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CASE HISTORIES: BARTONELLA-LIKE ORGANISMS. JOSEPH J. BURRASCANO JR., M.D. East End Medical Associates, P.C. East Hampton, NY. BARTONELLA. Is the most common of all tick-borne pathogens Fairly distinct clinical syndrome

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Case histories bartonella like organisms l.jpg

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.


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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.


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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.


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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.


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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.


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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.


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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.


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Bartonella Rashes

Red bumps- may form scabs

J.J. Burrascano Jr. M.D.


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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.


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More Bartonella

Back of legs

J.J. Burrascano Jr. M.D.


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Bartonella

Lower back

J.J. Burrascano Jr. M.D.


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Bartonella

Under the arm

J.J. Burrascano Jr. M.D.


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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.


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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.


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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.


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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.


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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.


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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.


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THANK YOU !

J.J. Burrascano Jr. M.D.


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