10 March 2014 A Doctor's Guide: How to Miss Co-infections and Kill Patients
This week in our "Breakfast with Brooks: Waffle and Fudge" series, which analyses the answers to patients' questions given by Dr Tim Brooks, head of Britain's Lyme testing unit at RIPL, the biowarfare research lab at Porton Down, we look at the issue of tick-borne co-infections.
Each of Dr. Brooks' answers is given a rating out of ten for two parameters: MW (Meaningless Waffle) and FTI (Fudging the Issues). We also occasionally award marks out of ten for Truth, when and if we detect any.
Question 6 Why is no further consideration given to the possibility of tick-borne co-infections in patients who test negative for these at regional labs, given the multiplicity of strains and the fact current tests are only able to detect a fraction of these pathogens?
Dr. Brooks' Answer
A wide range of tests for tick-borne infections is available to the NHS through local laboratories and the service offered by RIPL, other PHE laboratories and associated laboratories in NHS centres. These cover everything from Crimean Congo Haemorrhagic Fever to Q Fever.
Tests are selected according to the presentation of the patient, and the likely exposure history by the referring physician. If clinical details are provided that suggest another infection is involved, RIPL automatically includes relevant tests when indicated.
MW =10 FTI=10
Elena Cook's Comment:
The question addressed a key issue - that of the insensitivity of tests used to detect co-infections in the UK. In his by-now-so-familiar "fudge" style, Dr. Brooks avoids the issue altogether, waxing lyrical instead about the "wide range" of tests on offer.
Is this an acceptable answer?
Well, close your eyes for a moment, and imagine that, rather than a pain and fatigue-wracked Lyme patient, you are a healthy fishmonger.
Now imagine that Dr. Brooks is not a stone-hearted biowarfare scientist in charge of UK Lyme diagnostics, but a reasonably ethical and conscientious food inspector.
One day, without warning, Dr. Brooks the food inspector walks into your shop and enquires about the freshness of your stock.
Which is your reply:
1. I assure you everything is fresh, sir, here is my list of suppliers, my records of date of purchase, etc...
2. We stock everything from kippers to Atlantic bluefin tuna.
Would Dr. Brooks the food inspector find the second answer acceptable? No. And neither should we be satisfied with his.
Let's take the dangerous tick-borne co-infection Human Granulocytic Anaplasmosis (HGA) for example. According to Dr. Brooks' recent report to the Health and Safety Executive (1), this disease is to be diagnosed either by antibody tests, or blood smear.
But several recent studies show that the antibody response to HGA is often delayed, so that this method may not be useful in the acute period. Does it matter if the patient is diagnosed in the acute period or not? Yes, it most certainly does, although to read what Dr. Brooks has told the HSE, you could be forgiven for thinking otherwise. Brooks states that most HGA infections "resolve within 30 days even without treatment." Though he does admit that serious disease can occur, he maintains that this only happens in "special circumstances", such as immunosuppression or cancer.
Other authorities would beg to disagree. Chinese scientists, for example, warn that "misdiagnosis may result in severe multi-organ symptoms or even death in healthy adults and children.(2) (my emphasis).
Rather than a disease which fades away even without treatment, they found that in one province, "100% of patients had severe clinical manifestations." The fatality rate of HGA in China is 26.5%. (3)
With usual condescension towards non-western scientists, PHE would undoubtedly pooh-pooh this finding on the grounds that the researchers were Chinese.
Well, what about Dr. Brooks' tick-borne disease co-thinkers in the US, where HGA and other ehrlichioses are a bit better recognised? Dr. Stephen J. Dumler is a co-author of the atrociously flawed IDSA guidelines denying the reality of chronic Lyme. He was also co-author, with Dr. Susan O'Connell and other Denialists, of the offensive Lancet article a few years ago, which caricatured anyone who believes that Lyme disease is not easily cured as an "antiscience" extremist. He has also written many other papers best consigned to the compost heap. In short, a pillar of Lyme Denialism and a man after Tim Brooks' own heart.
Yet even he found that while one third to one half of patients developing complications of HGA ended up hospitalised, nevertheless only 6 percent had an underlying condition causing immunosuppression. (4)
What about blood smear, the other diagnostic method recommended by Brooks? The bacteria which cause HGA take up residence inside white blood cells, and can be seen on staining under the microscope. So this would seem a good method.
Unfortunately, it does not always work. According to Dumler, at best, blood smear misses a quarter of patients. At worst, it only catches a quarter. Moreover the sensitivity of the method declines after the first week, and can also be decreased by Doxycycline treatment (though treatment must never be delayed because of this.)
