Friday, June 13, 2008

Fibromyalgia revisited

Case study: A 43 year old woman complains of fibromyalgia for years. She has a complex medical history. She has had fibromyalgia for many years. She has also been treated for ADD, attention deficit disorder. she has a history of bleeding peptic ulcers which has required a partial gastrectomy. Her complaints include: fatigue, anorexia and weight loss, pain- muscles and joints, nausea, brain fog and cognitive dysfunction. She has been on narcotics (opioids) for years to control her pain. One way her fibromyalgia has been treated is with trigger point injections. She comes into the office every two weeks and has her tender points injected with an anesthetic solution. This has offered some pain relief but has not been curative. Numerous Lyme Western Blot tests have been negative. An IgeneX WB was negative, but suggestive. There was a reaction at the 41band with indeterminate reactions at two critical bands, 31 and 39. Her C6 peptide was 0.29. Her Chlamydia pneumonia IgG titer was elevated at 512. Her CD57 levels have been low, ranging from 30 to 60. She has severe vitamin D reversal, with OH 25 less than 7 and 1,25 75. She has a low IgA level of 53. The celiac antibody profile is negative. But the antibodies are not 0. A Lyme co-infection panel showed an elevated IgG titer 1:40 to Babesia microti.

After 2 years of treatment she is finally getting much better. What has worked and why.
Best antibiotics: Amoxicillin, Zithromax, Flagyl. Chronic Lyme is probably a factor. Babesia antibodies show exposure to Ixodes, the Lyme vector. Her WBs are borderline. The C6 is elevated in my experience. Patients who test positive for Lyme by WB typically have a C6 index between 0.2 and 0.3. The higher cut off point0f 0.9 (per lab reports) relates only to acute Lyme disease. No one has studied C6 antibody in chronic Lyme. The test is so specific that any level over 0.1 suggests exposure to the Lyme organism. (This is based on discussions I have had with researches who have developed the test- this of course is unpublished) The vitamin D dysregulation favors the Marshall hypothesis that L-forms of Borrelia contribute to this abnormality which alters immune function to favor the intracellular bacteria. The CPN titer is probably significant. I have observed that patients who test positive for multiple bacteria associated with L-forms tend to have more vitamin D dysregulation. CPN has been highly associated with fibromyalgia as well. This triple antibiotic cocktail is relatively effective for CPN. Adding Rifampin may be helpful. I would avoid Stratton's recommendation to use INH: liver toxic.
Other drugs: Benicar has made a big difference. I use it only at low doses, 20mg or 40mg. It helps balance vitamin D. The higher doses seem potentially dangerous to me.
Mepron: It is hard to know if the Babesia infection is active, but a 2 month course of this agent, along with Zithromax seemed reasonable. I asked about recurrent flu like symptoms and got a positive response. I think it helped.
Wobenzym-N: Has been effective in reducing pain.
Questran (Cholestyramine): Has been effective with improvements in cognitive dysfunction.
Gluten free diet: She never got stool test for gluten sensitivity from Enterolab. She tried this diet on an empiric basis. This has made a huge difference in her symptoms.
She has required pain medications during the treatment, but she is beginning to taper off.
Key Points: Fibromyalgia. Lyme, Babesia and CPN infection. Vitamin D dysregulation. Gluten sensitivity. Treatment as outlined above effective over a period of two years.

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