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

J.J. Burrascano Jr. M.D.

CASE HISTORIES:CASE HISTORIES:

BARTONELLA-LIKE ORGANISMSBARTONELLA-LIKE ORGANISMS

JOSEPH J. BURRASCANO JR., M.D.JOSEPH J. BURRASCANO JR., M.D.

East End Medical Associates, P.C.East End Medical Associates, P.C.

East Hampton, NYEast Hampton, NY


BARTONELLABARTONELLA

• Is the most common of all tick-borne Is the most common of all tick-borne pathogens pathogens

• Fairly distinct clinical syndrome Fairly distinct clinical syndrome

• This tick-associated strain of Bartonella This tick-associated strain of Bartonella appears to be different from that appears to be different from that described as “cat scratch disease”described as “cat scratch disease”


BARTONELLA-LIKE ORGANISM BARTONELLA-LIKE ORGANISM (“BLO”)(“BLO”)

Predominantly neurologic disease, and less Predominantly neurologic disease, and less vascular manifestations.vascular manifestations.

Standard Bartonella blood testing is Standard Bartonella blood testing is commonly non-reactive. commonly non-reactive.

The usual Bartonella medications do not The usual Bartonella medications do not work for this work for this

For these reasons I like to refer to this as a For these reasons I like to refer to this as a “Bartonella-like organism” (BLO) “Bartonella-like organism” (BLO)

One day BLO may be identified to be an One day BLO may be identified to be an altogether different organism altogether different organism


CASE HISTORIES CASE HISTORIES

• 13 consecutive patients13 consecutive patients• All were PCR + for Bartonella All were PCR + for Bartonella • Age 33-75, median 48 Age 33-75, median 48 • 4/13 bite, 5/13 EM. None with both4/13 bite, 5/13 EM. None with both• 5 males, 8 females5 males, 8 females• Ill before Diagnosis: Ill before Diagnosis: – 60 d (one patient) 60 d (one patient) – 2-32 yrs 2-32 yrs – median 10 yrsmedian 10 yrs


CASE HISTORIESCASE HISTORIES

• Lyme- 12 sero +, 5 PCR + (all were also Lyme- 12 sero +, 5 PCR + (all were also sero +) One with EM was sero & PCR sero +) One with EM was sero & PCR negative for Lyme!negative for Lyme!

• Babes- 9 positive- 3 sero + , 3 PCR +, 3 Babes- 9 positive- 3 sero + , 3 PCR +, 3 FISH +, 3 Bowen smear + ( 2 sero & FISH +, 3 Bowen smear + ( 2 sero & PCR +; one FISH & Bowen +) PCR +; one FISH & Bowen +)

• Ehrl/Anapl- noneEhrl/Anapl- none

• Others- MF-3; Chl- 2; CMV-2; HHV-6- 1Others- MF-3; Chl- 2; CMV-2; HHV-6- 1


INDICATORS OF BLO INDICATORS OF BLO

• CNS symptoms out of proportion to the CNS symptoms out of proportion to the other systemic symptoms of chronic other systemic symptoms of chronic Lyme Lyme

• Increased irritability of the CNS, with Increased irritability of the CNS, with agitation, anxiety, insomnia, and even agitation, anxiety, insomnia, and even seizures or seizure-like activityseizures or seizure-like activity

• Tender subcutaneous nodules along Tender subcutaneous nodules along the extremitiesthe extremities

• Sore soles, especially in the AMSore soles, especially in the AM


INDICATORS OF BLOINDICATORS OF BLO

• Gastritis, lower abdominal pain Gastritis, lower abdominal pain (mesenteric adenitis) (mesenteric adenitis)

• Lymph nodes may be enlarged, Lymph nodes may be enlarged, sometimes with a sore throat sometimes with a sore throat

• Red rashes. These rashes may be red Red rashes. These rashes may be red papular eruptions, spider veins, or the papular eruptions, spider veins, or the appearance of red streaks like stretch appearance of red streaks like stretch marks that do not follow skin planesmarks that do not follow skin planes


Bartonella RashesBartonella Rashes

Red bumps- may form Red bumps- may form scabsscabs


Bartonella RashesBartonella RashesLinear rashes- look like stretch marksLinear rashes- look like stretch marks

Photos taken by Dr. Martin Fried, with thanksPhotos taken by Dr. Martin Fried, with thanks

to him and to the Lyme Disease Associationto him and to the Lyme Disease Association


More BartonellaMore Bartonella

Back of legsBack of legs


BartonellaBartonella

Lower backLower back


BartonellaBartonella

Under the armUnder the arm


TESTING IS VERY INSENSITIVE TESTING IS VERY INSENSITIVE

• Clinically + Bartonella, with + response to treatment: Clinically + Bartonella, with + response to treatment: only 20% are + on serology or PCR (80% false only 20% are + on serology or PCR (80% false negative rate!)negative rate!)

