SPECT Brain Imaging in Chronic Lyme Disease.

Topics with information and discussion about published studies related to Lyme disease and other tick-borne diseases.
X-member
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SPECT Brain Imaging in Chronic Lyme Disease.

Postby X-member » Wed 15 Aug 2012 19:19

http://www.ncbi.nlm.nih.gov/pubmed/22889796

Clin Nucl Med. 2012 Sep;37(9):e219-22.

SPECT Brain Imaging in Chronic Lyme Disease.

Donta ST, Noto RB, Vento JA.


Source

From the *Department of Medicine (Infectious Diseases), Boston University Medical Center, Boston, MA; †Department of Diagnostic Imaging (Nuclear Medicine), Rhode Island Hospital, and The Warren Alpert Medical School of Brown University, Providence, RI; and ‡Department of Diagnostic Imaging and Therapeutics (Nuclear Medicine), University of Connecticut School of Medicine, Farmington, CT.


Abstract

OBJECTIVES:

Lyme disease is an infectious disease that frequently involves the central nervous system, leading to cognitive and/or mood dysfunction. The basis for these symptoms remains to be defined but may be the result of a vasculitis or metabolic abnormality secondary to the infection. SPECT scans of the brain might provide an objective measure of abnormalities present in patients with otherwise difficult to objectify clinical findings. The objective of this study was to determine the frequency, location, and severity of abnormalities in SPECT scans of the brain of patients with chronic Lyme disease.

METHODS:

A total of 183 individuals who met the clinical definition of chronic Lyme disease underwent SPECT scanning of the brain using Tc and standard nuclear imagine techniques. Abnormalities of perfusion to affected areas of the brain were defined as mild, moderate, or severe.

RESULTS:

Of all patients, 75% demonstrated abnormalities in perfusion to various areas of the brain, most notably the frontal, temporal, and parietal lobes. Patients considered to be seropositive and those considered seronegative had similar rates, types, and severity of perfusion defects. Abnormalities of MRI of the brain were seen in 14% of patients. Treatment with antibiotics, especially those with intracellular-penetrating activity, resulted in resolution or improvement of abnormalities in 70% of patients over a 1- to 2-year period.

CONCLUSIONS:

Brain SPECT scans are abnormal in most patients with chronic Lyme disease, and these scans can be used to provide objective evidence in support of the clinical diagnosis. The use of certain antibiotic regimens seems to provide improvement in both clinical status and SPECT scans.



Explanation of the word perfusion (from Wikipedia):

http://en.wikipedia.org/wiki/Perfusion

RitaA
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby RitaA » Wed 15 Aug 2012 20:09

Thanks for posting this very interesting abstract, Carina.

While SPECT scans may provide valuable information, they are rarely (if ever) ordered for Lyme disease patients in Canada.

If I'm understanding this correctly, a PET scan (usually reserved for research purposes in Canada) might provide additional data for Lyme disease patients:

http://neuro.psychiatryonline.org/artic ... eid=103251

WINDOWS TO THE BRAIN | December 01, 2008

Acute and Chronic Lyme Disease: Controversies for Neuropsychiatry

Robin A. Hurley; Katherine H. Taber
The Journal of Neuropsychiatry and Clinical Neurosciences 2008;20:iv-6.

[snip]

As is true in other conditions, functional imaging may show abnormalities not apparent on structural imaging. A recent retrospective study of patients with neurological symptoms attributed to Lyme disease found that 83% (19/23) had areas of mild-moderate hypometabolism on FDG-PET scans obtained either just prior to or just after commencement of antibiotic therapy.20 The most common location was the temporal lobe (17/23) in one (5/17) or both (12/17) hemispheres. Hypometabolism in frontal and/or parietal cortex and/or subcortical areas was also present in some cases. The authors noted that they found no correlation between any specific metabolic pattern and age, duration of illness, prior treatment, or current medications. Follow-up PET scans obtained in three patients were congruent with clinical state: one patient had no significant changes in either symptoms or PET scan; two patients had a worsening of symptoms and greater areas of abnormality in their PET scans. Previous SPECT scans were available for nine patients. One was normal, as was the PET scan. Diffuse cortical hypoperfusion was present on the other eight SPECT scans. The PET findings were quite divergent in these cases: three were normal, three had bitemporal hypometabolism, one had hypometabolism only in the basal ganglia, and one had global hypometabolism. Thus, PET (cerebral metabolism) and SPECT (cerebral blood flow) did not provide identical information.

[snip]


Claudia
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby Claudia » Wed 15 Aug 2012 20:53

The Yale Medical School neurologist that diagnosed my son with late-stage CNS Lyme disease ordered an MRI, PET scan, and SPECT scan when doing all the testing and work ups as part of his initial evaluation for suspected Lyme disease.

