Chronic coinfections in patients diagnosed with chronic Lyme

Topics with information and discussion about published studies related to Lyme disease and other tick-borne diseases.
edbo
Posts: 90
Joined: Sat 2 Feb 2013 21:48

Chronic coinfections in patients diagnosed with chronic Lyme

Post by edbo » Mon 16 Jun 2014 22:10

Am J Med. 2014 Jun 11. pii: S0002-9343(14)00476-8. doi: 10.1016/j.amjmed.2014.05.036. [Epub ahead of print]

Chronic coinfections in patients diagnosed with chronic Lyme disease: a systematic literature review.

Lantos PM1, Wormser GP2.

Abstract

PURPOSE:

The controversial diagnosis of chronic Lyme disease is often given to patients with prolonged, medically unexplained physical symptoms. Many such patients are also treated for chronic co-infections with Babesia, Anaplasma, or Bartonella in the absence of typical presentations, objective clinical findings, or laboratory confirmation of active infection. We have undertaken a systematic review of the literature to evaluate several aspects of this practice.

METHODS:

Five systematic literature searches were performed using Boolean operators and the PubMed search engine.

RESULTS:

The literature searches did not demonstrate convincing evidence of 1) chronic anaplasmosis infection, 2) treatment responsive symptomatic chronic babesiosis in immunocompetent persons in the absence of fever, laboratory abnormalities and detectable parasitemia, 3) either geographically widespread or treatment responsive symptomatic chronic infection with Babesia duncani in the absence of fever, laboratory abnormalities and detectable parasitemia, 4) tick-borne transmission of Bartonella species, or 5) simultaneous Lyme disease and Bartonella infection.

CONCLUSIONS:

The medical literature does not support the diagnosis of chronic, atypical tick-borne coinfections in patients with chronic, nonspecific illnesses.

duncan
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Re: Chronic coinfections in patients diagnosed with chronic

Post by duncan » Mon 16 Jun 2014 22:55

Lantos and Wormser again? Aren't they retired or something yet?

Has the IDSA been reduced to a one horse town? Where is the new blood? I would welcome some new evangelists from the IDSA, and new talking points that actually pivot around new studies and meaningful findings - some that actually may carry relevance to patients. The recent puzzling crop of inexplicable "literature reviews", that sprout indiscriminately from time to time, to me seem little more than one wasted exercise after another in circling the wagons, and are quite frankly embarrassing imo.

velvetmagnetta
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Re: Chronic coinfections in patients diagnosed with chronic

Post by velvetmagnetta » Tue 17 Jun 2014 6:31

Way to put the work in, Wormser!

Wow. How much do they pay you to "evaluate" minus the "value"? I think I could actually get off disability and do that job!

Henry
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Joined: Thu 10 Nov 2011 18:49

Re: Chronic coinfections in patients diagnosed with chronic

Post by Henry » Tue 17 Jun 2014 18:08

Richard Horowitz has written a book entitled, " Why Can't I Get Better? Solving the Mystery of Lyme Disease and Chronic Disease". In that book and elsewhere, he has re-defined Lyme disease as a multiple systemic infectious disease syndrome (MSIDS) involving several co-infections, including those noted by Lantos and Wormser. The cited publication of Lantos and Wormser is significant in that it shows, after an extensive search of the peer-reviewed scientific literature, that there is no evidence to support such an unfounded view. If Lantos and Wormser are wrong, I challenge you to provide such evidence. You certainly are entitled to your own opinions -- but not to your own "facts". How many patients have been victimized by remedies based on these unproven concepts? Where are the results of controlled clinical studies showing that they are beneficial and safe?

duncan
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Joined: Wed 5 Sep 2012 18:48

Re: Chronic coinfections in patients diagnosed with chronic

Post by duncan » Tue 17 Jun 2014 18:21

Henry, who in the world are you writing in response to?

If it's to me, then please slow down and explain what you are talking about regarding "facts" vs opinion, and how your diatribe directly relates to what I wrote.

While you are at it, are you suggesting the Lantos/Wormser exercise was little more than a knee-jerk reaction to Horowitz? Really?? That pair doesn't have anything better to do than try to smear a book?

Regardless, to me it still has the sad feel of another vain attempt at circling the wagons...:)

hv808ct
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Re: Chronic coinfections in patients diagnosed with chronic

Post by hv808ct » Tue 17 Jun 2014 18:25

Excerpts from:
Chronic coinfections in patients diagnosed with chronic Lyme disease: a systematic literature review. Lantos PM, Wormser GP. Am J Med. 2014 Jun 11.