There are other methods known. Polymerase Chain Reaction (PCR), for example, is reported by various authors to be a good method. However, Dr. Brooks does not recommend this method in his report to the HSE.
With insensitive tests in use, it would seem more important than ever that doctors are informed enough to make a clinical diagnosis. However, few NHS doctors, faced with a febrile patient with flu-like symptoms, low white cell count, low platelets, and elevated liver enzymes would ever suspect HGA, even in a tick-infested area in the middle of the tick season. In fact, most British doctors have probably never heard of it.
If HGA is, as Brooks told the HSE, very rare, then perhaps it does not matter so much. But how do we know that it is rare?
A recent paper noted that 18.7% of shrews in an English forest showed evidence of HGA infection. Shrews are commonly parasitised by the same ticks that carry Lyme.
Clearly HGA is present here. And HGA can kill - rapidly. Can our Health Service really afford to be as complacent as Dr. Brooks would like it to be?
Question 7 is devoted to Babesia, so we won't discuss it now. But what about Bartonella? Bartonella does not even garner a mention in Dr. Brooks' report to the HSE, although Crimean-Congo Haemorrhagic Fever does.
Well, barring a biowarfare attack (or an escape from Dr. Brooks' Porton biowar lab), a patient bitten in the UK is unlikely to come down with Crimean-Congo Haemorrhagic Fever. But what about Bartonellosis?
Finding information about Bartonella in the UK is not so straightforward. If you (or your doctor) should visit the tick-borne disease section of Public Health England's website, you won't even find it listed.
However, in the unlikely event of a UK doctor being aware that Bartonellosis can be acquired by tick-bite, he or she could eventually find information by using the "A-Z" index of the website. There he would discover that Bartonellosis is diagnosed at PHE's Colindale lab, generally by serology (antibody tests). Just over 100 people are diagnosed each year, but because the two strains tested for, Bartonella henselae and Bartonella quintana, can be acquired from a cat scratch and from body lice respectively, there is no way of telling from this statistic just how many cases were tick-acquired.
Still, the fact that Bartonella is absent from PHE writings on tick-borne disease suggests the proportion may be very low. After all, they are not likely to test for something which they do not appear to accept exists, are they?
PHE's testing protocol notwithstanding, it is known that patients can suffer from chronic Bartonella infection and still be negative on antibody tests in use, even when the bacteria is present in their bloodstream.(5)
There are many other co-infections known to occur in Lyme Disease patients, and in general there is a huge overlap between their presentations, and that of Lyme itself. However, none of them seem to have merited so much as a mention in the Tick-borne Diseases section of PHE's website. Dare we guess that it is pointless to enquire about the sensitivity of testing for them, as none is ever carried out?
Question 7
Given that the CDC has admitted it has no test capable of ensuring the blood supply is safe as far as Babesiosis is concerned, why are UK patients reporting tick bite and babesiosis-like symptoms told this disease has been ruled out?
Dr. Brooks' Answer
Who is giving whom this response, and in what context?
MW=10 Elena Cook's Comment:
Now, that's an old trick. When you can't or don't want to answer a question, you respond by asking one yourself instead.
Well now, let's look at Dr. Brooks' question a bit more closely. It has an air of wounded pride about it, no? As if to say:
We at PHE have ensured that Britain is unrivalled at Babesiosis detection. Which unprincipled quack out there has been tarnishing our sterling reputation by falsely advising patients their Babesiosis has been ruled out?
Well, let's run through a few facts:
1. The Tick-borne disease section of PHE's website states that Human Babesiosis is found ONLY in patients who have had their spleen removed (even though the fact that healthy people with intact spleens can get it was described as far back as the 1970's).
2. In his report to HSE, Dr. Brooks explains that one of the symptoms of Babesiosis is enlargement of the spleen.
The spleen?
Yes, the spleen.
What spleen?
Why, the surgically removed spleen, of course. Somewhere, perhaps 100 miles away, a spleen sitting in a jar of formaldehyde in a pathologist's cupboard mysteriously enlarges - out of sympathy, no doubt, with its former owner, who, it senses, has been bitten by a tick.
But, more seriously, what do we make of this apparent paradox? On the one hand, PHE tells us you can't acquire Babesiosis unless you have lost your spleen, on the other hand, they tell us, one sign of Babesiosis in an enlarged spleen? What is going on?
Well, you see, biowarfare scientists who lie about serious public health matters are a bit like spiders on Smirnoff. Sooner or later, they are bound to end up entangled in a web of their own making.
So what about detection methods? Well, (no doubt because even the most experienced clinician might find it a bit tricky to palpate a non-existent spleen), PHE rely on antibody tests and blood smear (as in HGA).
