The Great Masquerader

Many people who have chronic Lyme (usually not treated immediately after infection, or with inadequate treatment remain sick for more than a year) are misdiagnosed with other things since the manifestations of Lyme can vary so widely. Some people may have all the symptoms, some people just one or two. The classic constellation of symptoms may include:

• Fatigue – may be overpowering and debilitating
• Sleep issues – either too much sleep or insomnia
• Pain syndromes – joint pain, muscle pain, nerve pain, migraines
• Neuropsychiatric – “brain fog,” mood swings, rages, depression, anxiety, OCD, neurosis, psychosis, loss of cognitive function
• Gastrointestinal – an often-overlooked source of GI issues
• Cardiac - heart block, POTS, other irregular heart rhythms and carditis

Less than 50% of Lyme patients remember a tick bite PMID 24749006, and among those who do, only about 10% get the classic bullseye rash. (Smith, 2002)
Most people aren’t tested for Lyme until the standard medical explanations have been thoroughly explored and exhausted without providing relief.

Literally. Bb has a mobile corkscrew form called a spirochete that can burrow through the tissues anywhere in the body. It can corkscrew into cells where it drops its cell wall.

This presents some difficulties:

The antibiotics that work on the mobile form can’t make it inside cells. Different antibiotics are needed to reach inside cells.
Regardless which antibiotics are used, the bacteria have dropped the outer coat proteins, so the antibodies the immune system produced to target and kill the spirochetes can’t recognize or bind to this cell-wall deficient form.
In a stroke of eerie genius, the Borrelia organism can also coat itself in proteins and lipids from the host cell on its way in, effectively making it look like part of the body itself.
Additionally, when Bb is presented with a threat such as antibiotics, it can enter a cyst/round body form that requires yet other antibiotics and help from different antibodies from the immune system to suppress the organism.

It’s complicated chasing down a bug that can produce an array of different outer surface proteins, each requiring a different immune response. It’s like a criminal with numerous disguises and detection-evasion skills.

This is Dr. Joseph Burrascano’s apt description of ticks. They don’t just carry Lyme. They carry dozens of microbes including bacteria, viruses, protozoa and other organisms.

Rocky Mountain Spotted Fever is carried by many different types of ticks including wood and dog ticks and can be fatal in a severe case if not promptly treated. The same is true of Powassan virus, Heartland virus, and a number of other emerging infections that are becoming more prevalent.

In addition to Bb, many patients are infected with other organisms when they are bitten by a tick. Common findings are Bartonella, Babesia, Mycoplasma and Rickettsial species, just to name a few. Occasionally we will find Tularemia or Brucella.

Patients with co-infections often have more severe and complex presentations. For those not fortunate enough to be treated promptly for Lyme upon infection, co-infections play a significant role in the symptom complex and can impact many body systems. In later stages, co-infections can be equally challenging as the Lyme itself to treat.

In chronic cases, we often treat multiple infections and downstream impacts on every body system. There is evidence for chronic persistence of each of these infections.

For more information about types of ticks and what they can carry visit https://www.lymedisease.org/types-of-ticks/

The most commonly used tests such as ELISA and Western Blot for Lyme rely on the body’s ability to produce antibodies. Those infected with Lyme have suppression of the B-lymphocytes, the white blood cells responsible for producing antibodies. Therefore, it is not at all unusual to see the sickest patients return negative antibody tests. In these cases we must use direct tests, meaning tests that look for the DNA of the microbe directly such as FISH, PCR and culture in samples taken from blood, urine, CSF, etc. Unfortunately, the sensitivity of all these tests is low.

The Western Blot has a much better sensitivity, but often isn’t ordered because the ELISA screening test misses over 50% of those who are actually infected.

• Overall, the two-tiered system of testing for Lyme misses 56% of those infected. (Stricker 2007)
• 52% of patients with chronic disease are negative by ELISA but positive by Western blot. (Donta 2002)

Use a reputable lab.
IgeneX is considered the gold standard for a reason.  They have refined the Western Blot using recombinant protein technology that makes their ImmunoBlots much more sensitive and specific than the "gutted" version of the test offered by large commercial labs.

In our clinic, we always order the Western Blot or ImmunoBlot and usually order direct tests such as PCR or FISH as well. It’s not uncommon to have to run several tests before finding any evidence of infection.

