Dr Bocks Article

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I have cleaned up this scanned copy as best I could, I did not try to

correct the references. Hope this is helpful, I found it very interesting.

J. Bock, M.D., has been involved in alternative and integrative

medicine for over 20 years. He has extensive experience in the integrative

treatment of chronic Lyme disease. Dr. Bock is also a certified

acupuncturist. He is medical director of the Centers forr Progressive

Medicine and Patients Alliances.

COVER STORY

INTEGRATIVE TREATMENT OF LYME DISEASE

by J. Bock, M.D.

Picture this scenario: You have a patient who started feeling fatigued, a

kind of fatigue she had never felt before. Various joints started aching in

different places, starting with the big joints (hips, knees), elbows,

ankles, fingers, and toes. She complains of headaches and pain in the back

of the neck. She has problems remembering names or retrieving thoughts. She

has no history of arthritis, and no personal or family history of

depression.

You elicited a history of flu symptoms a few months ago, but there's no

evidence of a tick bite or bulk eye rash, i.e., erythema chronica migrans,

(ECM). On the other hand, your patient lives in-or recently traveled to an

epidemic area for Lyme disease. She gives you the history she gave to her

general practitioner. Physical examination and initial Lyme test were

negative, and she was given symptomatic treatment for her symptoms.

Unfortunately, this scenario can happen to all-too-many physicians. Lyme

disease starts as a centralized process in the area around the bite, then

progresses to an early, then late disseminated state. Approximately 40% to

50% of patients never find a tick bite or ECM rash. Lyme disease can easily

be dismissed in its early stages. Infection can lead to chronic Lyme

disease.

CONFUSING CONDITON

Why is it so difficult to diagnose Lyme disease? Borrelia burgdorferi, a

bacterial spirochete, causes the condition. This type of bacteria can invade

all parts of the body, including skin, muscles, joints, nervous system, the

cardiovascular system, ocular tissue, sinus tissue, gastrointestinal tract,

and lungs. Lyme disease can also mimic different illnesses and syndromes. it

is an infection that triggers a variety of host responses, depending on the

individual. The spirochete actually burrows into lymphocyte cells, and exits

with the cellular membrane surrounding itself. Thus, it can stimulate an

immunological response, including autoimmune mechanisms. Patients with

HLA-DR4 and HLA-DR2 genotypes may have genetic predispositions to chronic

Lyme disease. At least one laboratory study reports that IL6-deficient mice

have decreased TH2 responses and increased Lyme arthritis.

The complex interaction of the Borrelia spirochete, the host, and the immune

response that the bacterium elicited, can explain the varied and often

confusing persistence of fatigue and other symptoms of the chronic Lyme

patient, even after antibiotic treatment. It is possible that dead

spirochetes, fragments of spirochetes with or without the persistence of

live

spirochetes cause inflammation, cytokine and immune disregulation, and

autoimmunity by molecular mimicry. Autoimmune reactions include positive

anticardiolipin antibodies, positive antinuclear antibody (ANA), and

positive antithyroid antibodies.

" No one knows why in some patients with late Lyme disease, symptoms

eventually diminish or disappear, whereas in other patients, the symptoms

persist. The bacteria survive in numbers too low to be detected by

conventional tests, yet high enough to produce illness; according to the

National Institute of Allergic and Infectious Disease (NIAID). NIAID is now

using the term " persistent Lyme disease syndrome " (PLDS). NIAID states, " We

don't know whether these symptoms associated with PLDS are caused by one or

more of the following: an ongoing infection with BB (Borrelia burgdorferi),

another tick-borne pathogen, re-infection with BB, an autoimmune or primary

response associated with the initial infection, or some yet-to-be-identified

mechanism: " Unanswered questions regarding PLDS include:

What type of antibiotics are most effective?

How long should they be taken?

Do benefits last with antibiotic therapy, and if so,for how long?

What outcomes can be used to determine a sufficient treatment?

Chronic Lyme disease most often produces persistent arthritis, nervous

system problems, and cardiac symptoms. It can have many different

presentations, depending on 1) which body system is affected, 2) the

individual's response to the infection, and 3) the time between initial

onset and diagnosis. Patients can go from physician to physician and get

multiple diagnoses, including arthritis, anxiety, depression, and

neurological problems such as memory deficits and cognitive dysfunction.

Cognitive dysfunction involves brain processing and word retrieval, and can

present as a

brain disorder. Borreliosis causes a chronic infection of the nervous system

and may

produce a syndrome indistinguishable from multiple sclerosis. Fatigue

presents as a

spectrum that includes fibromyalgia symptoms, all the way to chronic fatigue

immune dysfunction syndrome.

