Report of Findings of a Clinical Case on Lyme Disease

By Deidre Chupalio

Acupuncture has been around and able to treat a multitude of mysterious symptoms and illnesses over its 3000-year history, including the most common vector-borne disease in North America, Lyme Disease (LD).

Understanding Lyme Disease

LD is transmitted by ticks infected with the spirochete Borrelia burgdorferi. The course of the disease varies among individuals, with the majority experiencing mild symptoms; however, in some cases of untreated Lyme, the infection can spread to the heart, joints, nervous system, and other organs. According to the CDC, although most cases of Lyme disease can be cured with a two to four-week course of oral antibiotics, many patients can experience pain, fatigue, or difficulty thinking for more than six months after treatment (Post-Treatment Lyme Disease Syndrome, 2019). This condition is called persistent Lyme disease or Post-Treatment Lyme Disease Syndrome (PTLDS).

Diagnosis and Early Treatment

According to research by Palmieri et al. (2013), current research on the diagnosis of early LD can be made on the clinical presentation of the classical bulls-eye rash or erythema migrans (EM) and on a history of known tick bite or probable exposure, as serologic testing is insufficiently sensitive in the early acute phase of LD. Supporting serologic evidence is necessary to secure the diagnosis for disseminated stages. The CDC (2019) recommends a two-tier approach for detection of B. burgdorferi-specific antibodies: IgM antibodies, produced during early weeks of LD, can help identify recent infections of B. burgdorferi; IgG antibodies, present >6 weeks after the onset of illness, rise to higher concentrations than IgM antibodies, and can persist for months or years. First-generation ELISA testing for the detection of anti-Borrelia antibodies lack specificity. The inclusion of a second, more specific serological method (Western blotting) is used to exclude false-positive ELISA samples (Palmieri et. al, 2013).

Patients suffering from early LD and EM are treated with antibiotics on an outpatient basis. Palmieri et al. (2013) suggests doxycycline (100 mg twice daily by mouth), amoxicillin (500 mg twice a day by mouth), or cefuroxime (250 mg twice a day by mouth) for 10–14 days, each equally efficacious. Doxycycline is often the drug of choice because it is also considered the treatment for the Gram-negative bacterium Anaplasma phagocytophilum, a potential tick-borne coinfection. According to Flaws & Sionneau (2011), approximately 10-20% of patients treated for LD with a recommended 2-week course of antibiotics will have lingering symptoms of fatigue, headache, musculoskeletal pain, arthritis, and lethargy, as mentioned previously, or PTLDS.

Researchers

Recent research on Lyme was performed by Yale University (2020) researchers, who expressed more than 1,000 human genes in yeast and analyzed their interactions with 36 samples of B. burgdorferi. They found that one protein, Peptidoglycan Recognition Protein 1 (PGLYRP1), acts like an early warning signal to the immune system when exposed to the bacteria. They found that, when exposed to the Lyme spirochete, mice lacking PGLYRP1 had much higher levels of B. burgdorferi than mice with the protein and showed signs of immune system dysfunction. Researchers reported that “stimulating the ability of people who make more of this protein could help fight infection and could explain why people with higher levels of PGLYRP1 may be less susceptible to infection by B. burgdorferi” (Yale University, 2020).

Alternative Approaches and Promising Drugs

New research conducted by a Stanford Medicine study in 2020 also shows great promise for Azlocillin, a drug which is not on the market yet, but was tested in mouse models of Lyme disease at 7-day, 14-day, and 21-day intervals and was found to eliminate the infection. According to research by Pothineni and Rajadas (2020) for the first time, Azlocillin was also shown to be effective in killing drug-tolerant forms of B. burgdorferi in lab dishes, indicating that it may work as a therapy for PTLDS. Pothineni and Rajadas have patented the compound for the treatment of LD and are working with a company to develop an oral form of the drug. Researchers plan to conduct a clinical trial in the near future.

