. Although they appear to help many patients, their clinical
effectiveness in chronic illness patients has not been carefully evaluated. They
appear to be useful during therapy to boost the immune system or after
antibiotic therapy in a maintenance program to prevent relapse and opportunistic
secondary infections.
LIPID REPLACEMENT THERAPY FOR CHRONIC INFECTIONS AND RESTORING MITOCHONDRIAL
FUNCTION
Lipid Replacement Therapy is useful in
providing membrane lipids in unoxidized forms to repair nerve and mitochondrial
membranes that are damaged by heavy metals, chemicals and infections.20 For LD
patients we recommend the oral supplement Healthy Aging containing NTFactor
(Nutritional Therapeutics). This product comes as tablets that are taken twice
per day. For children it should be ground up between two spoons into a course
powder that can be added to several spoonfuls of applesauce. The NTFactor is not
bitter, but it is slightly sour, and some children actually like the taste.
The dose should be 4-6 tablets twice per day. For children 1/2-1 tablet for
children up to 2 years-old, 2 tablets for 2-3 years old and 3-4 tablets for 4-5
years-old and 4-5 tablets 5 years-old and older.
Research has demonstrated no adverse responses with NTFactor even many times
these doses. Since this formulation is a completely natural membrane lipid
mixture, there are no known toxicities and no known toxic dose limits. NTFactor
can also be taken in a form with vitamins, minerals and probiotics (Propax).
Lipid Replacement Therapy has been shown to improve fatigue scores and
mitochondrial function in various chronic illnesses.20
References
1. Burgdorfer WA, Barbour AG, Hayes SF, et al. Lyme disease – a tick-borne
spirochetosis? Science 1982; 216:1317-1319.
2. Kind A, Schned E, Anderson F, et al. Lyme Disease guidelines for Minnesota
clinicians: epidemiology, microbiology, diagnosis, treatment and prevention.
Minnesota Department of Public Health, 1999. http://www.state.mn.us/divs/dpc/adps/lyme/guideline.
3. Gale A, Ringdahl E. Tick-borne diseases. Amer Fam Physican 2001; 64:461-466.
http://www.aafp.org/afp/200110801/461
4. Burrascano JJ, Jr. Advanced topics in Lyme Disease. Diagnostic hints and
treatment guidelines for Lyme and other tick borne illnesses. LymeNet On-Line
Library, Burrascano Treatment Guidelines, 2000. http://www2.lymenet.org/domino/file.nsf/UID/guidelines
5. Nicolson GL, Nasralla M, Franco AR, et al. Diagnosis and Integrative
Treatment of Intracellular Bacterial Infections in Chronic Fatigue and
Fibromyalgia Syndromes, Gulf War Illness, Rheumatoid Arthritis and other Chronic
Illnesses. Clin Pract Alt Med 2000; 1(2):92-102. http://www.immed.org/illness/infectious_disease_research
6. Nicolson GL, Nasralla M, Franco AR, et al. Mycoplasmal infections in fatigue
illnesses: Chronic Fatigue and Fibromyalgia Syndromes, Gulf War Illness
and Rheumatoid Arthritis. J Chronic Fatigue Syndr 2000; 6(3):23-30 http://www.immed.org/illness/infectious_disease_research
7. Verdon ME, Sigal LH. Recognition and management of Lyme Disease. Amer Fam
Physician 1997; 56:427-436. http://www.aafp.org/afp/970800ap/lymedis
8. Klempner MS, et al. Intralaboratory reliability of serologic and urine
testing for Lyme disease. Amer J Med 2001: 110:217-219.
9. Mylonakis E. When to suspect and how to monitor Babesiosis. Amer Family
Physican 2001; 63:1969-1974. http://www.aafp.org/afp/20010515/1969
10. Eskow E, Adelson ME, Rao RV, Mordechai E. Evidence for disseminated
Mycoplasma fermentans in New Jersey residents with antecedent tick attachment
and subsequent musculoskeletal symptoms. J Clin Rheumatol 2003; 9:77-87.
11. Nicolson GL, Gan R, Haier J. Multiple co-infections (Mycoplasma, Chlamydia,
human herpesvirus-6) in blood of chronic fatigue syndrome patients:
association with signs and symptoms. Acta Pathol Microbiol Immunol Scand 2003;
111: 557-566.
