A New Look at The Role of HBOT in Neurovascular & Rheumatic Diseases: Borrelia, Bartonella, & Parasitic Infections

Transcription

1 A New Look at The Role of HBOT in Neurovascular & Rheumatic Diseases: Borrelia, Bartonella, & Parasitic Infections HBOT 2012 Long Beach, CA AUGUST 12, 2012 B Robert Mozayeni, MD Translational Medicine Group, P.C. & THE Center for Translational Medicine - 501c(3) North Bethesda, MD Copyright all rights reserved do not reproduce or distribute without permission

2 Disclosure Chief Medical Officer of Galaxy Diagnostics, LLC

3 Key Points - I Lyme disease is complicated and represents a symptom complex of multiple co-infections, inflammation and endocrine abnormalities. There are new diagnostic tests that identify the role of various microbes, other than Borrelia burgdorferi, in chronically ill patients. A prevalent infection and cause of neurological and rheumatic disease includes Bartonella spp. regarding which the presenter and colleagues have recently published a paper in the CDC s journal, Emerging Infectious Disease (May 2012). This data will be discussed. These infections are primarily resident with the vascular system and thus, affect vascular hemodynamics at many levels. The oxygen sensitivity of Bartonella spp. is unknown and the biology suggests it may be resistant to HBOT.

4 Key Points - II A new high sensitivity test has made us aware that Bartonella spp. is an important emerging infection. Really, it is our awareness of this microbe that is emerging. We don t know the oxygen sensitivity of these emerging organisms. Bartonella spp. infect principally, the endovascular tissue and blood components. This makes the organism very important to the understanding of chronic neurological and rheumatic diseases. Neurological symptoms can be the result of vascular inflammation from endovascular infections. Rheumatological disease, including rheumatoid arthritis, may be the result of endovascular infections or be complicated by endovascular infection during immune-suppressive therapy. These conditions present special challenges and potential new treatment options in the care of a patient receiving HBOT.

5 One Health Initiative One Health Task Force Report - JAVMA 233:2 July 15, of the 1,461 diseases now recognized in humans, approximately 60% are due to multihost pathogens characterized by their movement across species lines. And, over the last three decades, approximately 75% of new emerging human infectious diseases have been zoonotic. King, LJ et. al. (CDC)

6 Post-Lyme Syndrome: Case I -18 yo female honors student, severe fatigue, positive Borrelia western blot (IgM), partial response to oral antibiotics Differential Diagnosis & Treatment options: a) persistent Lyme - use i.v.? b) post Lyme syndrome = autoimmune? c) an emotional disease d) use HBOT - WHY?

7 CASE I: Baseline

8 CASE I: After Rx (30d azithromycin)

9 Post Lyme Syndrome: Case II

10 Post Lyme Syndrome: Case II

11 Post Lyme Syndrome: Case III

12 Bug vs Terrain The disease results from interactions between the pathogen and the host. Autoimmunity Infection - trigger or persistence

13 What Factors Determines Disease? Host Factors Pathogen Factors High / Acute Infectious Disease (Inpatient) Pathogenicity Low / Chronic Rheumatology (Outpatient)

14 Pathogenesis: Inflammation and Coagulation infection > inflammation > fibrin deposition > flow impairment = SYMPTOMS Wagner, et al.

15 Timeline of Bartonella Study Spring 2008: began search for better tests for chronic Bartonella infection as there was no other option (entirely ineffective serological tests and culture platforms at commercial labs) Fall 2008: Began collaboration with Dr. Breitschwerdt s & team, testing 296 patients suspected of having inflammatory small vessel disease based on neurovascular symptoms Spring 2012: Published in CDC s journal, EID

16 Clinical Signs of Small Vessel Disease - Patient Selection nerves are most sensitive trip wires white matter areas of brain are watershed areas: no collateral flow, metabolically very active disconnection syndrome with cognitive impairment executive dysfunction, reduced bandwidth, delayed psychomotor processing, and reduced working memory are common features

17 Bartonella in Immunocompetent Patients Journal of Emerging Infectious Diseases Vol. 18, No. 5, May

18 Abstract Bartonella spp. infection has been reported in association with an expanding spectrum of symptoms and lesions. Among 296 patients examined by a rheumatologist, prevalence of antibodies against Bartonella henselae, B. koehlerae, or B. vinsonii subsp. berkhoffii (185 [62%]) and Bartonella spp. bacteremia (122 [41.1%]) was high. Conditions diagnosed before referral included Lyme disease (46.6%), arthralgia/arthritis (20.6%), chronic fatigue (19.6%), and fibromyalgia (6.1%). B. henselae bacteremia was significantly associated with prior referral to a neurologist, most often for blurred vision, subcortical neurologic deficits, or numbness in the extremities, whereas B. koehlerae bacteremia was associated with examination by an infectious disease physician. This cross-sectional study cannot establish a causal link between Bartonella spp. infection and the high frequency of neurologic symptoms, myalgia, joint pain, or progressive arthropathy in this population; however, the contribution of Bartonella spp. infection, if any, to these symptoms should be systematically investigated.

19 Bspp PCR results by Dx most 1/2 1/3rd

20 Blood 69 Culture 48 Serum 23 PCR+ Yields

21 Major Symptoms & Consultations

22 Clinical Experience Generally positive and consistent time course of response to treatment suggests, but does not establish a causal link between Bartonella sp. infection and the rheumatic and neurological symptoms reported in this patient group. Negative transthoracic cardiac echo on more than 25% (N>50) - no valvular disease established. No patient was referred for trans-esophageal echocardiogram (TEE). Liver cysts occasionally observed, and resolve with treatment. In one case, a benign breast cyst was positive for Bartonella by PCR. So, what is fibrocystic breast disease, really?

23 Antibodies Develop & Disappear During Treatment Antibody (IFA) Titer During Treatment CNS improved arthropathy Bvb I Bvb II Bvb III Bh Bk antibiotics started 0 5/17/10 8/9/10 9/13/10 10/13/10 11/15/10 12/1/10 12/15/10 1/13/11 3/7/11 6/17/11 7/1/11

24 An Exemplary Bartonella Case 32 yo veterinarian with probable childhood and occupational exposure molecular isolations: Bk Bh H1 Bh H1 Cal1 Bh SA2 Bspp x 3 Bh persisting after treatment Other: PCR+ isolate from breast cyst, acquired ligamentous laxity, and articular pannus Different roles for HBOT at different points in her care.

25 When do we Treat? The Clinical Science Challenge Dz Severity (present and future risk) Absent Low Mod High Rx: Risk v Benefit (NNT, NNH) Low No? Yes YES Mod No No? Yes High No No No Yes

26 Summary Implications for HBOT therapy of patients with chronic neurological, rheumatic conditions in the setting of chronic infections will be discussed. The oxygen sensitivity of various microbes involved must be evaluated systematically. Until it can be established that HBOT can treat the infections thought to be carried by the patient, HBOT should be used carefully to avoid causing neurological complications. HBOT in the range of 1.5 to 2.0 ATA is optimal for CNS symptoms that result from small vessel inflammation associated with these new chronic infections.

27 THANK YOU Team Bartonella: Ed Breitschwerdt Ricardo Maggi Elizabeth Pultorak Barbara Hegarty Julie Bradley Maria Correa Vector Borne Disease Reference Lab at the NC State College of Veterinary Medicine Galaxy Diagnostics, LLC