LymeNet Europe

Gastrointestinal Lyme disease may cause gut paralysis and a wide range of diverse GI symptoms with the underlying etiology likewise missed by physicians. Borrelia burgdorferi, the microbial agent often behind unexplained GI symptoms—along with numerous other pathogens also contained in tick saliva—influences health and vitality of the gastrointestinal tract from oral cavity to anus. Disruptions caused by GI borreliosis (Lyme) may include, amongst many others, distortions of taste, failure of other neural functions that supply the entire GI tract—paralysis or partial paralysis of the tongue, gag reflex, esophagus, stomach and nearby organs, small and/or large intestines ("ileus"), bowel pseudo-obstruction, intestinal spasms, excitability of gut muscles, inflammation of lumen lining tissues, spirochetal hepatitis, possibly cholecystitis, dysbiosis, jejunal or ileal incompetence with resultant small intestine bacterial overgrowth (SIBO), megacolon, encopresis and rectal muscle cramping (proctalgia fugax).


NUTRICEUTICALS AND ANTIMICROBIALS TO RESTORE THE IMMUNE SYSTEM AND THE GI TRACT
Restoration of gastrointestinal systems damaged by tick-borne diseases can be a formidable task depending on the presentation and severity of symptoms, antimicrobial or other treatments involved, and any side effects thus incurred. The goals are to enhance gut motility or reduce spasticity, remove toxins, improve patients' general and gut-lining immunity while killing off invaders such as tick-borne microbes, fungi, and other gut opportunists (62,63).

Painful rectal area muscle spasms in Lyme patients usually respond to alprazolam (Xanax) 0.25 mg (1?2 to one tablet) best chewed for quick relief and Natural Calm, a formulary of instant release, water-soluble magnesium. Rectal cramps probably can be prevented most of the time by using the highest tolerated doses of daily magnesium—slow release is the recommended approach but many patients also need the quick-acting powder at bedtime to prevent all kinds of Lyme-caused muscle cramping or spasms.

Dietary intake of all sugars and non-complex carbohydrates should be totally avoided while patients take antibiotics. Probiotics—high quality lactobacillus (2 enteric-coated pearls) once or twice daily or more as needed and bifidus (at least one cap) once daily are essential for gut protection during and following antibiotic treatment. Immunity and energy enhancers such as extract from reishi mushrooms, Cordyceps sinensis (at least one 740 mg capsule daily), Co-Enzyme Q10 (100 mg twice daily), green tea, acetyl L-Carnitine (500 mg at least twice daily), Vitamin B Complex-50 to 100, folate, sublingual B12, magnesium (slow release tablets) taken to tolerance daily, gamma linolenic acid (GLA) as refrigerated Oil of Evening Primrose (1?2 tsp. daily) or borage oil (one 1,000 mg soft gel daily), Omega 3 EFA fish oil (one soft gel 3–4 times per day), selenium (200 mcg one cap daily), alpha lipoic acid (100 mg daily) and a comprehensive multivitamin (59)—all can be of great benefit

Healing agents will be needed to repair the gut lining and restore functions damaged by Lyme-Bartonella- Mycoplasma infections. That list may include oral preparations of liquid Aloe Vera, Oil of Clove drops, Uncaria spp., anti-fungal tannins, garlic, chewable licorice tabs, betaine, Enteric-coated Oil of Peppermint, Conjugated linoleic acid CLA) (1000 mg twice daily), a-lipoic acid (100 mg one daily), Slippery Elm demulcent capsules (325 mg 1–8 three times daily), and ursodiol bile acid tablets (64). Additionally, in the treatment of SIBO, complete stool analysis with culture and sensitivity of opportunistic bowel pathogens may elucidate the choice of antibiotic. Alternatively, a trial may be undertaken with rifaximin (Xifaxan) 200 mg three times a day until symptoms have cleared (60). Cholestyramine (Questran) may be useful in reducing the recycling neurotoxins produced by tick-borne diseases.

