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From An Email String:

Dear Patricia Conrad,
I have reviewed your paper from Int J. Parasitology from 2006 that discusses the intraerythrocytic stages of B. duncani. May I conclude that this organism causes intravascular hemolysis of infected RBC or do the species differences of duncani versus microti extend to absence of hemolysis as well?
Ritch Shoemaker MD
Pocomoke, Md


Dear Rich,
Yes, the pathogenesis appears the same as with B microti as far as we can tell. I think you also wrote to me previously about getting a photo of B. duncani. I hope this helps.
with best wishes,
Pat

Dr. Schaller posted that Pat Conrad told him that B. duncani doesn't cause intravascular hemolysis. The email below from Dr. Conrad would not support the contention that duncani doesn't cause intravascular hemolysis. "Pathogenesis appears the same" is her expression. Given that the most recent paper on the subject is 2006, the argument about duncani is perhaps one waiting for a data set from our colleagues in the Northwest. PerhapsDr. Gordon will chime in here with his experience, as he has the largest series of Lyme/tick borne illness patients in that area to my knowledge. Independent of whether or not an unusual form of Babesia can burst RBC is a much greater question of what clinical evidence is persuasive of an unusual condition. It is my opinion that if the unusual condition, say Babesia in this case, in a patient with suspected tick borne illness, is suspected then the medical record should be clear that the attending has performed a differential diagnosis and that process is transparent to a chart reviewer. Without a clearly demonstrated, transparent process of decision making, the physician will not withstand the slings and hollow-pointed arrows of the Post-IDSA consensus era review. Independent of the argument regarding the
validity of the IDSA consensus, I will guarantee you that opinion will be in
a court or medical review board hearing. That process is already begun in
Maryland, home of Johns Hopkins.

For example, we now have confirmation of Babesia acquired in Gibson Island, near Baltimore, though on the coast. If one is to postulate a clinical diagnosis of Babesia but doesn't look for supporting lab criteria as would ogically include hemolysis and a personal plus a pathologist's review of a thick peripheral blood film, I feel it is open season on the criticism of the diagnosis. Open season means that others can then look at all the charts they want to. If the chart review shows a consistent pattern of slipshod medicine then the practitioner won't be in a strong defensive position in a field where he must be well entrenched.

The mold wars provide a clearly charted path where these arguments go.
Anyone who is so naïve as to think the Lyme community won't see the same second wave of attacks is going to suffer and soon.
Ritch Shoemaker MD
Pocomoke, Md

Hi Ritchie, from Joe Burrascano-
I agree that a thorough review of a blood film is mandatory- unfortunately literature states that Babesia is no longer detectable on a blood smear after two weeks of infection.
You and I both know this is incorrect, but the problem is that nearly every commercial lab does only a superficial review of blood films, the result being almost 100% negative "parasite" smears.
Do you or your pathologists have a regimen/routine that can be shared with us? Hopefully if such a technique is more widely available, more and better diagnoses can be made.
Thanks
JJB

We have used Giemsa staining for some time though my lab isn't CLIA approved for that. Often the problem becomes what is a "thick film." Most docs don't look at peripheral smears and most don't have Giemsa; a simple Wright's stain is quick and easy and can be a good screen. I don't rely on my read of a film; I don't have credentials. But if I see something, my pathologist can see something too and comment on it.

The good news, though, is the specific apicomplexan stains. I feel the use of a fluorescent nucleic acid stain (SYT016) makes good sense. It has been around for some time now. I have read that there is a YOYO-1 stain that is even better than SYT016, but I haven't reviewed any literature recently.
Check with your hospital pathologist; I agree that unless you talk with the doc at the contracted pathology lab for Quest of LabCorp you won't get anywhere.
Ritch Shoemaker MD