DIAGNOSIS

Antibody assays of Borrelia burgdorferi (BB) can provide evidence of current

or previous infection. However, positive tests of BB antibodies do not

always indicate current infection, and patients with active Lyme disease can

test negative on antibody testing. Lyme disease is a clinical diagnosis.

Testing confirms the

diagnosis. First-stage testing is the Enzyme Link immunoabsorbent Test, and

Indirect

Immunofluoresence Microscopy Western Blot (immunoblot) assays are used for

secondary-level testing. The Western Blot tests the serum for the presence

of numerous KDA antibodies (both lgM and lgG), such as the 18, 21-25, 28,

30, 31, 34, 39, 41, 45, 58, 66, 83, and 93. A Western Blot IgM test of two

bands (e.g., 23, 41, or 39, 41) is a positive IgM test. Five bands on IgG

testing constitutes a positive Western Blot analysis by Center for Disease

Control (CDC) standards. This is set up on a research basis to make sure no

false positives are included in Lyme studies. Many Lyme positive patients

have evidence of three or four bands on testing. Seronegativity shows about

15% of the time. Seronegativity refers to a negative antibody result, even

though the patient has the disease. Patients may be susceptible to more

serious disease

when delaying treatment secondary to unrecognized sero negative testing.

Patients have

had negative testing for up to five years after the onset of symptoms.

Patients diagnosed

with multiple sclerosis (MS), living in an epidemic Lyrne area, with

atypical signs for MS,

deserve to be studied fully with Lyme and cerebrospinal fluid (CSF) testing

to determine if

Lyme disease is an etiology.Other tests that can be used to support a

diagnosis of Lyme

disease are polymerase chain reaction (PCR) testing (DNA amplification

testing), and the

LUAT (Lyme Urinary Antigen Capture Test). A study by Bayer in 1996 showed

that a sizable group of patients diagnosed on clinical grounds as having

Lyme disease, may

still excrete Borrelia DNA in the urine, despite antibiotic therapy This is

done using a

five-day course of antibiotics such as cefuroxine axetil. One takes a urine

test on the third,

fourth, and fifth day of antibiotic therapy, checking for Lyme antigen. Many

a case has

been diagnosed white waiting for the results to come back. An exaggeration

of symptoms,

a Jarisch herxheimer reaction (which is due to the spirochete's reaction to

being destroyed,

similar to what occurs in cases of syphilis), or an improvement in symptoms

may indicate

that the problem is related to Lyme disease. When encountering resistance to

therapy,

consider tick-born coinnfection with babesiosis or ehrlichiosis. Babesiosis

can present with flu-like symptoms, fever, chills, and low blood count.

Ehrlichiosis

presents with fatigue, severe headaches, muscle pain, leukopenia,

thrombocytopenia, and

elevated liver enzymes. Current testing includes serology peripheral blood

smears for

babesiosis and PCR studies.

TREATMENT

An integrative medical treatment of Lyme disease starts by considering the

whole picture. Look at the patient's recent disease history and

symptomatology; genetic tendencies, metabolism, past immune function

problems or infection, history of antibiotic treatment and duration of

treatment, coinnfection, nutritional and micronutritional status, and

psychospiritual factors. Treatment depends on the clinical course. An early

diagnosis of

Lyme disease by ECM rash, flu symptoms, arthralgia, and other Lyme

symptoms-necessitates a six-week course of antibiotics. Suplement this

treatment with probiotics to protect the intestinal flora. The majority of

patients seen at

Rhinebeck Health Center in New York have chronic symptoms, suggesting

possible

chronic Lyme disease. The conventional medical community views Lyme disease

as readily

treatable with four weeks of antibiotics.Despite the general avoidance of

antibiotics in this

integrative practice, this author finds that many Lyme patients need

prolonged courses of

antibiotic therapy.Patients presenting with Lyme symptomatology are often

erroneously

labeled as hypochondriacs. If a patient with chronic Lyme disease has not

had an

adequate course of antibiotics, but has continuing symptoms with chronic

infection, antibiotics are recommended. Choices include cefuroxine axetil

(2,000 mg a day), doxycycline (300 mg a day), clarithromycin (2,000 mg a

day), or azithromycin (500 mg a day). Some patients respond well to

penicillin G benzathine and penicillin G procaine suspension long-acting

penicillin LA, 2.4 million units ~ per week (always test for Pen-G allergy

by RAST testing). If intravenous therapy is needed, one can use sterile

ceftriaxone sodium, starting at two grams per day; azithromycin at 500 mg

per day; or doxycycline at 200 to 400 mg per day

Lyme disease has become the most common tick-born disease in the United

States.The areas at highest risk are the Northeast:Upper Midwest, and

Northern California. The most prevalent time of year for infection is from

May

to September The deer and mouse population are the reservoir for the

disease. Recent studies have found that acorns are food for the white-footed

mouse. Oak trees shed their acorns every three years, with 70% to 75% of the

trees shedding their acorns in a synchronous fashion. It has also been shown

that the year after a big acorn drop, increased cases of Lyme disease are

recorded. It is possible that this is due to the increased mouse population.

