Raj Patel, MD Page 1 Raj Patel, MD Raj Patel, MD Education: MS-Rutgers University MD – Robert Wood Johnson Medical School Residency-Family Medicine Post

Raj Patel, MDRaj Patel, MD Page 1

Raj Patel, MDRaj Patel, MD Education:

MS-Rutgers UniversityMD – Robert Wood Johnson Medical SchoolResidency-Family MedicinePost Graduate studies in Autism Spectrum Disorders & Lyme Disease

Research:Ampligen-CFIDS (Hemispherx Pharmaceutical)

Clinical:20+ years clinical experienceActive member of Defeat Autism Now (DAN)Active member of International Lyme and Associated Diseases Society (ILADS)

Raj Patel, MDMedical Options for Wellness570 Price Avenue, #200Redwood City, CA 94063

650-474-2130http://www.DrRajPatel.net

Raj Patel, M.D.

Lyme Disease

Overview Fastest growing vector borne infection

CDC estimated 24,000 cases in 2002 with the CDC itself admitting reported cases represent less than 10% of all cases.

2013 CDC estimates 300,000 new cases annually

Raj Patel, M.D.

Reported Cases of Lyme Disease, United States, 1995-2009

National Surveillance case definition revised in 2008 to include probable cases;details at http://www.cdc.gov/ncphi/disss/nndss/casedef/lyme_disease_2008.htm

Raj Patel, M.D.

Vector Life Cycle

www.cdc.gov/ncidod/dvbid/lyme/ld_transmission.htm

Raj Patel, M.D.


Lyme Disease

Overview

Tick bites frequently transmit multiple infections:BorreliaEhrlichia/AnaplasmaBabesia and other piroplasmsBartonella like organisms

Raj Patel, M.D.

Lyme Disease

Overview (con’t) Other possible coinfections to consider in differential diagnosis:

Bacteria - Mycoplasma, Chlamydia, RMSF, Tularemia, Q-Fever

Parasites - Filarasis, Amebiasis, Giardiasis, …

Viruses – EBV, CMV, HHV6, XMRV, Borna virus, Powassan virus, …

Transmission: Ticks Mosquitos, Fleas, Rodents Transplacental Breast milk Sexual

Raj Patel, M.D.

Lyme Disease

Lyme Disease Symptoms

Symptom presentation typically mixed depending on mix of infections present

Classic Symptoms Associated with Borrelia Starts gradually with flu-like symptoms

Multi system involvement when disseminatedMigratory arthralgias that evolve into arthritisOccipital headaches with neck stiffnessFatigueFour week cycle of symptom flare-upsEM rash (bulls-eye)

Raj Patel, M.D.

Lyme Disease

Classic Symptoms Associated with Babesia Rapid onset of symptoms (cyclic high fevers, severe headaches, & sweats

esp. at night)Air hungerDull global headachesProminent fatigue with exercise intoleranceSymptoms cycle every 4-7 daysHypercoagulable states

Raj Patel, M.D.

Lyme Disease

Classic Symptoms Associated with Bartonella like organisms CNS symptoms prominent (anxiety, agitation, insommnia, seizures, outbursts

and anti-social behavior)LymphadenopathySoles tender esp. in morningStriae (hyperpigmented stretch marks)Elevated VEGF (vascular endothelial growth factor) useful marker to follow

response to treatment.

Raj Patel, M.D.

Lyme Disease

Classic Symptoms Associated with Ehrlichia / Anaplasma Myalgias

Sharp knife like headaches behind eyesLow WBC countElevated liver enzymes

Raj Patel, M.D.

Raj Patel, M.D.

Lyme Western Blot Testing

Grier, T. Laboratory Tests. Lyme Times. Summer 2004:21-25

Raj Patel, M.D.

Lyme Western Blot Testing in Chronic Lyme Disease

Overview:

Reasons for seronegativity-Test done too early Antibiotics given early Early use of steroids B. burgdorferi not present in blood (it may be

in tissues as cell wall deficient form) Immuno-deficiency Presence of non-Borrelia burgdorferi species

Lyme WB should be used for screening. The College of American Pathologists (CAP) found that ELISA tests have poor sensitivity for screening purposes. (Bakken 1997)

Raj Patel, M.D.

