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Raj Patel, MD

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: 20+ years clinical experience

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Raj Patel, MD

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  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: 20+ 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 570 Price Avenue, #200 Redwood City, CA 94063 650-474-2130 http://www.DrRajPatel.net Raj Patel, MD

  2. 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. 2013 CDC estimates 300,000 new cases annually Raj Patel, M.D.

  3. Reported Cases of Lyme Disease, United States, 1995-2009 National Surveillance case definition revised in 2008 to include probable cases; details at http://www.cdc.gov/ncphi/disss/nndss/casedef/lyme_disease_2008.htm Raj Patel, M.D.

  4. Vector Life Cycle www.cdc.gov/ncidod/dvbid/lyme/ld_transmission.htm Raj Patel, M.D.

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  6. Lyme Disease Overview Tick bites frequently transmit multiple infections: Borrelia Ehrlichia/Anaplasma Babesia and other piroplasms Bartonella like organisms Raj Patel, MD

  7. Lyme Disease Overview (con’t) Other possible coinfections to consider in differential diagnosis: Bacteria - Mycoplasma, Chlamydia, RMSF, Tularemia, Q-Fever Parasites - Filarasis, Amebiasis, Giardiasis, … Viruses – EBV, CMV, HHV6, XMRV, Borna virus, Powassan virus, … Transmission: Ticks Mosquitos, Fleas, Rodents Transplacental Breast milk Sexual Raj Patel, M.D.

  8. 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) Raj Patel, M.D.

  9. 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 Raj Patel, M.D.

  10. 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. Raj Patel, M.D.

  11. Lyme Disease Classic Symptoms Associated with Ehrlichia / Anaplasma Myalgias Sharp knife like headaches behind eyes Low WBC count Elevated liver enzymes Raj Patel, M.D.

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  13. Lyme Western Blot Testing Raj Patel, M.D. Grier, T. Laboratory Tests. Lyme Times. Summer 2004:21-25

  14. 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) Immuno-deficiency Presence of non-Borrelia burgdorferi species 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) Raj Patel, M.D.

  15. 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 Raj Patel, M.D.

  16. Testing and Treatment After Tick Bite • Testing • PCR (blood and Serum) for Lyme, Ehrlichia, Bartonella, Babesia, Mycoplasma especially early in course of infection • FISH, PCR, or blood smear for Babesia • FISH or PCR for Bartonella • 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 >8 years. No treatment recommended for < 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. Raj Patel, M.D.

  17. 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 1;43(9):1089-134. Epub 2006 Oct 2 Raj Patel, M.D.

  18. 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 physician’s 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) Raj Patel, M.D.

  19. 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 1;319(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 Jul;25 Suppl 1:S52-6. “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 31;114(13-14);601-5. “Seronegative 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 Jan;42(1):32-42. Raj Patel, M.D.

  20. Ticks: Year round threat with Spring and Summer being prime time Carried by deer as well as other animals to your yard Mice become carriers when infected ticks feed on them. Subsequently, when non-infected ticks feed they become infected Found in cool moist areas, around shrubs and woody areas, tall grass, and around the edge of yards Ticks prefer moist skin folds: Back of neck Inside part of elbows and knees Hairlines In and around ears Protecting Yourself Raj Patel, M.D.

  21. Protecting Yourself Keep your pets protected: Particularly susceptible, frequently bringing deer ticks into your house Use Frontline or K9 Advantix monthly for cats and dog Use Damminix tubes to reduce deer ticks by more than 90% (tubes filled with cottton treated with Permethrin) Raj Patel, M.D.

  22. Minimize Exposure: Yard Prevention Yard prevention very important Keep lawn mowed, cut down brushy areas, & clear away leaves Trim trees to ensure adequate sunshine Creating a 3 ft. wide wood chip or gravel border and stone wall can reduce ticks by 50% Hiking Precautions Walk in middle of trails Wear light colored clothing Wear gloves, hat, long sleeves Use Deet type repellent on exposed skin Use Permethrin tick repellent on clothing Check yourself thoroughly afterwards After possible exposure take clothing and place in dryer at high heat for 15 minutes to kill ticks left behind Protecting Yourself Raj Patel, M.D.

  23. Lyme Disease vs. Mold Illness • Symptoms overlap greatly (fatigue, cognitive dysfunction, GI symptoms, arthralgias, myalgias, paresthesias, & mood changes) • Both trigger a Chronic Inflammatory Response with similar laboratory abnormalities. • Coexistence of these conditions present unique challenges especially in lyme and mold susceptible or multi-susceptible individuals. Raj Patel, MD

  24. Tips on Treating Lyme and Mold Illness 6 Steps: 1. Eliminate exposure to WDB. 2. Reduce biotoxin load and inflammation with Cholestyramine Raj Patel, MD

  25. Tips on Treating Lyme and Mold Illness 3. Identify and treat underlying infections a. GFCFSF diet b. Probiotics c. Minimize inflammation by supporting excretion of biotoxins (CSM, exercise, fluids, anti-inflammatory agents) d. Support energy levels (sleep, rest, mitochondrial and endocrine support) e. Go SLOW! Raj Patel, MD

  26. Tips on Treating Lyme and Mold Illness 4. Treat MARCONS 5. Correct all inflammatory markers (C4a, MMP9, VEGF, ADH, TGFb1) 6. Treat with VIP (if unable to tolerate VIP, look for occult infections or hidden mold exposure.) Raj Patel, MD

  27. *17 Reasons Lyme Patients Don’t Get Well 1. All co-infections have not been successfully identified and eradicated 2. Immune Dysfunction -autoimmune -immune deficiency 3. Inflammation -calm inflammatory response -frequently triggered by infections/toxins -address pain *Why Can’t I Get Better? Richard Horowitz, MD ISBN-10: 1-250-01940-0 Raj Patel, MD

  28. *17 Reasons Lyme Patients Don’t Get Well 4. Toxicity -heavy metals -environmental illness -mold/mycotoxins -EMF 5. Allergies/Sensitivities 6. Nutritional/Enzyme Deficiencies 7. Mitochondrial dysfunction 8. Psychological dysfunction -depression -PTSD -anxiety -Abuse *Why Can’t I Get Better? Richard Horowitz, MD ISBN-10: 1-250-01940-0 Raj Patel, MD

  29. *17 Reasons Lyme Patients Don’t Get Well 9. Neurological dysfunction 10.Endocrine disorders -Thyroid -Testosterone -Adrenal 11.Sleep disturbances -Stage 4 -Sleep Apnea 12. Autonomic dysfunction 13. GI disorders (Ehrlichia, Tularemia, Rickettsia, Borrelia species, Celiac, HHV6) *Why Can’t I Get Better? Richard Horowitz, MD ISBN-10: 1-250-01940-0 Raj Patel, MD

  30. *17 Reasons Lyme Patients Don’t Get Well 14. Liver dysfunction 15. Pain 16. Deconditioning *Why Can’t I Get Better? Richard Horowitz, MD ISBN-10: 1-250-01940-0 Raj Patel, MD

  31. THANK YOU Raj Patel, MD

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