Transcript BARTONELLA-LIKE ORGANISMS

CASE HISTORIES:
BARTONELLA-LIKE ORGANISMS
JOSEPH J. BURRASCANO JR., M.D.
East End Medical Associates, P.C.
East Hampton, NY
J.J. Burrascano Jr. M.D.
BARTONELLA
• Is the most common of all tick-borne
pathogens
• Fairly distinct clinical syndrome
• This tick-associated strain of Bartonella
appears to be different from that
described as “cat scratch disease”
J.J. Burrascano Jr. M.D.
BARTONELLA-LIKE ORGANISM
(“BLO”)
 Predominantly neurologic disease, and less
vascular manifestations.
 Standard Bartonella blood testing is
commonly non-reactive.
 The usual Bartonella medications do not
work for this
 For these reasons I like to refer to this as a
“Bartonella-like organism” (BLO)
 One day BLO may be identified to be an
altogether different organism
J.J. Burrascano Jr. M.D.
CASE HISTORIES
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13 consecutive patients
All were PCR + for Bartonella
Age 33-75, median 48
4/13 bite, 5/13 EM. None with both
5 males, 8 females
Ill before Diagnosis:
– 60 d (one patient)
– 2-32 yrs
– median 10 yrs
J.J. Burrascano Jr. M.D.
CASE HISTORIES
• Lyme- 12 sero +, 5 PCR + (all were also
sero +) One with EM was sero & PCR
negative for Lyme!
• Babes- 9 positive- 3 sero + , 3 PCR +, 3
FISH +, 3 Bowen smear + ( 2 sero &
PCR +; one FISH & Bowen +)
• Ehrl/Anapl- none
• Others- MF-3; Chl- 2; CMV-2; HHV-6- 1
J.J. Burrascano Jr. M.D.
INDICATORS OF BLO
• CNS symptoms out of proportion to the
other systemic symptoms of chronic
Lyme
• Increased irritability of the CNS, with
agitation, anxiety, insomnia, and even
seizures or seizure-like activity
• Tender subcutaneous nodules along
the extremities
• Sore soles, especially in the AM
J.J. Burrascano Jr. M.D.
INDICATORS OF BLO
• Gastritis, lower abdominal pain
(mesenteric adenitis)
• Lymph nodes may be enlarged,
sometimes with a sore throat
• Red rashes. These rashes may be red
papular eruptions, spider veins, or the
appearance of red streaks like stretch
marks that do not follow skin planes
J.J. Burrascano Jr. M.D.
Bartonella Rashes
Red bumps- may form
scabs
J.J. Burrascano Jr. M.D.
Bartonella Rashes
Linear rashes- look like stretch marks
Photos taken by Dr. Martin Fried, with thanks
to him and to the Lyme Disease Association
J.J. Burrascano Jr. M.D.
More Bartonella
Back of legs
J.J. Burrascano Jr. M.D.
Bartonella
Lower back
J.J. Burrascano Jr. M.D.
Bartonella
Under the arm
J.J. Burrascano Jr. M.D.
TESTING IS VERY INSENSITIVE
• Clinically + Bartonella, with + response to treatment:
only 20% are + on serology or PCR (80% false
negative rate!)
• Occasionally see elevated VEGF- <20% of clinically
suspect cases, but when elevated, can be followed
to assess efficacy of treatment
• Therefore, the diagnosis is a clinical one, based on
the above points.
• Also, suspect infection with BLO in extensively
treated Lyme patients who still are encephalitic, and
who never had been treated with a significant course
of BLO meds
J.J. Burrascano Jr. M.D.
ANTIBIOTIC TREATMENT
• Best = FQ. Levofloxacin > Cipro; efficacy
decreased if co-admin with erythros
• Cephalosporins- advanced generation best
but 8/9 relapsed; Bicillin similar
• Combination of Rifampin + Biaxin fair
• Combination of Flagyl + Biaxin fair
• Worst = erythromycin derivatives, even IV
azithromycin
• Doxycycline not much better (even IV doxy)
J.J. Burrascano Jr. M.D.
TREATMENT
RECOMMENDATIONS
• The drug of choice to treat BLO is levofloxacin.
• Levofloxacin is usually never used for Lyme or
Babesia, so many patients who have tick-borne
diseases, and who have been treated for them but
remain ill, may in fact be infected with BLO.
• Treatment consist of 500 mg daily (may be adjusted
based on body weight) for at least one month.
• Treat for three months or longer in the more ill
patient.
• It has been suggested that levofloxacin may be more
effective in treating this infection if a proton pump
inhibitor is added in standard doses.
J.J. Burrascano Jr. M.D.
TREATMENT
RECOMMENDATIONS
• Another subtlety is that certain antibiotic
combinations seem to inhibit the action of
levofloxacin, while others seem to be neutral.
• I advise against using or combining with an
erythromycin-like drug, as clinically such
patients do poorly
• Combinations with cephalosporins &
penicillins are okay
• Alternatives to levofloxacin include possibly
gentamicin and possibly streptomycin
J.J. Burrascano Jr. M.D.
SIDE EFFECTS FQ
• Levofloxacin is generally well tolerated, with
almost no stomach upset
• It may cause a painful tendonitis, usually of
the largest tendons. 2/15 courses in this
series
• Very rarely, it can cause confusion- this may
be relieved by lowering the dose. 0/15
• Levofloxacin and drugs in this family cannot
be given to those under the age of 18, so
other alternatives, such as cephalosporins
are used in children
J.J. Burrascano Jr. M.D.
GESTATIONAL TRANSMISSION ?
Animal studies show that Bartonella
may be transmitted across the
placenta. No human studies have
been done.
J.J. Burrascano Jr. M.D.
THANK YOU !
J.J. Burrascano Jr. M.D.