This is my understanding of the purpose for the different imagings:

MRI for abnormalities in brain structure

PET scan for abnormalities in brain metabolism

SPECT scan for abnormalities of blood flow in the brain

Firstly they are helpful in ruling in or out other possible neurological and some purely psychiatric conditions not related to Lyme disease infection, then secondly as supporting a Lyme disease diagnosis with findings of abnormalities being consistent with an acquired organic infection.

RitaA
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby RitaA » Wed 15 Aug 2012 21:41

Claudia,

Thanks very much for that summary -- which is consistent with the detailed information provided here:

http://www.columbia-lyme.org/patients/l ... fluid.html

Canadian doctors are generally not as liberal in ordering expensive tests as their U.S. colleagues -- sometimes to the detriment of their patients. That's one of the reasons that Canadians who can afford to do so will travel to the U.S. or Europe for medical care.

My former family physician resident told me that her training emphasized limiting the number of tests that doctors order, as well as keeping the number of referrals to specialists to an absolute minimum. I think she was feeling a bit disillusioned when she told me that, and it's entirely possible that she was just venting that day. On the other hand, my sister heard the very same thing from her very experienced primary care physician (in another city) just last week.

Rita

p.s. I did have a SPECT scan ordered many years ago, but that -- along with other abnormal test results -- did not result in my Lyme disease diagnosis. It took many more years before a specialist in Infectious Diseases put all the puzzle pieces together.

RitaA
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby RitaA » Wed 15 Aug 2012 23:08

Claudia wrote:The Yale Medical School neurologist that diagnosed my son with late-stage CNS Lyme disease ordered an MRI, PET scan, and SPECT scan when doing all the testing and work ups as part of his initial evaluation for suspected Lyme disease.


Claudia,

I hope I'm not getting too far off topic, but has the same neurologist been following your son's medical progress over the years? What explanation (if any) did s/he provide when your son relapsed (more than once, if memory serves me correctly) after discontinuing his antibiotic treatment?

I'm just wondering how conservative physicians/researchers explain the gap between a person responding very favourably to antibiotic treatment, but then developing post-treatment Lyme disease months later -- and especially more than once. I apologize if you've already written about this elsewhere, Claudia.

Rita

Claudia
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby Claudia » Thu 16 Aug 2012 1:37

Yes, he has seen the same neurologist over the years. The neurologist believes (as in it is his opinion) that my son's chronic illness is a combination of both Bb persistence and autoimmunity factors, most likely based on a genetic predisposition.

In a nutshell, he thinks that my son's illness can go one of two ways in the future:

1) He will have a chronic life-long illness that will require going back on antibiotics when he needs them, and going off when he can. Patients like him, that have had a very positive response to antibiotics, tend to respond favorably again with retreatment(s) if it becomes necessary.

We have also discussed the anti-inflammatory and neuroprotective properties of antibiotics.

2) He will eventually, slowly, get better and better over time without the need for further retreatment.

Along the lines of what Carina had posted on other threads "After discontinuation of treatment, there are 3 options':

Carina wrote:From Denmark, Daninfekt:

http://daninfekt.dk/news.php?readmore=21

Efter ophør med behandling er der 3 muligheder:

1. fastholdt bedring uden yderligere flares - gælder typisk folk med kort sygdomsvarighed (maks. 1-2 år) før beh. - god prognose på længere sigt!

2. månedlige flares, hvor bedring imellem flares dog når ned på samme niveau imellem flares; pt. oplever kun fortsat stigende symptomer under særlig stress / immunhæmning, flare aktivitet kan fortsætte i årevis - sårbar situation - en del vil senere opleve tilbagefald => behov for opfølgning / navlesnor til kontaktlæge ved behov, så begyndende tilbagefald kan standses i opløbet!

3. hurtigt tilbagefald med gradvis stigende symptomniveau efter ophør med antibiotika, dvs. pt. "bombes tilbage" til før behandlingsniveau i løbet af ca. 3 måneder; der er typisk nogenlunde samme gode effekt af genbehandling med antibiotika; blandings-infektion(er) / additive faktorer (immunhæmning? hormonelle forandringer? andet?) må mistænkes; dårlig prognose uden behandling!


Not a perfect translation (with google translate and me):


After discontinuation of treatment, there are 3 options:

1: Maintained improvement without further flares - typically applies to people with short disease duration (max. 1-2 years) before treatment. - Good prognosis in the long run!

2: Monthly flares, where recovery between flares, then reaches the same level between flares; patient experiencing only continue increasing symptoms with particular stress / immune suppression, flare activity may continue for years - fragile - some would later experience relapse => need for follow up / “safety net”= be able to contact a doctor when needed, so incipient relapse can be stopped early.

