Education:

1
Raj Patel, MD

• Education
• MS-Rutgers University
• MD Robert Wood Johnson Medical School
• Residency-Family Medicine
• Post Graduate studies in Autism Spectrum
  Disorders Lyme Disease
• Research
• Ampligen-CFIDS (Hemispherx Pharmaceutical)
• Clinical
• 18 years clinical experience
• Active member of Defeat Autism Now (DAN)
• Active member of International Lyme and
  Associated Diseases Society (ILADS)

Raj Patel, MD Medical Options for Wellness 5050
El Camino Real, 110 Los Altos, CA
94022 650-964-6700 http//www.DrRajPatel.net
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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. Tick bites
frequently transmit multiple infections Borreli
a Ehrlichia/Anaplasma Babesia and other
piroplasms Bartonella like organisms

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Lyme Disease Overview (cont)
Other possible coinfections to consider in
differential diagnosis Bacteria -
Mycoplasma, Chlmydia, RMSF, Tularemia,
Q-Fever Parasites - Filiariasis, Amebiasis,
Giardiasis, Viruses EBV, CMV, HHV6, XMRV,
Borna virus, Powassan virus, Transmission
Ticks Mosquitos, Fleas, Rodents
Transplacental Breast milk Sexual

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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 disseminated Migratory
arthralgias that evolve into arthritis Occipital
headaches with neck stiffness Fatigue Four week
cycle of symptom flare-ups EM rash (bulls-eye)


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Lyme Disease Classic Symptoms
Associated with Babesia Rapid onset of
symptoms (cyclic high fevers, severe headaches,
sweats esp. at night) Air hunger Dull global
headaches Prominent fatigue with exercise
intolerance Symptoms cycle every 4-7
days Hypercoagulable states

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Lyme Disease Classic Symptoms
Associated with Bartonella like organisms
CNS symptoms prominent (anxiety, agitation,
insommnia, seizures, outbursts and anti-social
behavior) Lymphadenopathy Soles tender esp. in
morning Striae (hyperpigmented stretch
marks) Elevated VEGF (vascular endothelial
growth factor) useful marker to follow response
to treatment.

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Lyme Disease Classic Symptoms
Associated with Ehrlichia / Anaplasma
Myalgias Sharp knife like headaches behind
eyes Low WBC count Elevated liver enzymes

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• Signs/Symptoms of Pediatric Lyme
• Neuropsychological
• Delayed Speech Decreased attention/focus
• Decreased receptive language/auditory processing
• Outbursts/Impulsivity Short term memory
  affected
• Difficulty with abstract reasoning Mood swings
• Physical
• Sensitivity to light/sound Fatigue
• Sleep disturbances/Nightmares New onset
  bedwetting
• Arthritis/Joint pains Abd. pain/Nausea/Diarrhea
• Chest pains/Palpitations Headaches/Stiff neck
• Food Intolerances

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• Signs/Symptoms of Autism Spectrum Disorders
• DSM Related
• Poor eye contact Sensory issues (light, touch,
  sound)
• Echolalia Repetitive movements/behav.
• Speech delay /or loss of previously acquired
  language
• Poor socialization/unaware of others
  feelings/does not respond to name
• Non DSM Related
• Abdominal bloating/Diarrhea/Constipation
  Hypotonia
• Difficulty with Abstract Reasoning
  Decreased attention/hyperactivity
• Insommnia
• Obscessive-compulsive behavior
• Food Intolerances

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Common Laboratory Markers in ASD and Chronic
Lyme Disease
Mitochondrial Dysfunction - Urine organic acid
testing Cerebral Inflammation and
Hypoperfusion - Spect scans Generalised
Inflammation/Viral Issues - Urinary
neopterin/biopterin Chronic Low level Viral
Titers - Blood testing IgG Mediated Food
Sensitivities - Blood testing Methylation
Cycle Impairments - Urine amino acid blood
testing

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Lyme Western Blot Testing

Grier, T. Laboratory Tests. Lyme Times. Summer
200421-25
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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) Free antibody not
available (maybe bound into immune
complexes) Antibody levels fall late
in disease 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)

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• What To Do If You Get A Tick Bite
• See a doctor immediately. The sooner treatment
  is started the better the results are.
• 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
• Save the tick. Laboratories can test the tick
  for the presence of lyme and associated
  coinfections.
• If a rash develops take photographs. It may help
  your doctor in making the diagnosis
• Laboratories vary in terms of the depth of lyme
  testing provided. Dr. Patel prefers to use the
  following
• Igenex
• www.Igenex.com
• 1-800-832-3200
• Stony Brook Laboratories
• http//www.path.sunysb.edu/labsvs/tickpics/TICKpic
  .htm
• 1-631-444-3824
• Clongen Laboratories
• www.Clongen.com
• 1-301-916-0173

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• Testing and Treatment After Tick Bite
• Testing
• PCR (blood and Serum) for Lyme, Ehrlichia,
  Bartonella, Babesia, Mycoplasma
• FISH for Babesia
• 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 gt8 years. No treatment recommended
  for lt 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.

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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 143(9)1089-134. Epub 2006
Oct 2

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• 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 physicians 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)

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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 1319(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 Jul25 Suppl
1S52-6. 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 31114(13-14)601-5. S
eronegative 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
Jan42(1)32-42.

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Medical Literature Persistent Infection Well
Documented 74 Remained PCR Positive Despite
Extended Antibiotic Therapy. Bayer ME, Zhang L,
Bayer MH. Borrelia burgdorferi DNA in the urine
of treated patients with chronic Lyme disease
symptoms. A PCR study of 97 cases. Infection.
1996 Sep.245. 347-53. 30 Remained PCR
Positive Despite Multiple Courses of Adequate
Antibiotic Therapy. Nocton JJ, Dressler F,
Rutledge BJ, Rys PN, Persing DH, Steere AC.
Detection of Borrelia burgdorferi DNA by
polymerase chain reaction in synovial fluid from
patients with Lyme arthritis. N Engl J Med 1994
Jan. 3304, 229-34. 165 Lyme patients treated
for at least 3 months -gt 32 (19.4) relapsed
despite therapy -gt 38 of relapsers
were culture or PCR positive Oski J, Marjamaki
M, Nikoskelainen J, et al. Borrelia burgdorferi
detected by culture and PCR in clinical relapse
of disseminated Lyme borreliosis. Ann Med. 1999
Jun31(3)225-232. 64 year old female presents
with bullous and ulcerating lichen sclerosis et
atrophicus (LSA). Lyme serologies were
repeatedly negative. Borrelia burgdorferi was
isolated by live culture from enlarging LSA
lesions even after 4 courses of Ceftriaxone.
After 5th course of ceftriaxone, improvements
seen in skin and negative cultures for B.
burgdorferi. Breier F, Khanakah G, Stanek G,
Kunz G, Aberer E, Schmidt B, Tappeiner G.
Isolation and polymerase chain reaction typing of
Borrelia afzelii from a skin lesion in a
seronegative patient with generalized ulcerating
bullous lichen sclerosis et atrophicus. Br J
Dermatol. 2001 Feb144(2)387-92.

20

Two Standards of Care IDSA (Infectious
Diseases Society of America)
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 143(9)1089-134. Epub 2006
Oct 2