Professor Monica Embers (Lymedisease.org, 2020) discusses the current treatment on LD and talked a great deal about how Borrelia spirochetes activate immune suppression, allowing it to evade eradication by the immune system. Her team has studied variable antibody responses among infected non-human primates and human Lyme patients. They noted a pattern in which an early robust immune (B-cell) response predicts better clinical outcomes, whereas more patients with persistent Lyme have indications of an impaired immune response. Given the current research on LD and PTLDS, it still mainly focuses on the Western pharmaceutical approach instead of whether traditional Chinese medicine using acupuncture and herbs can help manage these patients’ pain. The case study discussed in this paper will examine a 44-year-old female who was diagnosed with Lyme eight years ago and still struggles with the lingering symptoms of PTLDS.

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Chinese Medical Theory

Despite Borrelia burgdorferi’s recent classification from Lyme and Old Lyme, Connecticut 1975, as the bacterium causing the disease, ticks, and Lyme disease has been around for thousands of years (Lyme Disease Facts and Statistics, 2020). The concept of a pathogen that can penetrate the body’s defenses and then persist, causing chronic illness without necessarily killing the host, is ancient, with roots stretching back to the Shang dynasty, some 4,000 years ago (Maclean & Lyttleton, 2013). From the Han dynasty (206 BCE- 220 CE), the reference to lurking pathogens from the Huang Di Nei Jing Su Wen is well known. There are references scattered throughout the classical literature to persistent pathogenic phenomena, called Gu worms, or parasites of antiquity, sections of the Shang Han Lun and Wen Re Lun, and more recently Qing dynasty developments by Lei Feng and Liu Bao-Yi.

Concept of Gu Syndrome in Chinese Medicine

These lingering pathogens, as seen in PTLDS patients, are described as Gu toxins or Gu zheng, which can be translated as “possession syndrome” (Maclean & Lyttleton, 2013). This is how Chinese medicine diagnoses a person’s body when it is overcome by one or many parasitic-type organisms. The character Gu reflects “the idea of worms in a vessel, hinting at rottenness and decay, with the suggestion of the body being consumed from within, … where the vessel of the human body was inhabited by parasites and influences from the environment” (p. 502). This can be seen in the pictogram of one of the oldest characters, Gu, which in written language depicts worms breeding in a pot as seen here: .

According to Dr. Heiner Fruehauf, an acupuncturist who has been working with patients with LD for over 20 years, whether initiated by man-made Gu poisoning or by natural infection, a parasitic situation labeled as Gu syndrome traditionally indicates the presence of particularly vicious parasites, or a superinfection of many different kinds of parasites that combine their toxic potential to gradually putrefy the patient’s body and mind (ClassicalChineseMedicine.org, 2020). From a modern perspective this definition of Gu syndrome points to aggressive helminthic, protozoan, fungal, spirochete, or viral afflictions that have become systemic and inflammatory in an immune-compromised patient.

Treatment Plans

The clinical case study presented here is a patient who suffered with LD years ago, and still struggles with recurring symptoms to this day despite treatment with rounds of antibiotics years ago. Patient S.M. is a 44-year-old female who is currently suffering from fatigue, anxiety, and whole body musculoskeletal pain She is 5’2”, 104 pounds, and after her initial Lyme diagnosis in 2012, she was on high levels of antibiotics, 3-4 different types thrice daily. This is when she felt her body begin to “shut down.” She states that she switched to essential oils for her pain and symptom relief, instead of antibiotics, taking them internally, and began using cupping to alleviate pain. Prior to her diagnosis at age 36, S.M. states that she had given birth to a daughter. S.M. started getting extremely sick after the birth, which is when she was diagnosed with LD, and says she has “been in remittance” for a few years.

She has hiked all over the country and Canada and does not know when she picked it up or from where; she did not recall ever seeing a tick bite or bulls-eye rash. Prior to her Lyme diagnosis, she had had a history of lower leg problems including the foot, knee and big toes, which were operated upon and took longer to heal than expected. After her diagnosis, she developed arthritic pain and joint pain which persists to this day. Her current medications and supplements include vitamin D (10,000 IU/day), methylfolate plus, and glycine (due to methylation issues), and her allergies include Bactrim (sulfa meds), gluten, dairy, and nightshades. She also complains of night sweats and trouble sleeping—originally she had trouble staying asleep, but she now has trouble falling asleep as well. She is still experiencing menstrual cycles, but she has noticed them reduced to every other month and with slower flow, so she thinks she may be experiencing peri-menopausal symptoms in addition to PTLDS.