In addition, approximately 65% of patients are sero positive at initial

diagnosis, and approximately 20% sero convert as the treatment begins.

Because Lyme disease is a clinical diagnosis, one critical aspect is the

patient's response to treatment. The patient's response to previous

intervention determines each step in his or her subsequent treatment . For

instance, if a patient has a herxheimer reaction 3 weeks into treatment,

it is our experience that he or she should be treated with antibiotics for

approximately five to six more weeks. Clinically, I like to see five to six

weeks of asymptomatic condition, or a plateau at an acceptable level of

symptoms, as a guide to the end point of antibiotic therapy. This decreases

the chance of relapse after antibiotic treatment. Even with two to three

months of antibiotic treatment, recurrences have occurred with no evidence

of new tick bite.Treatment for any co-infection may also be necessary.

NATURAL MEDICINE AND LYME DISEASE

Patients with Lyme disease are placed on a nutritional regimen that includes

anti-inflammatory eicosanoids, such as fish oil and borage seed oil. A

high-potency multivitamm/mineral formula is also used. Since muscle pain and

spasm are present in many cases, a calcium/magnesium supplement is usually

prescribed. Extra magnesium is recommended if symptoms are predominantly of

a fibromyalgia picture. Additionally, malic acid is appropriate when

fibromyalgia symptoms are secondary to the underlying disease. CoQ1O and

other mitochondrial nutrients (e.g., carnitine and lipoic acid) promote

energy production. Intravenous nutrients, such as vitamin C and B vitamins,

are often utilized for immune function enhancement.

The use of electroacupuncture (EAV) is recommended for therapy-resistant

problems. This technique picks up underlying deficiencies or excesses of

certain acupuncture readings, e.g., liver; large intestine, or spleen. It

also reportedly detects toxicities that interfere with the body's healing

(e.g., mercury toxicity elimination problerns, or pesticide toxicity).

When a patient is placed on antibiotic therapy, it is imperative to give him

or her probiotics (e.g., Lactobacillus acidophilus or bifidum) and

Saccharomyces boulardii. This prevents imbalance in the intestinal flora,

which could lead to intestinal dysbiosis and/or C. dificile infection.

Chronic candidiasis and intestinal dysbiosis are frequently encountered in

the treatment of Lyme patients. In some cases, natural anti-fungal therapy

is utilized. Nystatin or fluconazole can also be used. Occasionally,

intestinal cleansing is necessary. Milk thistle extract can help prevent

potential dysfunction of liver enzymes from antibiotic therapy

COGNITIVE ENHANCEMENT IN LYME DISEASE

Cognitive difficulties are part of the neurologic syndrome of chronic Lyme

disease. The severity of cognitive dysfunction in Lyme disease can fluctuate

from day to day and from week to week. Cognitive difficulties can manifest

as an inability to start projects, difficulty in doing multiple tasks,

getting lost going places, memory loss, concentration problems, personality

changes, and irritability. Psychiatric problems include panic disorder;

bipolar disorder, paranoia, schizophrenia, obsessive-compulsive disorder,

and in children, attention deficit disorder.These findings are often

documented on

neuropsychological testing and spect scan. Findings on scans show decreased

blood flow

to parts of the brain. Supplements that help with cognitive enhancement

include

L-acetyl-carnitine and antioxidant compounds. Herbal extracts such as Ginkgo

biloba can also help. For others, cognitive enhancement medications, such as

pregnenolone, may be more effective. In some cases, cognitive abilities

improve when

sub-clinical hypothyroid problems are treated. Again, one must treat the

associated anxiety

depression, and sleep disorders. Neurobiofeedback can also help treat the

cognitive dysfunction associated with Lyme disease.

Stress affects the Lyme patient in various ways. The disease is chronic.

Obviously, this often creates frustration, anxiety, and fearfulness. Stress

can cause immunosuppression. It can also affect the hypothalamic pituitary

adrenal access, manifesting as hypoadrenla. This can exacerbate the prior

condition and present as fatigue, chronic exhaustion, chronic dizziness,

chronic headache, low blood pressure, low blood sugar, and anxiety.

It is important to provide an integrative program for managing the effects

of stress on the body:

1. Relaxation techniques and stress-reduction management, including the use

of biofeedback.

2. Chronic disease groups for general emotional support.

3. General immune support (e.g., maitake or reishi mushrooms, ginseng,

astragalus).

4. Endocrine enhancement, concentrating on nutritional and herbal support

for the adrenal gland. This includes vitamin C, vitamin B6, pantothenic

acid, and possibly

DHEA (measure levels before and after treatment).