The standard two-tiered testing espoused by the CDC and IDSA for surveillance of prevalence of the disease was NOT intended to be  adhered to as diagnostic criteria by clinicians. Please note the following excerpt from the MMWR 2007;56(23):573-576 CDC publication on the topic: For surveillance purposes, a reportable case of Lyme disease is defined as 1) physician-diagnosed erythema migrans >5 cm in diameter or 2) at least one objective late manifestation (i.e., musculoskeletal, cardiovascular, or neurologic) with laboratory evidence of infection with B. burgdorferi in a person with possible exposure to infected ticks. This surveillance case definition was developed for national reporting of Lyme disease; it is not intended to be used in clinical diagnosis.

By mainstream rationale, testing for Lyme is to be initiated with the ELISA, which has a sensitivity of approximately 50% as shown by published peer-reviewed studies. PMID: 8748261

Imagine if a screening test for HIV were only able to find 50% of the infected patients?! We would still have an AIDS epidemic on our hands.

Borrelia sensu strictu or Lyme disease in the strict definition.
The most frequently ordered tests on the market are only able to detect one strain, the B-31subtype of Borrelia burgderfori. The better tests are able to detect antibodies to Lyme caused by both the B-31 and the 297 strains of Borrelia burgderfori.

But wait, there are more!
Borrelia sensu lato or the larger Lyme family includes Borrelia afzelii and Borrelia garinii. These are transmitted by the hard bodied ticks of the Ixodes group, including Ixodes scapularis and Ixodes pacificus in the US, Ixodes ricinus in Europe, and Ixodes persulcatus in the Orient. In this age of easy global travel, we see many a patient who can clearly identify becoming ill while travelling abroad. We have to test specifically for these strains of Lyme sensu lato when there is a history of foreign travel.

Borrelia by any other name still feels like Lyme - The Relapsing Fever Group
There are other members of the Borrelia family that cause a Lyme–like illness known as Relapsing Fever. Like most things in the Lyme world, it’s hard to make sense of it all.

Lyme-like illness can be caused by members of the Borrelia family such as Borrelia hermsii, miyamotoi, parkeri, turicatae and others. These Borreliae are mainly carried by soft-bodied ticks of the genus Ornithodoros which can go a long time between blood meals, and can harbor these Relapsing Fever strains of Borrelia for years. These ticks, unlike hard-bodied ticks such as Ixodes feed very quickly, and can transmit infection in as little as 15 minutes. PMID: 18755384

Mice, chipmunks, squirrels and prairie dogs are important reservoir hosts for these strains of Borrelia, and many people become ill while staying in rustic cabins or camping where rodents are prevalent. Ticks can come out and feed on the cabin or tent dwellers at night. Since all tick saliva has anesthetic compounds in it, bites usually go unnoticed.

And then there is Borrelia recurrentis, which is transmitted by the body louse, and can therefore be spread from person to person by body lice. This bacterium also causes a Lyme-like illness the common symptoms of which include abdominal pain, fever, headache, confusion, vomiting, stiff neck, joint pain, and muscle aches. Linda Houhamdi, Didier Raoult, Excretion of Living Borrelia recurrentis in Feces of Infected Human Body Lice, The Journal of Infectious Diseases, Volume 191, Issue 11, 1 June 2005, Pages 1898–1906, https://doi.org/10.1086/429920

Be aware that in any area of the country or world ticks can transmit infections dangerous to humans of which Lyme is only one.

• Grasp as close to the skin as possible with tweezers and pull straight out.
• Do not twist, poke, or otherwise aggravate the tick. Any agitation of the tick causes further regurgitation of infectious material from the midgut increasing the risk of infection.
• Do not burn or cover with Vaseline

Save the tick for testing:

Realize that experienced Lyme-literate physicians and scientists estimate the tick testing to be only about 50% accurate.  Infectious agents can be missed.

Igenex: https://igenex.com/product/tick-test/
Tick Report: https://www.tickreport.com/
Ticknology https://ticknology.org

Save tick in Ziploc bag or jar with a damp piece of paper towel or a green leaf.
Monitor area closely for any type of eruption. Be vigilant for any unusual symptoms.
Contact a Lyme-literate practitioner immediately if any symptoms occur.

As previously stated, there is no consensus within the medical community about the proper approach to treatment of Lyme disease and the many associated infections. There is no cookbook approach, and no guideline beyond what treatment should consist of immediately following a tick bite. Even on treatment of a tick bite the major factions in medicine (IDSA & ILADS) disagree.