The treatment plan for this patient would include a treatment frequency of 2-3x/week for a minimum of 3-6 months. There would be a re-assessment every eight treatments and herbal formula adjustments every 2-3 weeks, depending on the patient’s reaction. The objective measurements to track the progress would include an increase in energy, or a reduction in anxiety, body pain, night sweats, and arthritic or joint pain. The following two treatment plans are what I would suggest for Patient S.M., including acupuncture, cupping and herbs. The etiology of her condition is: Taxation, Miscellaneous (tick bite), and 7 Emotions. The treatment principle for this patient is to: detoxify and move stagnant LV qi and blood, eliminate parasites, calm the spirit by nourishing qi and yin, and tonify qi and blood.

Treatment #1: Acupuncture Points and Rationale (bilateral):

GB 34 – soothe the LV qi and tonify tendon and sinews
SP 21 – Great Luo – whole body pain
PC 6 – Luo – harmonizes the qi and blood in whole body
Ren 17 – Mu of PC – descends qi in chest – helps lessen anxiety
LV 3/LI 4 – 4 Gates – regulates the LV and spreads qi to stop whole body pain
SP 6 – Luo – tonify 3 yin meridians
ST 36 with needlehead moxa – tonify qi in body for fatigue
HT 7 with KD 6 – for night sweats (yin xu heat)

*Cupping would be performed on the inner and outer UB lines to help with the back, neck and shoulder pain.

Herbal Formula: Jia Jian Su He Tang (Modified Perilla and Mentha Decoction)

Ingredients and Administration:

Zi Su Ye (Folium Perillae Frutescentis) 15g
Bo He (Herba Menthae) 15g
Dang Gui (Radix Angelicae Sinensis) 21g
Chuan Xiong (Radix Ligustici Wallichii) 15g
Gan Cao (Radix Glycyrrhizae Uralensis) 15g
Ze Lan (Herba Lycopi Lucidi) 6g
Bai Zhi (Radix Angelicae) 15g
He Shou Wu (Radix Polygoni Multiflori) 15g
Huang Qi (Radix Astragali) 15g
Bai He (Bulbus Lilii) 15g
Chen Pi (Pericarpium Citri Reticulatae) 6g
San Leng (Rhizoma Sparganii) 6g
E Zhu (Rhizoma Curcumae Zedoariae) 6g
Yu Jin (Tuber Curcumae) 3g
Mu Xiang (Radix Saussureae seu Vladimirae) 3g
Ding Xiang (Flos Caryophylli) 3g
Wu Jia Pi (Cortex Acanthopanacis Radicis) 15g

Add 3 slices of Sheng Jiang (Rhizoma Zingiberis Officinalis Recens). If patient becomes constipated after taking Jia Jian Su He Tang, switch to Su He Tang.

Treatment #2: Acupuncture Points and Rationale (all bilateral):

LI 11 – draining technique – clear heat
LI 4 – draining technique – Master command point for pain
UB 43 and UB 13 – garlic moxibustion – Back Shu of LU – tonify back
UB 23 and DU 4 – tonify KD and alleviate back pain
PC 8 – clear heat to help with anxiety
DU 16 – calm spirit and to eliminate sweating, headache and heaviness in body
SJ 5 and PC 6 – strongly move qi to alleviate pain

Herbal Formulas:

Su He Tang (if needed to change from Jia Jian Su He Tang) + Zhi Bai Di Huang Wan (for Yin Xu Night Sweats) + Modified Chai Hu Shu Gan Tang (With Duan Mu Li, Duan Long Gu and Zhen Zhu Mu) to spread LV qi, promote qi circulation, harmonize the blood and alleviate pain.

Instructions for Herbal Formula: Take Su He Tang if Jia Jian Su He Tang is not working after 2-3 weeks, but the patient must come back into the office and discuss how they are feeling after taking daily for a week to two weeks. Zhi Bai Di Huang Wan is to be taken for a week to see if it helps with the yin deficiency, while stopping the Jia Jian Su He Tang to address the Gu symptoms, and then possibly switched to a Modified Chai Hu Shu Gan Tang over the course of weeks or months after initial treatment. All must be managed and modified accordingly.