While many aspects of Lyme disease are well accepted by the mainstream medical community, considerable controversy surrounds “chronic Lyme disease”, an ill-defined diagnosis that some clinicians give to patients with alternative diagnoses or medically unexplained symptom complexes. In many instances these patients are also diagnosed with chronic co-infection with Anaplasma, Babesia, or Bartonella. In the context of chronic Lyme disease these pathogens are often diagnosed in the absence of typical presentations or objective clinical findings, and without laboratory confirmation.

In this systematic review we address several major questions relevant to the diagnosis of co-infections in patients with a diagnosis of chronic Lyme disease. These questions are the following:

1) Is there evidence of persistent human granulocytic anaplasmosis (HGA)?
2) How is relapsing or persisting babesiosis identified and diagnosed?
3) Has chronic Babesia duncani infection been described?
4) Is there convincing evidence for tick-borne human Bartonella infection?
5) Is there convincing evidence for simultaneous Lyme disease and Bartonella infection?

Case reports, case series, and primary scientific studies were selected from among the search results. Review articles, correspondence, and editorials were excluded. We limited our search to studies with human subjects. This was done by manually reviewing the papers and excluding those in which the subjects were non-human (rather than adding a search function limit to the PubMed query). Because Anaplasma phagocytophilum was formerly categorized as Ehrlichia, we included Ehrlichia and ehrlichiosis in the search terms for this query.

There is no debate in the scientific community that Ixodes spp. ticks transmit a number of important human pathogens, and sometimes in combination. In addition to B. burgdorferi, the causative agent of Lyme disease, Ixodes ticks may transmit B. microti and other human Babesia species, A. phagocytophilum, tick-borne encephalitis virus, Powassan virus, and emerging pathogens such as Borrelia miyamotoi. These infections may occur in isolation or in various combinations, and it is well-established that co-infections have important clinical, diagnostic, and therapeutic implications. Active infection is characterized by objective clinical findings (e.g., fever or laboratory abnormalities). Practitioners who frequently offer the diagnosis of chronic Lyme disease often do not rely on more accepted standards of clinical and laboratory testing. In such circumstances many patients also receive spurious diagnoses of chronic anaplasmosis, babesiosis, and bartonellosis.

We have performed a systematic review of the medical literature in order to evaluate whether published science supports chronic, cryptic infections with these pathogens. Because of basic biological, clinical, and epidemiologic differences among HGA, babesiosis, and bartonellosis different search terms were required for each pathogen.

Our search did not yield any reports of chronic, relapsing, or refractory HGA in humans. Persistent infection in domestic and wild ruminants, and persistent veterinary infections with related microorganisms (e.g., A. marginale) cannot be assumed to predict the plausibility of chronic HGA in humans. To date there is no basis upon which to diagnose a human patient with chronic HGA.

Persistent babesiosis produces the same clinical and laboratory abnormalities that are seen in acute babesiosis, and patients remain both PCR and blood smear positive. In fact, immunocompromised patients who are at risk of persistent or recurrent babesiosis often have higher parasitemias and generally more severe disease. This is the only group of patients for whom there is evidence that a course of anti-babesia drug therapy that exceeds 10 days duration is beneficial. We found no evidence that active babesiosis, as demonstrated by a positive PCR or blood smear, produces purely subjective complaints (e.g., fatigue, pain, cognitive symptoms) that are unaccompanied by fever or by laboratory abnormalities.

Unlike HGA and babesiosis, which in nature are exclusively transmitted to humans by Ixodes spp. ticks, we have found no convincing evidence that this is a natural or even plausible mode of transmission for Bartonella spp. Our search yielded no case in which tick-borne bartonellosis was unequivocally established. Not only is tick-borne human bartonellosis unfounded to date, but there is very little literature to support Lyme disease-Bartonella coinfection at all, regardless of the means of acquisition.

The putative association between ticks, Lyme disease, and B. henselae infection is ultimately derived from two problematic sources of data. The first is a limited number reports of mostly European subjects in whom clinical infection with B. henselae and B. quintana has been temporally associated with a tick bite. The second source of data is the observation that many tick specimens contain Bartonella DNA when subjected to PCR analysis. This has been demonstrated primarily in the Eurasian ticks I. ricinus and I. persculatus and to a lesser degree in the North American tick I. scapularis. Nonetheless, it should come as no surprise that ticks would contain Bartonella DNA – ticks feed on a variety of mammalian hosts that may be reservoirs for Bartonella spp. The presence of Bartonella DNA in the tick does not prove that the tick is a competent vector for transmission to a second mammalian host. Vector competence of I. scapularis ticks for B. henselae has never been demonstrated in an animal system.

The medical literature does not support the diagnosis of chronic, atypical tick-borne coinfections in patients with chronic, nonspecific illnesses.