What To Do If You Get A Tick Bite

1. See a doctor immediately. The sooner treatment is started the better the results are.

2. Go to www.lymediseaseassociation.org for a list of lyme literate MDs (LLMD). Otherwise, take a copy of the ILADS treatment guidelines with you for your doctor http://www.ilads.org/files/ILADS_Guidelines.pdf

3. Save the tick. Laboratories can test the tick for the presence of lyme and associated coinfections.

4. If a rash develops take photographs. It may help your doctor in making the diagnosis

5. Laboratories vary in terms of the depth of lyme testing provided. Dr. Patel prefers to use the following:

Igenex www.Igenex.com 1-800-832-3200Stony Brook Laboratorieshttp://www.path.sunysb.edu/labsvs/tickpics/TICKpic.htm 1-631-444-3824Clongen Laboratories www.Clongen.com 1-301-916-0173

Raj Patel, M.D.

Testing and Treatment After Tick Bite

Testing

PCR (blood and Serum) for Lyme, Ehrlichia, Bartonella, Babesia, Mycoplasma especially early in course of infectionFISH, PCR, or blood smear for BabesiaFISH or PCR for Bartonella Western-Blot not useful. Take 2-6 weeks to turn positive

Treatment:

IDSA: Rx within 72 hours with Doxycycline 200 mg (4mg/kg) one time dose if age >8 years. No treatment recommended for < 8 years unless

symptoms warrant it.ILADS: No specific Rx. Use clinical judgement based on geographical

location, type of tick, if engorged, and method of removal.Burrascano Guidelines: Treat 28 days regardless of age.

Raj Patel, M.D.

Two Standards of Care

IDSA (Infectious Diseases Society of America)

Denies existence of chronic Lyme disease.Requires serological evidence for treatment (positive PCR or IgM on WB)Treatment restricted to 2-3 weeks of single antibiotic

(typically Doxycycline 100mg BID)

“…unproven and very improbable assumption that chronic B. burgdorferi infection can occur in the absence of antibodies against B. burgdorferi in serum.”

“patients who remain seronegative, despite continuing symptoms for 6-8 weeks, are unlikely to have Lyme disease…”

“To date there is no convincing biologic evidence for the existence of symptomatic chronic B. burgdorferi infection among patients after receipt of recommended treatment regimens for Lyme disease.”

“Retreatment is not recommended unless relapse is shown by reliable objective measures.”

Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 Nov 1;43(9):1089-134. Epub 2006 Oct 2

Raj Patel, M.D.

Two Standards of Care

ILADS (International Lyme and Associated Diseases Society) • “Since there is currently no definitive test for Lyme disease, laboratory

results should not be used to exclude an individual from treatment.• Lyme disease is a clinical diagnosis and tests should be used to support

rather than supersede the physician’s judgment.• The early use of antibiotics can prevent persistent, recurrent and refractory

Lyme disease.• The duration of therapy should be guided by clinical response, rather than

by an arbitrary (i.e., 30 days) treatment course.• The practice of stopping antibiotics to allow for delayed recovery is not

recommended for persistent Lyme disease. In these cases, it is reasonable to continue treatment for several months after clinical and laboratory abnormalities have begun to resolve and symptoms have disappeared.”Evidence Based Guidelines for the Management of Lyme Disease. The International Lyme and Associated Diseases Society. Expert Rev. Anti-infect. Ther.2(1), Suppl. (2004)

Raj Patel, M.D.

Medical Literature

False Seronegativity in Lyme well documented

…chronic lyme disease cannot be excluded by the absence of antibodies against B. burgdorferi.”Dattwyler RJ, Volkman DJ, Luft BJ, Halperin JJ, Thomas J, Golightly MG. Seronegative Lyme Disease. Dissociation of specific T- and B- lymphocyte responses to Borrelia burgdorferi. N Engl J Med. 1988 Dec 1;319(22):1441-6.

“Greater than 70% of patients with chronic Lyme disease were seronegative by CDC criteria. Donta ST. Tetracycline therapy for chronic Lyme disease. Clin Infect Dis 1997 Jul;25 Suppl 1:S52-6.

“Lyme borreliosis patients who have live spirochetes in body fluids have low or negative levels of borrelial antibodies in their sera.”Tylewska-Wierzbanowska S, Chmielewski T. Limitation of serological testing for Lyme borreliosis: evaluation of ELISA and western blot in comparison with PCR and culture methods. Wien Klm Wochenschr. 2002 Jul 31;114(13-14);601-5.