3: Quickly relapse with gradually increasing symptom levels after discontinuation of antibiotics, ie. patient. "bombed back" to pre-treatment levels within approx. 3 months, there are typically the same good effects of retreatment with antibiotics; mixed infection (s) / additive factors (Immune suppression? Hormonal disturbances? Else?) Must be suspected; poor prognosis without treatment!

Claudia
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Location: Connecticut, USA

Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby Claudia » Thu 16 Aug 2012 1:58

This is a bit off topic, but has some bearing on that, about the "conservative physicians/researchers," this is about a conversation that I had about 5 years ago, and posted about on LNE 4 years ago, and has popped into my head now again, and I want to bring it up here.

Claudia wrote:
Fri 29 Aug 2008 9:21
(from viewtopic.php?f=8&t=1708&start=10)

o2bdead wrote:

I would like to see one long-term chronic Lymie who has gone into remission untreated. Can you point me to even one? Even a second-hand story of one would be okay.


o2bdead, here's two:

from The New York Times, June 17, 2001

Stalking Dr. Steere Over Lyme Disease
By DAVID GRANN

... In the late 1970's, as Steere's team fanned out along the Connecticut River, about 50 miles away in Westport, Conn., my 11-year-old sister woke up with tingling in her joints. My father, a cancer specialist, thought she had some sort of flu, but 24 hours later she couldn't walk. As my mother and I looked on, my father carried her out to the car and took her to Stamford Hospital. When he returned with her several hours later in a wheelchair, I could hear him talking to my mother in hushed voices in the bedroom. The next day, he took her to a specialist at Yale, who said that despite negative tests, she probably had an acute form of juvenile rheumatoid arthritis and might die. He recommended that my father admit her to the hospital and treat her with high dosages of steroids. But still unsure why her tests were negative, my father decided to wait. That night, he searched his medical books, trying to find out what she had. I could see him in the study, hunched over his desk, folding the pages in half. Medicine, he always believed, was like a language: each disease has its own meaning. But what was a disease that had no name?

[SNIP]

... When my father stumbled upon his findings in the Annals of Internal Medicine in 1977, my sister's disease had already subsided on its own, as it would in many, but her affliction now had a name -- Lyme," after the town in Connecticut in which it was discovered.

http://www.nytimes.com/2001/06/17/magaz ... 1220155200


Last year I was hiking on some local trails here in Connecticut with my dog and met a woman also out hiking along with her two dogs. As we hiked and began talking, I mentioned that my son and dog both had chronic Lyme infections. She listened to me and later into the conversation she told me she was one of the original Old Lyme patients that the Steere/Yale team studied back in the 1970's and she was coming up on the thirtieth anniversary of it all.

Here's what she told me:

She was six years old at the time that she became infected -- her family spent summer vacations camping at the beach camping grounds in Old Lyme. That summer she had a massive circular rash and became unable to move from terrible back, hip and knee pain. At its worse, her father had to carry her, she couldn't move. She had to start first grade on crutches. She was placed in the antibiotic placebo group in the study. She went on to fully recover within several weeks and has been followed up with yearly by Yale, tested each year with blood work. She still tests "highly positive." She has continually refused the antibiotics she has been offered each time based on each year's positive test. Mainly because she feels no need for them because overall she feels fine.

She said that Dr. Steere told her that "you never totally get rid of the infection," even with antibiotics.

What she told me is that she occasionally feels "Lymie" over the years, "you can just tell" she said "when it's the Lyme," this happens when she is really stressed, not sleeping well, and her immune system is further compromised from being sick from a bad flu or virus. She told me that the worse relapse she had was while away at college when she was over-tired from not getting enough sleep, stressed with class work during finals, and caught a bad stomach illness/flu that was making a lot of people ill in her dorm, including her roommate. She left her college campus in Colorado, returned home to Connecticut and saw Dr. Steere, who had left New Haven/Yale and was in Boston. He wanted to put her on IV antibiotics, but she refused it because she wanted to get back to college and didn't want to be hooked up to an IV line at college. She eventually returned to feeling well again.

When I had this interesting chance meeting with her she was 36 years old, had a successful professional career, commuting into NYC for her job, and had even bought her own home as a single woman. She had recently become engaged to be married. Her only fear was passing the infection on to any children they may have, based on the fact that she continues to test positive for an active infection.

She was orginally acutely ill with Lyme disease, never took any antibiotics, and in her case it resolved on it's own with only one major relapse in 30 years and several minor relapses.

Did the children in these two examples of untreated, long-term remission have just Bb and no other complicating TBI's? Is there something different about their immune systems? Their genetics? Will they eventually become chronically ill down the road?

RitaA
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby RitaA » Thu 16 Aug 2012 2:49

Claudia,

Thank you SO much for posting all of this. I really do appreciate it.

Here's wishing you and your son all the best.