Food therapy would be discussed, as well as, supplement suggestions for S.M. She is advised to avoid the following: chicken, duck, fish, and shrimp, and all forms of sugar, honey, jujube dates, and other sweet substances. This is discussed in Chinese texts including Zhigu Xinfang (New Approaches to Gu Therapy) from 1823, in which the patient is advised to increase amounts of the following: tofu, celery, cabbage, spinach, lotus root, shiso (perilla) leaves, peppermint, garlic, horseradish, ginger, bitter melon, black mu’er fungus, lychee, longan, oranges, tangerines, grapefruit, plums, pomegranates, watermelon, vinegar and green tea (Quinn, 2016). However, if any of these items should further aggravate the condition, it should also be avoided. Supplement suggestions for this patient would include: 5HTP, CBD, magnesium glycinate, vitamin B6 and vitamin B12.

Alternative Approaches to Treating Lyme Disease

There are alternative and new approaches that are available in treating LD. According to Lymedisease.org (2020), Professor Tim Haystead and a team of researchers from Duke University are currently working on identifying B. burgdorferi infection using a “small molecule imaging probe” similar to imaging techniques. They are working on developing targeted therapy comparable to cancer treatments. As Haystead explains, similar to the way the HER2 gene is identified, the “Hsp90” protein is found in all mammalian cells. The bacterial equivalent of Hsp90, called “HtpG” protein, is found in most bacteria. This Hsp90 protein enables our genes to multiply and Haystead and the Duke researchers discovered that Borrelia uses the HtpG proteins in a similar manner. Haystead described the concept of molecular targeted therapies, which includes one method of using drugs to selectively target the Borrelia protein (HtpG) while avoiding normal human tissue and other healthy bacteria. The other method will use a fluorescent biomarker, meaning that it is activated by light, which can be used both as a direct diagnostic tool and to selectively deliver targeted drugs.

The most promising drugs identified by Duke researchers are being sent to Johns Hopkins to be tested for effectiveness against Borrelia. The researchers at Johns Hopkins will then select the most effective drug candidates and send them to Embers’ team at Tulane, to be tested on animals, with human trials as the final phase. Haystead says he and his team have identified three different targeted therapies and plan to start testing them in January 2021.

Biomedical Considerations

There are a few newly identified biomedical markers to measure progress for LD, according to Professor Mark Soloski of Johns Hopkins University, who presented research being done at the JHU Lyme Disease Research Center (Lymedisease.org, 2020). The research center has been conducting a years-long “Study of Lyme disease Immunology and Clinical Events (SLICE)” on a set of clearly defined patients diagnosed with early Lyme and treated with a standard course of antibiotics. The SLICE study looks at how the immune system (mostly T-cells) responds to LD and has compiled a comprehensive serum profile of two types of Lyme patients—those who get better and those who do not.

Soloski (Science Daily, 2020) says there are patterns of immune response, but that it is still not known how or why T-cells vary from one patient to another for those with PTLDS. In general, the patients with milder symptoms appear to have normal white blood cell and liver levels, while the patients with more symptoms show low lymphocytes and higher liver levels (Lymedisease.org, 2020). In addition, the JHU researchers have found that a signaling protein (chemokine), specifically the T-cell chemokine known as CCL19, remains elevated in the group of patients who do not improve following standard treatment for LD. In the 70-90% of patients who do return to normal function after treatment, the CCL19 levels began returning to normal at 3-4 weeks post-treatment. In the PTLDS patients, the CCL19 remains elevated at one year post-treatment. Soloski is also interested in studying how microglial cells and dendritic cells impact the disease process.

Community Resources

There are many useful community resources at www.lymedisease.org (2020). The website focuses on providing free resources for both members and non-members. For an additional cost, the website grants members access to a multitude of research and informative articles. It features resources regarding LD prevention, a patient resource guide to tick testing, symptoms of LD, the patient’s guide and co-infections chart, and a community resource network called MyLymeData. This network allows thousands of LD patients to share their symptoms and stories to create a supportive community. There is also a feature on the website called Lyme Action Network that provides information and statistics for families and those suffering with PTLDS.

