GASTROINTESTINALGASTROINTESTINALTIC BORNE INFECTIONSTIC BORNE INFECTIONS

Martin D. Fried, MD, FAAPMartin D. Fried, MD, FAAPPediatric GastroenterologyPediatric Gastroenterology

Physician Nutrition SpecialistPhysician Nutrition Specialist

3200 Sunset Ave Suite 1003200 Sunset Ave Suite 100

Ocean, NJ 07712Ocean, NJ 07712

Gastrointestinal ComplaintsGastrointestinal Complaints

abdominal painabdominal pain vomitingvomiting

blood in stool blood in stool constipationconstipation

heartburnheartburn chest pain chest pain

soilingsoiling diarrheadiarrhea

mouth soresmouth sores MULTISYSTEMMULTISYSTEM

difficult swallowdifficult swallow Skin rashesSkin rashes

Apthous UlcersApthous Ulcers

Canker SoreCanker Sore

Erythema NodosumErythema Nodosum

PsoriasisPsoriasis

UlcersUlcers

ColitisColitis

Rectal FissureRectal Fissure

Skin Tag vs GranulomaSkin Tag vs Granuloma

Psoriasis with GranulomaPsoriasis with Granuloma

Bartonella

Borrelia burgdorferi

H pylori

Mycoplasma

Salmonella, EBV

Clostridium difficile

SINGLE INFECTIONS 30SINGLE INFECTIONS 30

Lyme

Bartonella

Helicobacter

Mycoplasma

36

9 12

COINFECTIONS = 20COINFECTIONS = 20

LymeBartonellaMycoplasma

6 10 2

TRIPLE INFECTIONS = 6TRIPLE INFECTIONS = 6

LYME

BARTONELLA

MYCOPLASMA

HELICOBACTER

2

4

80 PATIENTS, 88 INFECTIONS80 PATIENTS, 88 INFECTIONS

0

5

10

15

20

25

30

35

BART MYCO HELICO LYME

Heartburn, Abdominal Pain, Heartburn, Abdominal Pain, Skin Rash, Skin Rash,

Gastritis, and DuodenitisGastritis, and Duodenitis

Bartonella henselae

• Cat Scratch FeverCat Scratch Fever

• LymphandenopathyLymphandenopathy

• hepatitis-elevated liver enzymeshepatitis-elevated liver enzymes

• SplenitisSplenitis

• PneumonitisPneumonitis

• Fever Unknown OriginFever Unknown Origin

Gastrointestinal BartonellaGastrointestinal Bartonella

• Hepatosplenic AbscessHepatosplenic Abscess

• Abdominal Pain-burningAbdominal Pain-burning

• Mesenteric Adenitis-mimic AppendixMesenteric Adenitis-mimic Appendix

GI PresentationGI Presentation

• HeartburnHeartburn

• Abdominal PainAbdominal Pain

• Skin Rash-striae –stretch marksSkin Rash-striae –stretch marks

• Enlarged Lymph nodesEnlarged Lymph nodes

VIOLACEOUS RASHVIOLACEOUS RASH

NEW BLOOD VESSELS NEW BLOOD VESSELS

GI InfectionsGI Infections• tic bitetic bite• No prior GI complaintsNo prior GI complaints• No steroid useNo steroid use• No abrupt weight gainNo abrupt weight gain

Infection and or DietInfection and or Diet

• Pain not resolved by antacids, Pain not resolved by antacids, Histamine blockers, PPIHistamine blockers, PPI

Skin RashSkin RashViolaceous- deep reddish purpleViolaceous- deep reddish purpleSerpinginous- “snake like”Serpinginous- “snake like”Breast or lower backBreast or lower backGroin or back kneeGroin or back kneePeriumbilical (belly button)Periumbilical (belly button)Inner thighInner thigh stretch marks are differentstretch marks are different

Mesenteric AdenitisMesenteric Adenitis• CT AbdomenCT Abdomen

• Lymph Nodes > 1cm in diameterLymph Nodes > 1cm in diameter

• May mimic appendicitisMay mimic appendicitis

Endoscopy and BiopsyEndoscopy and Biopsy• AssessAssess thethe GI mucosaGI mucosa

– H. pyloriH. pylori

– Bartonella by PCRBartonella by PCR

– Borellia burgdorferi PCRBorellia burgdorferi PCR

– Mycoplasma PCRMycoplasma PCR

– Ehrlichia and Babesia PCREhrlichia and Babesia PCR

Bartonella PathologyBartonella Pathology• Chronic Gastritis and or duodenitisChronic Gastritis and or duodenitis

• No UlcerNo Ulcer

• No evidence of allergy (eos)No evidence of allergy (eos)

• No Acute Inflammation (polys)No Acute Inflammation (polys)

Bartonella RashesBartonella Rashes• MaculopapularMaculopapular• UrticarialUrticarial• