BARTONELLA-LIKE ORGANISMS by 5i2tCzcD

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									    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
•   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.

								
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