“Seronegative patients in the study had higher rates of positive CSF PCR”Keller TL, Halperin JJ, Whitman M. PCR detection of Borrelia burgdorferi DNA in cerebrospinal fluid of Lyme neuroborreliosis patients. Neurology. 1992 Jan;42(1):32-42.

Raj Patel, M.D.

Protecting YourselfProtecting Yourself

Ticks:

Year round threat with Spring and Summer being prime timeCarried by deer as well as other animals to your yardMice become carriers when infected ticks feed on them.

Subsequently, when non-infected ticks feed they become infected

Found in cool moist areas, around shrubs and woody areas, tall grass, and around the edge of yards

Ticks prefer moist skin folds:Back of neckInside part of elbows and kneesHairlinesIn and around ears

Raj Patel, M.D.


Keep your pets protected:

Particularly susceptible, frequently bringing deer ticks into your house

Use Frontline or K9 Advantix monthly for cats and dogUse Damminix tubes to reduce deer ticks by more than 90%

(tubes filled with cottton treated with Permethrin)

Raj Patel, M.D.


Minimize Exposure:

Yard PreventionYard prevention very importantKeep lawn mowed, cut down brushy areas, & clear away leavesTrim trees to ensure adequate sunshine Creating a 3 ft. wide wood chip or gravel border and stone wall

can reduce ticks by 50%

Hiking PrecautionsWalk in middle of trails Wear light colored clothingWear gloves, hat, long sleevesUse Deet type repellent on exposed skinUse Permethrin tick repellent on clothingCheck yourself thoroughly afterwardsAfter possible exposure take clothing and

place in dryer at high heat for 15 minutes to kill ticks left behind

Lyme Disease vs. Mold IllnessLyme Disease vs. Mold Illness

Symptoms overlap greatly (fatigue, cognitive dysfunction, GI symptoms, arthralgias, myalgias, paresthesias, & mood changes)

Both trigger a Chronic Inflammatory Response with similar laboratory abnormalities.

Coexistence of these conditions present unique challenges especially in lyme and mold susceptible or multi-susceptible individuals.


Tips on Treating Lyme and Mold IllnessTips on Treating Lyme and Mold Illness

6 Steps:1. Eliminate exposure to WDB.2. Reduce biotoxin load and inflammation

with Cholestyramine



3. Identify and treat underlying infectionsa. GFCFSF dietb. Probioticsc. Minimize inflammation by supporting excretion of biotoxins (CSM, exercise, fluids, anti-inflammatory agents)d. Support energy levels (sleep, rest, mitochondrial and endocrine support)e. Go SLOW!



4. Treat MARCONS5. Correct all inflammatory markers (C4a,

MMP9, VEGF, ADH, TGFb1)6. Treat with VIP (if unable to tolerate VIP,

look for occult infections or hidden mold exposure.)


*17 Reasons Lyme Patients Don’t Get Well*17 Reasons Lyme Patients Don’t Get Well

1. All co-infections have not been successfully identified and eradicated

2. Immune Dysfunction-autoimmune

-immune deficiency

3. Inflammation-calm inflammatory response

-frequently triggered by infections/toxins-address pain

*Why Can’t I Get Better? Richard Horowitz, MD ISBN-10: 1-250-01940-0



4. Toxicity-heavy metals -environmental illness-mold/mycotoxins -EMF

5. Allergies/Sensitivities6. Nutritional/Enzyme Deficiencies7. Mitochondrial dysfunction8. Psychological dysfunction

-depression -PTSD-anxiety -Abuse




9. Neurological dysfunction10.Endocrine disorders

-Thyroid -Testosterone

-Adrenal

11.Sleep disturbances-Stage 4 -Sleep Apnea

12. Autonomic dysfunction13. GI disorders (Ehrlichia, Tularemia, Rickettsia,

Borrelia species, Celiac, HHV6)*Why Can’t I Get Better? Richard Horowitz, MD ISBN-10: 1-250-01940-0



14. Liver dysfunction15. Pain16. Deconditioning



THANK YOU


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Raj Patel, MD Page 1 Raj Patel, MD Raj Patel, MD Education: MS-Rutgers University MD – Robert Wood Johnson Medical School Residency-Family Medicine Post