http://www.thehumansideoflyme.net/viewa ... 7ececc50ac

Gastrointestinal manifestations. Gastrointestinal signs and symptoms are common in the early stages of Lyme disease. In a study of 314 patients with early Lyme disease, the predominant clinical findings included anorexia (in 23% of patients), nausea (in 17%), vomiting (in 10%), abdominal pain (in 8%), right upper-quadrant tenderness (in 8%), hepatomegaly (in 5%), splenomegaly (in 6%), and diarrhea (in 2%) [1]. Approximately 10% of the patients had symptoms that were suggestive of hepatitis. Subclinical hepatitis occurred in 27% of patients during the early stages of disease, according to one study [2]. Abnormal liver function test (LFT) findings generally indicate mild hepatocellular injury. Patients with early disseminated Lyme disease are more likely to have abnormal LFT findings than are patients with localized disease [3]. The results of 3 different studies that evaluated abnormal LFT findings in patients with Lyme disease are compared in table 2. However, elevations in aspartate aminotransferase and alanine aminotransferase levels may indicate Lyme diseaseassociated myositis in some patients and may not be related to underlying hepatic injury

http://www.journals.uchicago.edu/CID/jo ... 49150Guest

Liver function in early Lyme disease
H W Horowitz, B Dworkin, G Forseter, R B Nadelman, C Connolly, B B Luciano, J Nowakowski, T A O'Brien, M Calmann, G P Wormser
Department of Medicine, Westchester County Medical Center, Valhalla, NY 10595, USA

Abstract
To evaluate the frequency, pattern, and severity of liver function test abnormalities in patients with Lyme disease associated with erythema migrans (EM), 115 individuals with no other identifiable cause for liver function test abnormalities who presented with EM between July 1990 and September 1993 were prospectively evaluated. For individuals with abnormal liver function tests, common causes of hepatitis, including hepatitis A, B, and C, were excluded. A local control group was used for comparison. Forty-six (40%) patients had at least one liver test abnormality, and 31 (27%) had more than 1 abnormality compared with 19 (19%) and 4 (4%) of controls, respectively (P < .01 for each comparison). -Glutamyl transpeptidase (28%) and alanine transaminase (ALT) (27%) were the most frequently elevated liver function tests among Lyme disease patients. Anorexia, nausea, or vomiting was reported by 30% of patients, but did not occur more frequently in patients with elevated liver function tests compared with those with normal values. Patients with early disseminated Lyme disease were more likely to have elevated liver function studies (66%) compared with patients with localized disease (34%) (P = .002). After antibiotic treatment, elevated liver function tests improved or resolved in most patients. Liver function test abnormalities are common in patients with EM but were mild, most often not associated with symptoms, and improved or resolved by 3 weeks after the onset of antibiotic therapy in most patients.

PMID: 8675158

Liver function test abnormalities in early Lyme disease.Kazakoff MA, Sinusas K, Macchia C.
Family Practice Residency Program, Middlesex Hospital, Middletown, Conn.

OBJECTIVE: Lyme disease is a widespread, tick-borne, spirochetal infection with multiple organ system involvement Hepatic dysfunction has not been emphasized in the literature. We report clinical findings and laboratory abnormalities in 73 patients with the pathognomonic erythema migrans rash early in the course of the illness. DESIGN: Case series. SETTING: Offices of family physicians in private practice and the model offices of a family practice residency program in the lower Connecticut River valley, an area to which Lyme disease is endemic. PATIENTS: Thirty-seven female and 36 male patients with erythema migrans who had not yet been treated with antimicrobial agents. MAIN OUTCOME MEASURE: Liver function tests. RESULTS: Twenty patients (27%) had liver function abnormalities. Elevation of gamma-glutamyltransferase was the most common finding. Only seven patients (9%) had a positive titer in response to the enzyme-linked immunosorbent assay for Lyme disease. Other laboratory and clinical findings are described. CONCLUSION: Subclinical hepatitis is a common finding in early Lyme disease.

PMID: 8130920

Hepatic disorders related to Lyme disease. Study of two cases and a review of the literature][Article in French]


Dadamessi I, Brazier F, Smaïl A, Delcenserie R, Dupas JL, Capron JP.
Service d'Hépato-Gastroentérologie, CHU, Hôpital Nord, Amiens. dadamessi@free.fr

We report two cases of Lyme disease, revealed by hepatic damage in a 71- and a 59-year old man. In the first case, the disease was revealed by febrile jaundice whereas, in the second case, results of liver tests showed cytolytic and cholestatic abnormalities with fever. Lyme disease is a zoonosis due to infection by Borrelia burdorferi transmitted by ticks. The multiple phases of the disease explain the polymorphism of the clinical manifestations. Usually, extrahepatic symptoms are first observed, including neurological tropisms of Borrelia burdorferi. On the contrary, hepatic impairment due to Lyme disease is rare, often asymptomatic and with biological manifestations only.

