Lyme Disease: The Perfect Storm

Lyme disease is one of the most controversial diagnoses in medicine today. While some patients clearly have evidence of Lyme disease on serology, others may have active infection without the test being positive. Lyme disease is a multi-system disease and like many diseases that affect multiple systems, the diagnosis is complex. In this blog I will discuss what we know about Lyme disease and what are the current recommendations for diagnosis and treatment.

What is Lyme disease?

Lyme disease is caused by a spirochete bacterium called Borrelia burgdorferi& which is transmitted by the tick vector. The Ixodes tick is the primary vector for transmission of Lyme disease. The other organisms that are co-transmitted with Lyme disease include Babesia& and Anaplasma, as well as some viruses. The problem is that these co-infections may lead to more severe disease and more difficult treatment courses.

Diagnosis:

The diagnosis of Lyme disease has been challenging. Serology is unreliable early in the course of the disease and may be falsely negative even later in the infection. The standard two-tiered approach of serology: ELISA (enzymatic linked immunosorbent assay) followed by a western blot is the standard of care; however many false negatives result from this approach. Co-infections with Babesia& and Anaplasma& may be present with or without positive serology.

The problem of persistent infection:

It is now clear that Borrelia burgdorferi can persist in the body despite antibiotic treatment. The organism has several survival mechanisms that allow it to escape the immune system and antibiotic therapy. These include:

1. The ability to vary its surface antigens which allows it to evade the immune response
2. The ability to down regulate its metabolic rate and enter a dormant state where it is not susceptible to antibiotic therapy
3. The ability to form biofilms which protects from immune attack and antibiotics

These mechanisms make Lyme disease a very difficult condition to treat. A spirochete with these capabilities could theoretically continue to cause disease even after treatment. This is what is referred to as "post-treatment Lyme disease syndrome" (PTLDS).

The "perfect storm" model:

I would like to propose that the pathogenesis of Lyme disease should be understood as the "perfect storm" model. In this model, the following components are involved:

1. The infecting agent: Borrelia burgdorferi with its various co-infections
2. The host immune response: The vigor and appropriateness of the immune response will help determine the severity of the infection and the ease of treatment.
3. Nutritional and metabolic factors: The ability of the body to detoxify, heal and regenerate tissue depends on adequate nutritional status. These factors will influence both the immune response and the ability of the body to heal.
4. Genetic factors: HLA type appears to influence both the acquisition of the infection and the severity of the infection as well as the response to treatment.
5. Stress and life stressors: The impact of psychological stress on immune function is well established. Multiple life stressors at the time of Lyme infection or re-activation may influence the severity of illness.

The convergence of all these factors determines the clinical presentation and clinical course of Lyme disease. When the immune system is strong, when nutritional status is optimal, when there are few life stressors, then even if the organism is acquired infection will be minimal. Conversely, when immune function is compromised, when there are nutritional deficiencies, and when there are multiple life stressors then the "perfect storm" conditions exist, which allow for more severe infection and treatment resistant disease.

Treatment:

Standard treatment is antibiotic therapy; however, based on the perfect storm model I would like to propose that treatment should include the following components:

1. Standard antibiotic therapy as indicated by the CDC guidelines
2. Support of immune function through nutritional support and the use of immunostimulating herbs such as Astragalus and Andrographis
3. Optimizing nutritional status—in particular micronutrients such as vitamin D, vitamin B12, zinc, and CoQ10 that support immune function
4. Detoxification support—given the inflammatory response to bacterial byproducts (endotoxins) support of detoxification pathways is important
5. Support of neurological healing—since Lyme affects the nervous system, support of neurological healing with nutrients such as B vitamins and phospholipids may be beneficial
6. Stress reduction