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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

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1. J.J. Burrascano Jr. M.D. CASE HISTORIES: BARTONELLA-LIKE ORGANISMS JOSEPH J. BURRASCANO JR., M.D. East End Medical Associates, P.C. East Hampton, NY

2. 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?

3. 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

4. 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

5. 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

6. 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

7. 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

8. J.J. Burrascano Jr. M.D. Bartonella Rashes Red bumps- may form scabs

9. 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

10. J.J. Burrascano Jr. M.D. More Bartonella Back of legs

11. J.J. Burrascano Jr. M.D. Bartonella Lower back

12. J.J. Burrascano Jr. M.D. Bartonella Under the arm

13. 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

14. 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)

15. 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.

16. 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

17. 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

18. 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.

19. J.J. Burrascano Jr. M.D. THANK YOU !

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