jwissmille

source: Lyme Disease 1991-patient /physician perspective - Lora Mermin,
editor
-can be found at your local library

Jarisch-Herxheimer Reaction

James H. Katzel, M.D.

Dorland's Illustrated medical Dictionary says this about the Jarisch-
Herxheimer Reaction: "An increase is syphilitic symptoms after
administration of antisyphillitic drugs." Although it is an illustrated
dictionary, there is no illustration next to the words. I wonder what they
would put next to such a definition......I suppose if they were to
illustrate the Jarisch-Herxheimer Reaction, they would have to put a
patient with syphilis or, more recently, a Lyme borreliosis patient
standing in fright with extremities extended and large circles radiating
from his eyes. We're talking about one terrible feeling person.

From back in the 1960's, Professor Harvey described the Herxheimer
Reaction as an acute febrile reaction which may develope after treatment of
late syphilis has begun. But Professor Harvey felt that this was a rare
phenomena and such reactions were more common in patients with paresis,
and he felt that they might be associated with a trasient increase in
agitation and confusion as well as with fever and convulsions. His
suggestion was that small doses of adrenal corticosteroids such as 20 mg.
prednisone per day usually prevent or ameliorate the Herxheimer Reaction.

Events similar to this Herxheimer type Reaction have been described in
other disease states. I recently attended a medical conference where an
experienced middle-aged man physician/pathologist descibed "crashing" and
episodes of death after one dose of IV penicillin for children with
meningoccoccemia. Whether the death of these children was due to acute,
fulminating Waterhouse-Friderichsen syndrome or whether the deaths were due
to a Herxheimer-type Reaction to one dose of penicillin is still unclear.
The description of these events, which happened 40-50 years ago, is stilll
vivid in the memories of these physicians. At times they were reluctant
(but knew they had no choice) in giving the penicillin to these sick
children who they knew would die if not treated and who might die from
another cause with treatment.

The Herxheimer-type Reaction is somewhat different in Lyme....Because Lyme
is caused by a spirochete, much of what we learn and think about Lyme
borreliosis comes from our experience with syphilis. In the early stages
of killing the Lyme spirochete (Borrelia burgdorferi) with antibiotics
this Hexheimer type Reaction can be found if looked for.
Appparently it comes at different times. With I.V. antibiotics it may be
noted within days of treatment; with oral antibiotics it may be noted
within days to weeks of treatment. When these antibiotics begin to
destroy the Lyme spirochete, a toxin is given off causing either direct
reations or indirect actions through stimulation of the immune system. The
symptoms can vary from systemic reactions such as a low blood pressure,
fever,chills and hives, to more specific symptoms such as increase in joint
pain, headaches, rash or in general, a reversal or worsening of the Lyme
symptom complex.

Jarisch-Hexheimer Reaction should be watched for when treating Lyme
borreliosis patients, and the patient should be adequately warned about
this phenomenom. Mistaking the Herxheimer reaction for an allergic
reaction to antibiotics or serum sickness or some other catastrophe might
lead to prematurely stopping the antibiotics on the part of the physician
on non-compliance in taking the medications on the part of the patient.
When starting antibiotics, one expects to feel better, not worse. But if
warned that there may be a period where symptoms recur or flare up during
this reaction , better compliance can be expected. Herxheimer reactions
are at least ten times more common than true allergic reactions to antibiotics.

Steroids are not recommended at this time for Herxheimer Reaction in Lyme
patients. The best treatment is knowledge of the process so that panic
attacks, anxiety and worry do not occur. Benadryl, which is an
antihistamine, can be used to lessen the symtoms, and sometimes changing
the dose and/or timing of the antibiotics is needed to make the reaction
less symptomatic.

So next time you start antibiotics, ask your physician whether or not you
should expect a Herxheimer Reaction to occur. It may be a learning
experience for both of you, I'm not aware of any deaths from Herxheimer
Reaction in treating Lyme borreliosis. So give me a Herxheimer Reaction
over an allergic reaction any time."


In the Book, Everything You Need to Know About Lyme Disease by Karen
Vanderhoof- Forschner on page 53. She talks about what happens if the
eighth cranial nerve is affected by Lyme,"..Equilibrium disturbances such
as dizziness, vomiting, or reeling are also associated with nerve
dysfunction". With a Herxheimer Reaction symptoms get worse before they
get better. I know more than two people that experienced vomiting while
on IV antibiotics as part of a Herxheimer. They are now better.