PMID: 11319444

THE SPECTRUM OF GASTROINTESTINAL MANIFESTATIONS IN LYME DISEASE
Fried, Martin D.; Abel, M; Pietruccha, D.; Bal, A.

Department of Pediatrics Jersey Shore Medical Center, Neptune, New Jersey

Abstract 24

Purpose: To describe the GI manifestations of Lyme

Methods: Twenty two consecutive patients between the ages of 8 and 20 years presented with a history of chronic gastrointestinal symptoms coupled with multiple organ system complaints. A clinical diagnosis of Lyme disease was made. Endoscopic evaluation was performed to assess the gastrointestinal mucosa and to obtain biopsies for polymerase chain reaction (PCR) to the outer surface protein A (Osp A) of Borrelia burgdorferi. As controls, ten patients with biopsy proven Crohn's disease were also tested by PCR. The laboratory performing the PCR analysis was blinded to the diagnosis of all specimens they received.

Results: The presence of Lyme disease in the gastrointestinal tract was confirmed by PCR for B. burgdorferi DNA in 14 of 20 patients with the diagnosis of Lyme and in two of the control subjects with Crohn's disease. Biopsy evidence of gastritis, duodenitis and colitis was found in Lyme patients and associated with the detection of B. burgdorferi in the GI tract.

Conclusion: In patients living in an endemic area for Lyme disease who present with abdominal pain, acid reflux, chronic diarrhea or blood in the stool, Lyme should be considered as part of the differential diagnosis. In the absence of an erythema migrans rash or blood test confirmation of Lyme, diagnosis can be provided by PCR analysis of gastrointestinal biopsies.

http://www.jpgn.org/pt/re/jpgn/fulltext ... 28!8091!-1

Lyme Disease and the GI Tract
Lyme disease generally does not affect the GI tract alone, according to Martin D. Fried, MD,[9] of the Jersey Shore Medical Center, Neptune, New Jersey. Rather, GI disease is typically only one component of a systemic disease. Patients with Lyme disease can present with a variety of GI symptoms, including abdominal pain, chronic diarrhea, acid reflux, or blood in the stool. Children may develop encopresis -- the loss of bowel training -- which may indicate a neurologic effect of the spirochete.
Evaluation of patients suspected of having Lyme disease includes the ever-important history, physical examination, CBC, liver function tests, and endoscopic examination. The Lyme WB is generally not helpful, but PCR testing of biopsy specimens for B burgdorferi OspA can be useful. Silver staining of biopsy specimens can reveal spirochetes. For those who test positive by PCR, RNA polymerase testing of the biopsy sample can indicate whether the spirochetes are actively multiplying.

The differential diagnosis includes the majority of gastrointestinal diseases, such as pancreatitis, stool infections, peptic ulcer, Crohn's disease, and inflammatory bowel disease. Skin tags are an indication that the patient has Crohn's rather than a complication of Lyme disease. Crohn's patients have a malabsorption syndrome and are therefore generally underweight. By contrast, those with GI Lyme disease often also have fatigue or arthritis, and the inactivity may make them overweight.

Treatment involves antibiotics, but regular follow-up is important to detect recurrences and lack of response. Dr. Fried has seen B burgdorferi persist in the GI tract despite multiple rounds of antibiotics over many years.

http://www.medscape.com/viewarticle/418440

Oystein Brorson Sverre-Henning Brorson

Susceptibility of motile and cystic forms of Borrelia burgdorferi
to ranitidine bismuth citrate

Abstract

Gastrointestinal symptoms accompanying
Lyme disease have not been considered in the treatment
of Lymepatients yet. Here we examine the effect of
ranitidine bismuth citrate(RBC) on motile and cystic
forms of Borrelia burgdorferi invitro, to determine
whether it could cure this bacterialinfection in the gastrointestinal
tract.