The IDSA maintains that a tick must be attached 36 hours to transmit disease, which is patently false.  Their guidelines call for two weeks of Doxycycline 100mg twice daily for a symptomatic tick bite.  The life cycle of the Borrelia bacteria is approximately 4 weeks, therefore in order to adequately prevent long-term infection with Lyme, a minimum of 4-6 weeks of Doxycyline or other appropriate antibiotic is recommended by ILADS guidelines.

Since the suffering caused by chronic Lyme disease is so devastating, my professional advice is to treat any black-legged tick attachment with antibiotics immediately.  The risks associated with a short course of antibiotics are far less costly and dangerous than the suffering, expense and loss of function associated with chronic disease.

How to treat an asymptomatic tick bite:

Doxycycline 100mg 3x/day for 4 weeks

How to treat a symptomatic tick bite:
i.e. rash of any kind, fever, body aches "summer-time flu", headache, abdominal pain, joint pain, neurological problems, fatigue

Doxycycline 100mg 3-4x/day for 4-6 weeks

Vigilance for symptoms not attributable to Borrelia or symptoms that are worsening instead of improving with Doxycycline should be considered as possible co-infections and treated with appropriate agents such as:

Anti-malarials for Babesiosis - Malarone, Mepron, Coartem, Primaquine, Tafenoquine
Antibiotics for Bartonella, Brucella, Tularemia - Bactrim, Rifampin, Ciprofloxacin, Levaquin, Avelox

There are other medications that can be used for symptomatic tick bites although no accepted protocols exist on doses and duration of Azithromycin, Amoxicillin, Augmentin, Cefdinir, Cefuroxime and other.

ILADS.org

Lymedisease.org

Treat mold

Let’s face it, every Lyme literate doctor hopes they have a mold patient, not a Lyme patient.  Mold illness is much easier to treat, and the two illnesses can look almost identical.  

I highly recommend being evaluated and treated for mold illness before opening up the proverbial can of worms called chronic Lyme disease.

Sleep

Lyme and co-infections can and often do produce terrible insomnia and poor sleep quality.  Nothing will improve until sleep is properly addressed, therefore I always address this on the first visit.

Natural options:

• Liposomal melatonin 1-10mg immediately before sleep.  
• L-theanine 200-600 mg before bed.  Binds to GABA receptors in the brain, causing a very relaxing effect
• Classic sleep herbals such as:   Valerian, Passionflower, Skullcap, California Poppy, Kava, Oat straw, Hops and others.  
• Glycine - another doctor jokes “It should be in the water.”  Excellent detox aid and usually very calming.

Medications

• Trazodone, Amitriptyline - improve delta wave (deep stage 3 & 4 sleep), helping both with falling asleep and staying asleep.  
• Remeron - also improves slow wave sleep (stage 3 & 4) deeply restorative sleep
• Seroquel - an anti-psychotic that in small doses works well for sleep and mood stability
• Ambient, Lunesta - if you must.  High side effect profiles, but all that works in some cases.  Short acting, so don’t expect a full night’s sleep.

Diet

No one escapes my office without a discussion about diet.  There is no one size fits all, but general guidelines are:

• Get tested for food allergies and sensitivities.  Testing options include Meridian Valley Labs, US biotek, Genova, Alcat, Alletess, Cyrex, and many others.  These tests are not perfect, but they can help identify hidden causes of inflammation and distress.
• Follow an anti-inflammatory diet.  For most people, this generally means Paleo-like, or as though you were extending a Whole 30 protocol.  Grains tend to be highly allergenic and feed forward yeast, inflammation, insulin resistance and other undesirable processes.  Most of my Lyme patients experience the first symptom relief they’ve ever had by eliminating sugar and gluten.  The next most common offenders are dairy products and eggs, followed by other grains and legumes.  
• The best test for food irritants is an elimination diet, but it’s difficult to do.  I recommend testing with all its imperfections.

Hormones, Adrenals & Thyroid

Thyroid, adrenal and hormonal function govern nearly everything in the human body, and Lyme with its co-infections does a superb job disrupting these systems.  Think of it like “software bugs”.  The hardware is intact in most cases, but the software needs updates, debugs, and reboots.  
Many women develop irregular cycles, severe menstrual problems and infertility.  Men develop low testosterone and drive.  Almost everyone demonstrates deregulation of the hypothalamic/pituitary/adrenal/thyroid/gonadal coordination systems.    
Think of this like infrastructure support.  If you don’t have hormonal balance, it’s impossible to properly regulate sleep, day-night cycles, energy levels, gastrointestinal function, immune function and mood.  
Thorough testing of female/male/sex hormones, thyroid, adrenals, pituitary is a must.