Lifted from rel-risk.blogspot.com

duncan
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Re: Chronic coinfections in patients diagnosed with chronic

Post by duncan » Tue 17 Jun 2014 18:48

"The medical literature does not support the diagnosis of chronic atypical tick-borne coinfections in patients with chronic nonspecific illnesses."

Is it safe for me to assume "The medical literature" is speaking to historical literature? As in, in the past? Perhaps it wouldn't be a stretch to suggest these leading Lyme experts' time might be better spent by exploring new TBD frontiers? As in, emerging circumstances or new pathogens. Or, alternatively, I don't know, launching a study to either prove or disprove the new book's hypotheses? I may be wrong, but isn't that what scientists and researchers are supposed to be doing - practicing Science, as opposed to (if I am understanding Henry correctly) penning thinly veiled book reviews?

Besides, does the IDSA even believe in "chronic nonspecific illnesses" or is that the same ole spin that we've all come to know and love as the IDSA's label for chronic Lyme? Like I said, circling the wagons.

Margherita
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Re: Chronic coinfections in patients diagnosed with chronic

Post by Margherita » Tue 17 Jun 2014 19:13

An example:
Detection of Microbial Agents in Ticks Collected from Migratory Birds in Central Italy

TomaLuciano, ManciniFabiola, Di LucaMarco, CecereJacopo G., BianchiRiccardo, KhouryCristina, QuarchioniElisa, ManziaFrancesca, RezzaGiovanni, and CiervoAlessandra.

27 February 2014

1Department of Infectious, Parasitic and Immuno-mediated Diseases, Istituto Superiore di Sanità, Rome, Italy.
2Ricerca Fauna, Rome, Italy.
3National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy.
4Centro di Recupero per la Fauna Selvatica–LIPU, Rome, Italy.
6Present address: Institute for Environmental Protection and Research (ISPRA), Via Cà Fornacetta 9, 400064 Ozzano dell'Emilia, Italy.

Abstract

Tick species characterization and molecular studies were performed within ornithological surveys conducted during 2010 and 2011 in the Lazio Region of central Italy. A total of 137 ticks were collected from 41 migratory birds belonging to 17 species (four partial migrants and 13 long-distance migrants). Most ticks were nymphs, with a predominance of Hyalomma marginatum marginatum and H. m. rufipes, and a small portion of Ixodes and Amblyomma species. All tick species analyzed were infected, and the molecular pathogen recognition revealed the presence of Rickettsia aeschlimannii, Rickettsia africae, Erlichia spp., Coxiella burnetii, Borrelia burgdorferi sensu lato group, and Babesia microti, whereas no genomic DNA of Bartonella spp. or Francisella tularensis was detected. The results of the survey show that H. marginatum ticks appear to be a vector of microbial agents that may affect human and animal health and that migratory birds may be an important carrier of these ticks. Additional studies are needed to better investigate the role of migratory birds in the epidemiology of these pathogens.
Source: http://www.ncbi.nlm.nih.gov/pubmed/24576218

How can there be any medical literature supporting the existence of atypical tickborn co-infections in humans as till now practically no doctor/physician is testing his patients for it!? (After all, it's not recommended in the guidelines!)

Henry
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Joined: Thu 10 Nov 2011 18:49

Re: Chronic coinfections in patients diagnosed with chronic

Post by Henry » Tue 17 Jun 2014 20:39

Duncan: You misunderstand. It is NOT about Horowitz's book, but about a view (i.e., that chronic Lyme disease is the result of multiple co-infections) that is accepted by some without close scrutiny and with no evidence whatsoever. Here is a sample of what Horowitz and others have been saying: http://www.ilads.org/media/slides/slides_horowitz.php
How is it ethical to treat a patient based on such an unproven model of disease? That's the main point.

duncan
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Joined: Wed 5 Sep 2012 18:48

Re: Chronic coinfections in patients diagnosed with chronic

Post by duncan » Tue 17 Jun 2014 21:02

Henry, I feel no special affinity for ILADS, just so you know. They get some things right, and imo they get some things wrong.

If anybody is keeping count, the same can be said for how I perceive the IDSA.

Ultimately what I address here and in other places are what I think are injustices committed against the patient community. The reason I am more frequently responding to something said or done by the IDSA is because its damage is more pervasive in my opinion because its reach is so great within the community of clinicians. It may boil down to degree and immediacy.

However, as to your point about the need for scrutiny and supportive evidence in TBD research or claims: You will get no argument from me.

Where I suspect we may part paths from time to time is in definitions, the real impact of conflicts of interest, and the prioritization of the role and perspective of patients. There may be other areas of disagreement, but acknowledging the need for sound research that is followed by sound interpretation (unfettered by bias or legacy or mercenary concerns) is not one of them.

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