http://www.im.microbios.org/16december0 ... rorson.pdf

Acta Derm Venereol. 2007;87(5):418-21. Links
Early disseminated borreliosis with multiple erythema migrans and elevated liver enzymes: case report and literature review.Benedix F, Weide B, Broekaert S, Metzler G, Frick JS, Burgdorf WH, Röcken M, Schaller M.
Department of Dermatology, Eberhard Karls University Tübingen. frauke.benedix@med.uni-tuebingen.de

A 69-year-old man presented with multiple livid maculae and infiltrated urticarial plaques, as well as elevated liver enzymes. Based on typical clinical picture, histopathology and positive PCR from a skin biopsy, we diagnosed an early disseminated infection with Borrelia afzelii presenting with multiple erythema migrans (erythemata migrantia) and a subclinical hepatitis. During antibiotic treatment with intravenous ceftriaxone, the maculae and plaques vanished almost completely and the liver enzymes decreased within 14 days. Dermatologists should keep in mind that early disseminated borreliosis can present with multiple erythema migrans and hepatitis.

PMID: 17721649

An inefficient cellular immune response likely leads to
chronic hepatitis C virus (HCV) infection. Resolution
of chronic HCV infection in the absence of treatment
is a rare occurrence. We report the case of a 39-year
old white male with a 17-year history of chronic HCV
infection, who eradicated HCV following a serious illness
due to co-infection with Babesia (babesiosis), Borriela
Borgdorferi (Lyme disease) and Ehrlichia (human
granulocytic ehrlichiosis). We hypothesize that the
cellular immune response mounted by this patient in
response to his infection with all three agents but in
particular Babesia was sufficient to eradicate HCV.

CASE REPORT
This is the case of a 39-year-old white male with chronic
HCV infection likely acquired from a blood transfusion
during a splenectomy, following a motor vehicle accident
17 years ago. He had documented hepatitis C, genotype 1A
with a viral load of 772 000 IU/mL and two liver biopsies
five years apart, demonstrating mild fibrosis.
The patient was admitted to our institution following
a 4-wk history of fever, headache and profound malaise.
Laboratory values were as follows: 409 IU/mL AST,
89 IU/mL ALT, 46 000 white blood cells, and 21.2
hematocrit with visible target cells and schistocytes on
blood film. A blood smear revealed the presence of
intracellular erythrocytic inclusions with a corresponding
parasitemia level of 11.2%, consistent with babesiosis.
He was commenced on intravenous azithromycin and
atovaquone. Further work up also revealed a positive
EIA for Lyme disease, confirmed by Western blotting,
in addition to positive IgM antibodies to Ehrlichia.
Doxyclicine was added to the treatment regimen. The
patient was discharged from hospital seven days later with
a rising hematocrit and a parasite load of 0.4%.
Surprisingly, hepatitis C RNA was undetectable from the
serum sample taken two days following hospital admission.
The lower limit of detectable virus via quantitative
poylmerase chain reaction (PCR) technique at our institution
is 600 IU/mL. Repeat testing demonstrated normal ALT
and AST and a negative HCV RNA level via qualitative
PCR, which is sensitive to a level of virus greater than
100 IU/mL. The patient continued to have normal ALT
and AST and remained persistently HCV RNA negative
by qualitative PCR testing four years after his acute illness

DISCUSSION
Babesiosis is a tick-borne illness commonly seen in Europe
and the United States, caused by malaria-like parasites
that infect red blood cells and induce hemolysis. Infection
is transmitted to humans from cattle or rodents via the
Ixodid tick. This variety of tick also transmits Lyme disease
and ehrlichiosis and simultaneous infection with all three
pathogens can occur. We postulate that co-infection with
these pathogens caused CD4 cell proliferation and increased
production of endogenous interferon gamma (IFN ), which
proved sufficient for hepatitis C viral clearance. Spontaneous
clearance of acute HCV is dependent on a broad based
CD4+ and CD8+ T cell response, and it is likely that both
cytolytic and non-cytolytic mechanisms act to clear infected

. Non-cytolytic effector mechanisms include
production of cytokines such as IFN , which has been
shown to inhibit HCV replication in some but not all model
systems .

http://www.wjgnet.com/1007-9327/13/4268.pdf