General energy and stress supports:

These should be tailored to match symptoms and bloodwork findings.

• Ashwaganda 500-1000mg once or twice daily - calming, helps with energy and sleep
• Rhodiola - small amounts tend to increase energy while larger doses help with relaxing
• GABA 200-600 mg as often as needed any time of day or night to ease stress & anxiety
• Licorice  - for those with low blood pressure, under functioning adrenals, fatigue
• Eleuthero - a classic adrenal adaptogen for energizing
• Adrenal glandular containing formulas for those with under functioning adrenals
• Phosphatidylserine for those with high cortisol.  Very good for sleep.

Detoxification

Issues with detoxification is a common thread in those who become chronically ill with Lyme disease and associated co-infections.   We often find genetic issues (IntellxxDNA.com) in glutathione-producing pathways, methylation, solvent and petrochemical removal, and a host of other enzymatic systems within our bodies that are meant to neutralize toxins from both inside the body and out.
Detox becomes more important as we consider that the die-off products as we kill microbes can be extremely irritating to the  immune system and overload the liver, kidney, lymphatic and sweat outlets of the body.

Many people benefit from:

• Liposomal Glutathione 500mg in the evening or more when Herxing
• Toxin Binders such as activated charcoal, bentonite clay, GI Detox +, Biotoxin Binder, Chlorella.  The only challenge is most of these must be taken away from medications.
• Electrolytes - Alkalizing the bloodstream and urine is often overlooked.  Many people benefit from AlkaSelzer Gold and other similar items.  The right one for you should feel good in your system and make you feel better somehow.
• Epsom salt and baking soda baths help act as a “third kidney” pulling toxins out directly through the skin.  Furthermore, the sulfate in the Epsom Salts (Magnesium sulfate) soaks into the skin and directly neutralizes some toxins, and other sulfate molecules are used for transporting hormones.
• Saunas of all types:  Many of my patients can’t sweat, which is a major problem for detoxification through the skin.  Far infrared, near infrared, and Traditional Finnish radiant health saunas all have their own unique spectrum of toxin removal, each pulling a somewhat different profile of toxins out through the skin as well as into general circulation which then can be eliminated by the lymphatics, liver and kidneys.  Start low and work up.  
• IVs such as Myers’s Cocktail, Glutathione, Plaquex (Phosphatiodylcholine), Ozone, Amino acids

Inflammation Control

Deregulating the immune system and causing runaway inflammation is one of the survival strategies of Borrelia, Babesia, Bartonella, and other chronic stealth infections caused by tick-borne organisms.  

Many of my patients have Mast Cell Activation Syndrome (MCAS), auto-immune problems, arthritis, pain syndromes, brain fog, leaky gut, psychiatric issues, and other issues that indicate inflammation is out of control.  Helpful items include:

Herbal options

• Turmeric (curcumin)  500-1000mg 2x/day
• Boswellia 300-600mg 2x/day
• Quercitin 250-1000mg 2x/day
• Resveratrol 100-200mg 2x/day
• NAC 600-900 mg 1-2x/day

Prescription options

• Low Dose Naltrexone 1-9 mg at bed reduces microglial over-activation in the brain, which can help with pain and inflammation
• NSAIDS - rarely use these but sometimes needed in severe cases

Using a cell wall drug capable of killing mobile spirochetal forms is often a good place to start.  Examples include:

• Cefdinir
• Cefuroxime
• Amoxicillin
• Clindamycin
• IM Bicillin (Intramuscular injection of long acting penicillin)

The addition of a drug that can penetrate cells to kill bacteria that have dropped their outer coats is often the next step.  Examples include:

• Azithromycin
• Clarithromycin
• Minocycline
• Doxycycline

Attention to the cyst and round body forms is also necessary, but something I usually save for later stages of treatment.  Examples of medications that can be used to lower this reservoir of “seeds” that can “sprout” and turn back into viable spirochetes once antibiotics are withdrawn include may include:

• Tindamax
• Flagyl
• Alinia

And for persisters consider:

• Methylene Blue
• Disulfiram
• Daptomycin

Aggressive yeast control, C. difficile prevention, and protection of the gut flora is required of all patients.