Rita A

Lorima
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby Lorima » Fri 17 Aug 2012 14:32

Thanks, Claudia, that's really interesting. (And thanks, Rita, for all you do here.)

I assume that many people reach an equilibrium with the spirochete. This is how Steere reached his initial judgment that LD was "mild and self-limiting". I recently read in some respectable journal article that "7-25%" of people in Germany, depending on region, are seropositive for Bb (sensu lato, I presume). Obviously not all of them feel sick all the time, and it seems likely that some of them have had symptoms but recovered, probably multiple times. I think that's probably the situation in the US northeast and upper midwest, too. Presumably the percentage is lower in the regions that are said to be "low risk", but it's certainly very patchy, so it's inappropriate to generalize from small studies.

There's nothing unusual about this; most infections cause a range of signs and symptoms, from none at all, to death. For example, polio, tuberculosis, typhoid, influenza, etc.

I especially like the hiker's comment that "you can just tell when it's the Lyme". Many (most?) people have symptoms that, while not "provable" to a skeptical doctor (or family member, for that matter), are distinctive and identifiable to the patient.

To state the obvious implication, it's then a personal decision, or should be, whether to retreat, or watch and wait. The severity of the symptoms is a big factor, because when they are severe, they are disabling, and most people can't put their responsibilities on hold, while they rest. For instance, a person might decide to live with mild joint pain, but decide to treat for memory loss or disabling fatigue. I'm a fan of oral combination antibiotics, for my friends and family, but I can see how a person who is facing frank dementia, or crippling pain, would want the IV option. Fortunately, none of the patients to whom I'm close enough to help, are now in that situation.

Best wishes for you and yours,
Lorima
"I have to understand the world, you see."
Richard Feynman

RitaA
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Re: SPECT Brain Imaging in Chronic Lyme Disease.

Postby RitaA » Tue 21 Aug 2012 7:47

Here's some feedback from the author of "Relative Risk", enclosed in "[ ... ]" for the most part:

http://relative-risk.blogspot.com/2012/ ... oples.html

20 AUGUST 2012

Sam Donta- Undeterred by Other People’s Facts

Notes From:
SPECT Brain Imaging in Chronic Lyme Disease. Donta ST, Noto RB, Vento JA. Clin Nucl Med. 2012 Sep;37(9):e219-22.

Patients were considered to have chronic Lyme disease if they lived or were exposed to deer ticks in an endemic area for Lyme disease and had symptoms (2/3) of otherwise unexplained fatigue, musculoskeletal pain, and/or neurocognitive dysfunction persisting for more than 6 months, a definition similar to that of chronic fatigue syndrome.
[In other words, there’s no definition of chronic Lyme so who knows what these patients had.]

Patients given the diagnosis of chronic fatigue syndrome or fibromyalgia were not excluded from the analyses. All patients included in the study had serologic testing. Patients who had one or more reactions against proteins highly-specific for B. burgdorferi on Western immunoblots were considered seropositive patients (110 patients, 60%), and those without any such reactions were considered seronegative patients (73 patients, 40%) [Donta ref].

No statistical tests were used because interpretations of these scans were deemed to be qualitative. Scans were generally repeated at 1-year intervals, and correlations were made with the patient’s clinical status.

Most patients were treated with courses of intracellular-penetrating antibiotics, either tetracycline itself, 1500 mg/d, or the combination of clarithromycin (1000 mg/d) and hydroxychloroquine (400 mg/d) over at least a 3-month period, usually 6 monthsVa regimen that seems to result in resolution of sustainable improvement in patient symptoms.
[2 Donta refs and still ignoring the fact that B. burgdorferi is not an intracellular pathogen].

Whether the symptoms and/or the changes in the SPECT scans of the brain seen in patients with chronic Lyme disease are secondary to the effects of a neurotoxin found in B. burgdorferi [Donta ref] or due to other nonspecific effects remains to be determined.
[Again, ignoring the fact that B. burgdorferi does not produce any toxins].

The abnormalities seen on SPECT scan are not specific for Lyme disease.
[A lot of verbiage to get to one useful fact.]

Now here’s what some real neurologists and I.D. people have to say about SPECT and Lyme:

Single photon emission computed tomographic (SPECT) scans are often abnormal in patients with LD, but no pattern is specific for LD and these scans are often abnormal in patients without LD (Kalina et al, 2005; Halperin, 2008). Halperin (2010) stated that SPECT brain scans have been used with increasing frequency. In one study, quantitative SPECT, applied in a highly selected group of patients with well-characterized nervous system LD, showed patchy brain hypo-metabolism. However, qualitative brain SPECT, the technique used in clinical laboratories, is highly variable even in normal patients, and has no positive or negative predictive value in nervous system LD.

Well, at least he’s been consistent in his beliefs over the 15 years or so since I first met him.


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