12. Nicolson GL, Berns P, Nasralla M, Haier J, Pomfret J. High frequency of
systemic mycoplasmal infections in Gulf War veterans and civilians with
Amyotrophic Lateral Sclerosis (ALS). J Clin Neurosci 2002; 9:525-529.
13. Eppes SC. Lyme Disease: current therapies and prevention. Infect Med 2001;
18:388-395. http://www.medscape.com/SPC/IIM/2001/v18.n08/m1808.01eppe/mig-pnt-m1808.01.eppe
14. Dattwyler RJ, Volkman DJ, Conaty SM, et al. Amoxicillin plus probenecid
versus doxycycline for treatment of erythema migrans borreliosis. Lancet
1990; 336:1404-1406.
15. Luger SW, Paparone P, Wormser GP, et al. Comparison of cefuroxime axetil and
doxycycline in treatment of patients with early Lyme disease associated with
erythema migrans. Antimicrob Agents Chemother 1995; 39:661-667.
16. Nicolson GL: Considerations when undergoing treatment for chronic infections
found in Chronic Fatigue Syndrome,Fibromyalgia Syndrome and Gulf War Illnesses.
(Part 1). Antibiotics Recommended when indicated for treatment of Gulf War
Illness/ CFIDS/FMS (Part 2). Intern J Med 1998; 1:115-117, 123-128. http://www.immed.org/
17. Nicolson GL, Nasralla M, Franco AR et al. Diagnosis and Integrative
Treatment of Intracellular Bacterial Infections in Chronic Fatigue and
Fibromyalgia Syndromes, Gulf War Illness, Rheumatoid Arthritis and other Chronic
Illnesses. Clin Pract Alt Med 2000; 1:92-102.
18. Nicolson GL, Ngwenya R. Dietary considerations for patients with chronic
illnesses and multiple chronic infections. A brief outline of eighteen dietary
steps to better health. Townsend Lett 2001; 219:62-65. http://www.immed.org/illness/treatment_considerations
19. Horowitz R. Lyme Disease and other tick-borne diseases. ILADS Annual
Conference, October 29-30, 2005.
20. Nicolson GL, Ellithrope R. Lipid replacement and antioxidant nutritional
therapy for restoring mitochondrial function and reducing fatigue in chronic
fatigue syndrome and other fatiguing illnesses. J Chronic Fatigue Syndr 2006;
13(1):57-
Table 1. Treatment of Lyme Disease During the Different Stages of the
Disease12,13
| Clinical Stage | Time | Primary Treatment | Alternative Treatment |
| Early localized | 3-30 days |
doxycycline/amoxcillincefuroxime | erythromycin, clarithromycin azithromycin |
| Early disseminated 1-12 wks | 1-12 wks | doxycycline/amoxcillin/cefuroxime | erythromycin/clarithromycin/azithromycin |
| with CNS involvement |
ceftriaxone (iv)
|
penicillin G (iv)
|
|
| Late disseminated |
>2 months | ||
|
with arthritis
|
amoxcillin/doxycycline
|
penicillin G (iv) doxycycline
|
|
|
with CNS involvement
|
ceftriaxone (iv)
|
doxycycline (iv or po)penicillin G (iv) |
|
|
with cardiac involvement
|
amoxcillin
|
doxycycline (iv or po)
|
|
Table 2
| Lyme Borrelia | Mycoplasma/Ehrlichia | Bartonella | Babesia |
|
Amox+Probenecid+Macrolide+ Plaquenil+Flagyl/Tinidazole |
+Doxycycline | +Septra | +Mepron +Malarone +Artemesia +Lariam |
|
Bicillin+Macrolide+Plaquenil +Flagyl/Tinidazole |
+Doxycycline | +Septra | +Mepron +Malarone +Artemesia +Lariam +Mepron +Malarone +Artemesia _Lariam |
| Cephalosporin (PO/IV)+Macrolide+Plaquenil +Flagyl/Tinidazole |
+Doxycycline | +Septra | |
| Doxycycline+Plaquenil+ Flagyl/Tinidazole |
+Ciprofloxacin | +Septra+Rifampin | +Lariam +Malarone +Artemesia +Mepron +Malarone +Artemesia +Lariam |
| Macrolide_Plaquenil+ Flagyl/Tinidazole |
+Doxycycline | +Septra+Quinolone |
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