Yeast control:

• Low carb diet, Candida-type diet
• Nystatin
• Fluconazole
• Ketoconazole
• Grapefruit seed extract
• Caprylic acid
• Saccharomyces boulardii
• Garlic

Clostridium difficile (C. diff) prevention:

• Saccharomyces boulardii
• Berberine
• High dose probiotics

Biofilm Dissolution:

• Bolouke
• Lumbrokinase
• Nattokinase
• Other proteolytic enzymes
• Heparin
• IV Chelation (EDTA)
• IV Phophatidylcholine

• GENERAL:  Fatigue, malaise, chills, sweats, fevers, chronic fatigue, somnolence, restlessness, poor sleep, flu-like feeling, insomnia
• CARDIOVASCULAR & CIRCULATORY:  Endocarditis, myocarditis, pericarditis, hemolytic anemia (through invasion and destruction of RBCs), hypertension, pulmonary embolism, systemic vasculitis, arrhythmias, ischemic stroke, cardiomegaly (enlargement of the heart), heart valve problems, palpitations, POTS, edema
• GI:  Poor appetite, weight loss, sore throat, gastritis, gastroparesis, poor GI motility, difficulty swallowing, elevated liver function tests (LFT), enlargement of the liver, GERD (acid reflux), jaundice, gallbladder dysfunction, granulomatous hepatitis, liver cysts, abdominal pain 
• HEAD & NECK:  Headaches (can be severe or ice pick-like), migraines, vision changes or deficits, blurred vision, double vision, dry eyes, red eyes, conjunctivitis, neuroretinitis (ocular inflammation), ocular neovascularization, uveitis, retinal vasculitis, eye pain, floaters, photophobia, papilledema, tinnitus, hyperacusis, non-healing infections of the jawbone, cavitations, encephalopathy (brain swelling)
• IMMUNE/BLOOD-WORK:  Elevated VEGF, elevated liver function tests (LFTs), elevated alkaline phosphatase, pancytopenia, thrombocytopenia, MGUS, weakened immune response 
• SKIN:  Skin rashes, papules or papulovesicular rash, striae (stretch-mark appearance), acne, crusty scalp, Henoch-Schönlein purpura (purple spots on the skin), bacillary angiomatosis, petechiae, diffuse intravascular coagulation (DIC), spider veins, varicose veins, sweats (usually damp), running hot, tender subcutaneous nodules
• LYMPHATIC:  Splenomegaly (enlargement of the spleen), lymphadenopathy (enlargement of the lymph nodes), painful lymph nodes, edema/swelling (leaky blood vessels and lymph vessels)
• MUSCULOSKELETAL:  Fibromyalgia pain, pain in the soles of the feet (especially in the morning), ankle pain, rheumatoid arthritis, myositis (inflammation of the muscles), myalgia, lupus, osteomyelitis, joint pain, knee pain, pain in the chest or sternum, twitching or fasciculations, subcutaneous nodules, osteolytic lesions, bone destruction, stiff legs, bone pains, granulomatous inflammation
• NEUROLOGICAL:  Cognitive problems, memory loss, peripheral neuropathy, neuroapthies, MS-like symptoms, transverse myelitis, encephalitis, meningitis, hyporeflexia or areflexia (below normal or absent reflexes), seizures, crawling sensations, burning sensations in the skin, vibrating or shooting sensations, tremors, radiculitis, chronic demyelinating polyneuropathy, brain fog, temperature dysregulation, hyperesthesia (increase in sensitivity to stimuli) 
• PSYCHOLOGICAL:  Irritability, panic disorder, agitation, impulsivity, anxiety, depression, OCD, intrusive thoughts, anger, rages, combative behavior, suicidal feelings, bipolar disorder, hallucinations, confusion, disorientation, mood swings, antisocial behavior, paranoia, delusions 

Bartonella is a gram negative bacterium with a double cell wall that makes it resistant to many antibiotics that work on the simpler gram positive bacteria.  Therefore, double or triple antibiotic therapy over a period of at least 6 months, and in many cases up to 2-3 years may be required in difficult cases.  Patience is often required with chronic Bartonella cases.  

• Bactrim  (Sulfamethoxazole/Trimethorprim) - a moderately good Bart med
• Rifampin - penetrates blood brain barrier and biofilms.  Caution:  monitor liver, thyroid, hormones and CBC closely
• Minocycline - penetrates blood brain barrier.  Caution: can cause severe die-off reactions
• Rifabutin - much more powerful than Rifampin for severe intrenched infections  Caution: Monitor CBC and CMP monthly
• Pyrazinamide - a powerful advanced treatment  Caution:  Requires close laboratory monitoring.
• Methylene Blue - non-toxic.  Works on both replicating bacteria and sessile forms.