• Occasionally see elevated VEGF- <20% of clinically Occasionally see elevated VEGF- <20% of clinically suspect cases, but when elevated, can be followed suspect cases, but when elevated, can be followed to assess efficacy of treatmentto assess efficacy of treatment

• Therefore, the diagnosis is a clinical one, based on Therefore, the diagnosis is a clinical one, based on the above points. the above points.

• Also, suspect infection with BLO in extensively Also, suspect infection with BLO in extensively treated Lyme patients who still are encephalitic, and treated Lyme patients who still are encephalitic, and who never had been treated with a significant course who never had been treated with a significant course of BLO meds of BLO meds


ANTIBIOTIC TREATMENTANTIBIOTIC TREATMENT

• Best = FQ. Levofloxacin > Cipro; efficacy Best = FQ. Levofloxacin > Cipro; efficacy decreaseddecreased if co-admin with erythros if co-admin with erythros

• Cephalosporins- advanced generation best Cephalosporins- advanced generation best but 8/9 relapsed; Bicillin similarbut 8/9 relapsed; Bicillin similar

• Combination of Rifampin + Biaxin fairCombination of Rifampin + Biaxin fair• Combination of Flagyl + Biaxin fairCombination of Flagyl + Biaxin fair• Worst = erythromycin derivatives, even IV Worst = erythromycin derivatives, even IV

azithromycinazithromycin• Doxycycline not much better (even IV doxy)Doxycycline not much better (even IV doxy)


TREATMENT TREATMENT RECOMMENDATIONSRECOMMENDATIONS

• The drug of choice to treat BLO is levofloxacin. The drug of choice to treat BLO is levofloxacin. • Levofloxacin is usually never used for Lyme or Levofloxacin is usually never used for Lyme or

Babesia, so many patients who have tick-borne Babesia, so many patients who have tick-borne diseases, and who have been treated for them but diseases, and who have been treated for them but remain ill, may in fact be infected with BLO.remain ill, may in fact be infected with BLO.

• Treatment consist of 500 mg daily (may be adjusted Treatment consist of 500 mg daily (may be adjusted based on body weight) for at least one month. based on body weight) for at least one month.

• Treat for three months or longer in the more ill Treat for three months or longer in the more ill patient.patient.

• It has been suggested that levofloxacin may be more It has been suggested that levofloxacin may be more effective in treating this infection if a proton pump effective in treating this infection if a proton pump inhibitor is added in standard doses. inhibitor is added in standard doses.


TREATMENT TREATMENT RECOMMENDATIONSRECOMMENDATIONS

• Another subtlety is that certain antibiotic Another subtlety is that certain antibiotic combinations seem to inhibit the action of combinations seem to inhibit the action of levofloxacin, while others seem to be neutral. levofloxacin, while others seem to be neutral.

• I advise against using or combining with an I advise against using or combining with an erythromycin-like drug, as clinically such erythromycin-like drug, as clinically such patients do poorlypatients do poorly

• Combinations with cephalosporins & Combinations with cephalosporins & penicillins are okaypenicillins are okay

• Alternatives to levofloxacin include possibly Alternatives to levofloxacin include possibly gentamicin and possibly streptomycingentamicin and possibly streptomycin


SIDE EFFECTS FQSIDE EFFECTS FQ

• Levofloxacin is generally well tolerated, with Levofloxacin is generally well tolerated, with almost no stomach upset almost no stomach upset

• It may cause a painful tendonitis, usually of It may cause a painful tendonitis, usually of the largest tendons. 2/15 courses in this the largest tendons. 2/15 courses in this seriesseries

• Very rarely, it can cause confusion- this may Very rarely, it can cause confusion- this may be relieved by lowering the dose. 0/15be relieved by lowering the dose. 0/15

• Levofloxacin and drugs in this family cannot Levofloxacin and drugs in this family cannot be given to those under the age of 18, so be given to those under the age of 18, so other alternatives, such as cephalosporins other alternatives, such as cephalosporins are used in childrenare used in children


GESTATIONAL GESTATIONAL TRANSMISSION ?TRANSMISSION ?

Animal studies show that Bartonella Animal studies show that Bartonella may be transmitted across the may be transmitted across the placenta. No human studies have placenta. No human studies have been done. been done.


THANK YOU !THANK YOU !

Documents

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