5. For the anxiety associated with chronic Lyme disease, B vitamins,

magnesium, and valerian are recommended. These are usually preferable to

medical tranquilizers such as Ativan, Xanax and Klonopin for panic

attacks and anxiety. I have seen good results with Garum armoricum for mixed

anxiety and depression.

ACUPUNCTURE AND OTHER

ALTERNATiVE MODALITIES

One of the postulates of Chinese medicine is that an imbalance of chi

(energy flow of the body) causes illness, and that applying acupuncture to

certain " meridian " points on the body can correct this imbalance. The World

Health Organization now recognizes acupuncture as an appropriate treatment

for chronic muscular pain, fibromyalgia syndrome, radicular pain, neck pain,

muscle tension, headache, low back pain, arthritis, and substance abuse.

Acupuncture is also used for problems related to autonomic dysfunction,

fatigue, and insomnia. Studies have shown a decreased electrical resistance

at acupuncture points, and also that 50% to 70% of acupuncture points

correspond to Dr. Travell's trigger. A treatment regimen of acupuncture

in Lyme disease, combined with physical therapy, can decrease pain, increase

mobility, and improve fatigue states. However, one often finds acupuncture

treatment can aggravate the symptoms of a herxheimer reaction.

As with all illnesses, prevention is easier, safer, and less costly than

treatment.

· If you find a tick, tug gently but firmly with

blunt tweezers near the 'head " of the tick

until it releases its hold on the skin.

· To reduce the risk of infection, try not to crush the tick's body or

handle the tick with bare fingers.

· Swab the bite area thoroughly with an antiseptic to prevent bacterial

infection.

In chronic Lyme disease patients, depending on the clinical situation,

various other modalities can be instituted. This involves the use of natural

immune-modulating peptides to boost the immune system by supporting the T

helper cells, and to suppress an overactive immune system by supporting the

suppressor T-cell function. With the proper complementary or progressive

medical

approach, and by combining conventional and alternative therapies, we can

hopefully lead

patients with Lyme disease toward better health.

REFERENCE~

1. florwood t), Fischer: In " itro cvidcnce for lymphocytic membrane c1oaki~g

by Borrelia burgdorftri. fwme Disease Foundation, Scientific Con~rence,

April 1998.

2. Steerc AC, D'vyer E, Winch~ter R~ Arthritis with HIA-I)R4 and HLAi)~

alleses. New England Journal ofMcdicine 323:219-223, 1990.

3. Anquita J, Rimeon M, Samanta S, Barthols SW, Flaveli RA, Fikrig E:

Borrciia burgdorfrri infection: interieukin-6 deficient mice have decreased

TH-2 responses and incrcased Lyme arthntis.JournaloflnfrctiousD£wa'cs

178(5):1516-1525, Novemher 1998.

4. hilt BJ, Steinm~ CR, Datt~vyler R; Invasion of the central nervous system

by Borrrlia burgdorferi in acute disseminated infection. JAMA 267(10), March

1992.

5. Georgilis K, Peacoche M, Kiempner MS: Fibroblasts protect the Lyme

d's-ease spirochete, Bo~~ha burgdorftri, from cefriaxone in vitro. Journal

of infectious Diseases 166:440-444, 1992.

6. Preac-MursicV~W~~herK, Pfister, etak Survival ofBov " o'liaIni~ft~in

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1989.

7. P~ipavt)i~ NeL~sychiatric ~ ()~eopathic Association 98(7):373-378, July

1998.

8. National Institute ofAllergic and Infectious Disease, NIH Fact Sheet, May

1997.

9. Ibid.

10. Communication: Instinite of Ecosystem Studies, Millbrook, NY.

11. Feis) L Muitivariabie analy~isof160patientswith Lyme disease. Lyinc

Disease Conference, April 19, 1996.

12. N: Mitigen detection of Borrelia burgdorftn in urine. Lyme

Disease Scientific Conference, April 1998.

13. Nadelman RB, Worniser GP: Lyme borreliosis. The laneet 15(352):557-

565, August 1998.

14. Communication: Dr. n Reisenberg, i~uropsychology~ Cognitive

characteristics of chronic Lyme encepholapathy, ~ 0th Annual lnterliatiol)al

(~)nfcrcn(e, NiH, April 28-30, 1997.

15. Fallon N, et a': P6ychiatriL. manifestations of I.yme t'()rrelia:

Journal of Neurupsscholo~ 54:263-268,1997.

16. ~FraveII 3, eta': MyofascialPainandDv~netion. Baltimore: Willian's

& Wilkins,

1993.

17. Riederer P;Tenk H, Wcrner H, Bischko 3, RettA, Krisper H: Manipulation

of neursflransmitters by acupuncture: a preliminary communication. JNeural

Transm 37(1):81-94, 1975.