I was unable to find any incidence figures for the period from 2011 onwards. However, in response to a FOIA request recently, PHE coughed up the figures for the seven-year period ending in 2011. Five patients were positive on the antibody tests during those seven years.
"What, only five British patients acquired Babesia in seven years? In a country of almost 64 million people?! That would seem a less than stellar detection rate."
Wait a minute, whoever said that all five were diagnosed with Babesia? Dr. Brooks insists, in his report to HSE, that only blood smear is definitive, and no one without a positive one should be treated. Only one of the five patients had a positive blood smear.
"What, only one patient acquired Babesia in the UK in 7 years?!"
Hang on, whoever said it was acquired in the UK? The report clearly states that the patient got her Babesia infection in the US.
"What, ZERO cases of UK-acquired Babesiosis diagnosed in seven years?!"
Yes. And this despite the fact that our wildlife is teeming with Babesia parasites.
How do we know it is teeming with Babesia? Well, because PHE told us so in the 1996 issue of the PHLS bulletin* (PHLS is the old name for PHE.)
So, Dr. Brooks, you needn't demand, in your self-righteous way, "who is giving this response to whom?", as if to say, "who is the unprincipled quack sabotaging our excellent Babesia detection rate."
I think we know who he is.
References 1. http://www.hse.gov.uk/aboutus/meetings/committees/acdp/161012/acdp_99_p62.pdf 2. Dong T, Qu Z, Zhang L (2013) Detection of A. phagocytophilum and E. chaffeensis in Patient and Mouse Blood and Ticks by a Duplex Real-Time PCR Assay. PLoS ONE 8(9): e74796. doi:10.1371/journal.pone.0074796 3. Wang et al, "Molecular charcterisation of msp2/p44 of Anaplasma phagocytophilum from infected patients and Haemaphysalis longicornis in Laizhou Bay, Shandong Province, China" PLoS ONE 2013 8(10): e78189 4. Dumler et al, "Ehrlichioses in humans: epidemiology, clinical presentation, diagnosis and treatment" CID 2007:45 (Suppl) S45. 5. Maggi et al, "Bartonella henselae bacteremia in a mother and son potentially associated with tick exposure", Parasites and Vectors, 2013 b:101 6. http://www.hpa.org.uk/CDR/archives/CDRreview/1996/cdrr0396.pdf This is the same issue, incidentally, which admitted that Lyme Disease is a cause of dementia, in agreement with Drs. Alan Macdonald and Judith Miklossy. You can read more about that in my blog post at http://www.elenacook.org/blogalzh10feb14.htmlHowever, PHE certainly do not talk about this today, and as mentioned above, Dr Brooks' predecessor, Dr Susan O'Connell published an article declaring that all those who believe in persistent Lyme infection are harmful extremists. END The articles by Elena Cook on this website may be distributed as long as they are reproduced without changes, attributing the author, and the link to the original URL is included.
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posted
Sounds like the PHE in England is even more deceptive than the CDC on lyme incidence/testing!
I think here (US) the huge increase in lyme infection must be hitting some friends/relatives/ selves among the nation's movers & shakers, and money for research and more accurate statistics are beginning to come out, CDC or no CDC.
One thing I have to say in favor of lyme and co-infections, is that it does not discriminate between the bourgois and the aristocrats Posts: 254 | From North Carolina | Registered: Nov 2013
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Catgirl
Frequent Contributor (5K+ posts)
Member # 31149
posted
quote:Originally posted by Nancy L: One thing I have to say in favor of lyme and co-infections, is that it does not discriminate between the bourgois and the aristocrats :)
Yes, and they will understand what it feels like when they deteriorate--no fun when no one or medical system believes them (karma).
-------------------- --Keep an open mind about everything. Also, remember to visit ACTIVISM (we can change things together). Posts: 5418 | From earth | Registered: Mar 2011
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quote:Originally posted by Nancy L: Sounds like the PHE in England is even more deceptive than the CDC on lyme incidence/testing!
I'm sorry to have to say this, but the people purporting to represent patients here are also far more gullible than in your country.
In recent years, our main Lyme campaign has become so subservient to PHE that they no longer invite ILADS doctors to the conferences here. Some of our self-appointed leaders even pass on to patients the misinformation that originates with PHE, IDSA etc..
I'm sorry to have to say that, but it's the truth. The fact that we have the lowest detection rate in Europe, and the fact that we have the most spineless Lyme Disease campaign leaders, are probably not unrelated.
Elena
-------------------- Justice will be ours. Posts: 786 | From UK | Registered: Oct 2007
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