• GENERAL:  Fatigue, weakness, brain fog, confusion, dizzy/tippy feeling, anxiety, panic, OCD, exercise intolerance, high fevers, , chills, rigors, shaking, trembling, migraines, headaches, air hunger, night sweats, flushing. 
• CARDIOVASCULAR & CIRCULATORY:  Hemolytic anemia (destruction of red blood cells by parasites), heart racing, pounding, arrhythmias, fainting or near-fainting, chest pain, cough, POTS, edema (swelling), vasculitis (marbling or spiderweb appearance of blood vessels in skin), flushing, coagulation disorders, elevated d-dimer, fibrin degradation products and other clotting markers
• GI: Bloating, abdominal pain, gastroparesis, poor GI motility, SIBO-like symptoms, nausea, vomiting, constipation, diarrhea
• HEAD & NECK:Headaches (can be severe often suboccipital), migraines, vision changes or deficits, blurred vision, double vision, dry eyes, red eyes, conjunctivitis, eye pain, floaters, photophobia, tinnitus, hyperacusis, encephalopathy (brain swelling), neck pain and stiffness
• IMMUNE/BLOOD-WORK:Low red blood cell counts, sudden drops in ferritin and iron levels (hemolytic anemia), abnormal coagulation markers, increased monocytes, increased lymphocytes or lymphocytopenia, thrombocytopenia, elevated inflammation markers such as hsCRP, TGF-B1, EPX transient elevations in liver function tests (transaminases), hyperbilirubinemia, elevated histamine pathway markers such as histamine, IL-4, IL-5, IgE, Eosinophil Protein X
• SKIN:Flushing, running hot, drenching sweats, excessive sweating, skin rashes, papules or papulo-vesicular rash, diffuse intravascular coagulation (DIC), spider veins, vasculitis (marbling or spider-web appearance of blood vessels in skin) 
• LYMPHATIC:  Splenomegaly (enlargement of the spleen)
• MUSCOLOSKELETAL:  Joint pain, stiffness in joints and/or muscles, burning muscle pain with weakness
• NEUROLOGICAL:  Brain fog, confusion, ataxia, loss of corrdination, seizures, partial seizures, apraxia (loss of ability to perform noraml motor movements), receptive and expressive aphasia (difficulty understanding and/or communicating with speech), paresthesias (abnornal sensations such as insects crawling, biting in/on skin, cool breeze, vibrating sensations, feeling of cobwebs, hot water, buzzing/bubbling/popping sensations in various body parts), vertigo.
• PSYCHOLOGICAL:  Anxiety, depression, OCD, intrusive thoughts, nightmares and night terros, anger, rages, agitation, mood swings, severe PMS and menstrual problems, combative behavior, antisocial behavior, suicidal feelings, bipolar disorder, hallucinations, confusion, disorientation, paranoia, delusions. 

Babesia is a complex protozoal parasite, much more difficult to treat than its cousin, malaria.  Anti-malarials are used at relatively high doses over long periods of time.  The minimum effective treatment time for Babesia is 3 months given the life cycle of the parasite.  Many patients require several years of treatment to achieve lasting remission.

Most of these meds require a normal G6PD before administration:

• Clindamycin - the only antibiotic that works on Babesia
• Malarone - a garden variety anti-malarial.  Slows replication but doesn't necessariily kill parasites
• Mepron - see the above.  Resistance to this med is common.
• Primaquine - an old med, but Babesio-cidal.  May require much higher dosing than traditional dosing for malaria.
• Quinine - brutal side effects.  No one makes it through a treatment course.  We don't use it.
• Lariam - brutal side effects.  Psychotic breaks are freakishly common with this med.  We don't use it.
• Tafenoquine (brand names Krintafel and Arakoda ) - an outstanding Babesio-cidal medication.  It's a Primaquine derivative.  Much more effective than Primaquine with a minimum of die-off reactions.  
• Coartem - an outstandingly effective anti-malarial.  Caution:  MUST monitor QT interval (EKG) with this med.  Numerous med interactions. 
• Alinia - an anti-parasitic med with good activity against Babesia
• Methylene Blue - for persisters

Due to the unique effects of this parasite on red blood cell clumping and coagulation, fibrinolytics (blood thinners) are necessary for long-term clearance of this infection.  

• Heparin
• Bolouke/lumbrokinase
• Nattokinase
• Serrapeptase
• Pycnogenol
• Bromelain