Hartford Marriott Farmington, CT 2426 March 2000
Babesiosis has previously been regarded as a benign self-limiting illness; however recent evidence has shown that patients who are either immuno-compromised or co-infected with Borrelia burgdorferi and/or HGE are at risk for a more severe chronic disease state (Krause et al, JAMA 1996 June 5: 275(21): 1657-1666). Krause also noted persistent parasitemia after acute Babesiosis (NEJM 7/98, Vol 339, 160-165) when patients received Cleocin+Quinine (C+Q), and Horowitz described chronic persistent Babesiosis after acute treatment with Cleocin+Quinine (C+Q) and Atovaquone and Azithromycin (M+Z) (Abstract, 12th International Scientific Conference on Lyme Disease and Other Spirochetal & Tick-Borne Disorders, April 1999, NYC), with persistence of Babesial DNA despite repeated courses of both antibiotic regimens. This report describes clinical improvement in a cohort of co-infected Lyme patients using Mefloquine (Lariam) + Artemesia (L+A) as either first-line treatment for infections with Babesia microti, or after having filled standard regimens with C+Q or M+Z.
Babesia microti infections were diagnosed among a cohort of 70 chronic Lyme patients using IFA and/or PCR analysis. Patients were divided into 2 treatment groups: 52 patients (Group l) took 5 weeks of L+A, and 18 patients (Group 2) took 12 weeks of L+A. The first group was further subdivided into 25 patients taking L+A alone, and 27 patients using L+A with 1 dose of sulfa 1500mg (Gantricin) and Pyrimethamine 25mg (Daraprim) at the beginning of therapy. Patients received a loading dose of Mefloquine 250mg 5 capsules lx, followed by 1 capsule per week with Artemesia 250mg, 2, 3x per day. Group 2 received L+A for 12 weeks in combination with other antibiotics for Lyme and/or Ehrlichiosis. Patients received Compazine 10mg and Antevert (Meclizine) 25mg 1 hour before the loading dose, and subsequently every 6-8 hrs prn for nausea and dizziness. Patients filled out the Karnofsky scale after completing their therapy to evaluate ongoing symptomatology.
All patients completed the treatment regimen as prescribed. The most common side effects were dizziness and nausea, lasting for up to 3 days after the loading dose of 5 pills, with rare neuropsychiatric symptoms (anxiety/depression). Administration of the loading dose over 34 days decreased these side effects. In Group 1, among the 25 patients taking L+A alone for 5 weeks, there was a 21.5% mean improvement in symptoms (decreased fatigue, joint and muscle pain, sweats, fevers, or chills, headaches, and cognitive difficulties) with a 12.5% median improvement as evaluated by the Karnofsky scale. Among the 27 patients taking L+A+sulfa/pyrimethamine, there was an 18.5% mean improvement, and a 12.5% median improvement in symptoms. 37 patients from Group l were tested by PCR analysis at least 4 weeks post therapy, and 3/37 (8%) were found to be PCR positive. Among 18 patients taking L+A for 12 weeks (Group 2), there was a 10.3% mean improvement with a 12.5% median improvement, with 2/9 (22%) patients tested remaining PCR positive post therapy .
Mefloquine+Artemesia is a new and improved treatment regimen for chronic persistent Babesiosis. This regimen has been studied and shown to be effective in malaria (Antimalarial Activity of Mefloquine and Qinghaosu (Artemesia): Lancet, Aug 1982, 285-289), but has never been studied in patients with infections with Babesia microti, a malarial-like illness. Optimal effectiveness was seen with a 5-week cours; however certain patients were PCR positive post therapy, and needed retreatment with either a different regimen, longer course, or higher doses of L+A (2q 5-7 days), which occasionally was of clinical benefit. Treatment failures have therefore been seen with all presently available antibiotic regimens for Babesia microti and may reflect an exoerythrocytic stage of infection establishing a chronic carrier state. Further research is necessary into the role, diagnosis, and treatment of piroplasms in co-infected Lyme patients.