Prognosis

According to Flaws and Sionneau (2011), most patients respond to appropriate therapy with prompt resolution of symptoms within 4 weeks—if treated and diagnosed within the short and proper timeframe. Prolonged courses of antibiotic therapy for nonspecific symptoms that persist after completion of appropriate assessment and treatment of LD are not recommended (Palmieiri et al., 2013). The long-term outcome of adult patients with LD is generally favorable, but some patients have chronic complaints, as in the clinical case discussed and presented, for which many other patients may walk into our offices seeking treatment. Joint pain, memory impairment, and poor functional status secondary to pain are common subjective complaints in patients with LD, but physical examination and neurocognitive testing fail to document the presence of these symptoms as objective sequelae (Frehauf, 2020). Similarly, in highly endemic areas, patients with a diagnosis of LD commonly complain of pain, fatigue, and an inability to perform certain physical activities when followed for several years (CDC, 2019).

Summary of Key Learnings

Lyme disease is a single infection that can turn into a lifetime of debilitating pain. Over the years we have discovered that this one-time event can have longstanding effects on the body in the form of arthritis and joint pain, degeneration of the muscles, spine, and brain, and even heart conditions. Over the course of my research for this project, I found that there are options and many more discoveries coming in this field. There are alternative approaches and future possibilities for prevention, whether through targeted therapies or a vaccine. I also discovered is that, in the clinic, the patient often does not perfectly fit a simple diagnosis. These patients suffering with LD or Gu syndrome must be treated with a unique multi-disciplinary approach with acupuncture, herbs, food therapy and other modalities if applicable. I’ve learned to be even more patient with whoever walks in my door, because at the end of the day we have no idea what some people are dealing with and suffering from in silence.

References

Flaws, B., & Sionneau, P. (2011). The Treatment of Modern Western Medical Diseases with Chinese Medicine (Expanded Edition). Blue Poppy.

Fruehauf, H. (2020, September 18). Driving Out Demons and Snakes: Gu Syndrome, A Forgotten Clinical Approach to Chronic Parasitism. ClassicalChineseMedicine.Org. Retrieved from: https://classicalchinesemedicine.org/driving-out-demons-and-snakes-gu-syndrome-a-forgotten-clinical-approach-to-chronic-parasitism

Lyme disease: a case report with typical and atypical lesions. (2017, March). PubMed Central (PMC). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372433/

Lyme Disease Facts and Statistics. (2020, October 1). Bay Area Lyme Foundation. Retrieved from: https://www.bayarealyrg/about-lyme/lyme-disease-facts-statistics

LymeDisease.org – Advocating nationally for quality accessible healthcare for patients with Lyme disease. (2020, December 2). LymeDisease.Org. Retrieved from: https://www.lymedisease.org/

Maclean, W. & Lyttleton, J. Clinical Handbook of Internal Medicine: The Treatment of Disease with Traditional Chinese Medicine. Vol 3. (2013). Pangolin Press: Australia.

Palmieri, J. et. al. (2013). Lyme disease: case report of persistent Lyme disease from Pulaski County, Virginia. (2013). PubMed Central (PMC). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862396/

Post-Treatment Lyme Disease Syndrome. CDC. (2019, November 8). Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/lyme/postlds/index.html

Pothineni, V. & Rajadas, J. (2020, March 12). Potential treatment for Lyme disease kills bacteria that may cause lingering symptoms, study finds. News Center. Retrieved from: https://med.stanford.edu/news/all-news/2020/03/potential-treatment-for-lingering-lyme-disease.html

Quinn, B. (2016, January 15). Voice From the Mountaintop: Dr. Heiner Fruehauf on Traditional Chinese Medicine and Lyme. Lyme Nation. Retrieved from: https://www.lymenation.org/voice-from-the-mountaintop-dr-heiner-fruehauf-on-traditional-chinese-medicine-and-lyme

Scientists identify protein that protects against Lyme. (2020, November 11). ScienceDaily. Retrieved from: https://www.sciencedaily.com/releases/2020/11/201111144333.htm

Yale University. (2020, November 11). Scientists identify protein that protects against Lyme. ScienceDaily. Retrieved from: www.sciencedaily.com/releases/2020/11/201111144333.htm

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