This is from the 5/93 update to Lyme disease 1991- it is taken from Dr.
Burrascano's 5th edition of Lyme Disease Treatment Guidelines:...."In
virtually all patients, when antibiotics are begun, symptoms flare in a
Jarisch Herxheimer-like fashion. This will usually occur within the first
five days and usually lasts from several days to two weeks. A late
ocurring or prolonged Herxheimer often predicts that more aggressive or
prolonged treatment will be needed. Be sure to have the patients expect
increased symptoms initially and stick to the treatment. Don't mistake a
Herxheimer-like reaction as either a treatment failure or an allergic reaction.

"When IV antibiotics are given for more than three weeks, it is common for
a very SEVERE flare of symptoms to accur at the fourth week, similar to a
serum sickness reaction. This can be associated with leukopenia and/or
elevations in liver enzymes. You must follow these patients closely, and
decrease the dose temporarily or interrupt treatment for one to three days,
then resume carefully with s lower dose initially. This reaction only
seems to occur in those with longstanding, highly symptomatic disease. It
is IMPORTANT to expect this reaction, and quickly cut the dose, for if
you are able to continue therapy and get the patients through this rough
time, and continue IV meds through to the sixth week, then they
dramatically improve. Those whose treatment is stopped and not restarted
at this point usually need retreatment in the future due to ongoing or
recurrent symptoms."

Some quotes about the Herxheimer from another very Lyme literate
doctor..

What is a Herxheimer reaction?
Answer: The term was originally used to describe a reaction that occurred
6-10 hours after the initial treatment for syphilis. It consisted of
transient fever and a brief exacerbation of visible lesions. It is thought
that this is caused by either an allergic response to antigens or foreign
substances released by the organism when it is killed or that these
substances may have endotoxic properties. Much the same situation occurs
during the treatment of Lyme disease. Patients encounter a variety of
symptoms which may include fever, chills, rash and increased
symptomatology. Usually this reaction is seen with IV therapy but it can
(does-my words) occur during oral antibiotic therapy as well. The point at
which it happens during therapy varies from one antibiotic to another but
generally it does not occur prior to day 10. However, it is important that
you ask your doctor about this so that you will know what to expect.

Q. How can a Lyme patient be certain that he/she is experiencing a Herx
reaction and not an allergic reaction?

A: This is very difficult. Herx reactions are very common during
treatment of Lyme disease. It usually consists of fever, chills, sweats,
joint and muscle pain (me again-sounds like a fibromyalgia attack! I
couldn't resist.) and exacerbation of symptoms. It occurs in
approximately 50% of patients in varying degrees of severity. However,
this symptom complex is very similar to a type of allergic reaction that is
antiboby dependent, called serum sickness.
Originally serum sickness occured when large amounts of antiserum
prepared in horses or rabbits were injected into patients to protect them
from various diseases particularly during the period from 1900-1940. But
this reaction is also encountered with penicillin and other drugs.
Typically it occurs 3 days to 3 weeks after injection and the patient
experiences fever, enlarged lymph nodes and spleen, and painful joints.
Since a large amount of antigen or foreign substance is injected, there is
still a considerable amount of antigen available once antibody production
begins. This excess of free antigen is able to bind to newly formed
antibodies and form Ag-Ab complexes. In turn these complexes bind a
substance found in the blood called complement and attract
polymorphonuclear leukocytes (white blood cells). Lysosomal (digestive)
enzymes are released which cause tissue damage with destructive
inflammation of small blood vessels (vasculitis). Free complement in the
blood is depressed at the height of the reaction. This can be detected by
a blood test. Once the complexes are destroyed, free antibodies appear and
symptoms abate. But if the offending substance continues to be
administered, the vasculitis will result in chronic inflammmation.
Since the Herxheimer reaction seen in Lyme disease also involves a
reaction to a foreign substance (either one released by the organism once
it is killed or an endotoxin), it is important to carefully monitor the
patient once the reaction begins. Also, since the reaction is fueled by
excess antigen it can be controlled by decreasing the amount of antibiotic
that is used. This in turn decreases the amount of antigen or toxin. If
it is determined that this is not a detrimental situation it is important
not to stop therapy. It can be altered as described above but not stopped.
Once the patient has safely passed through this period he or she often
experiences a lessening of symptoms since reaction is often elicited in
response to spirochetal demise."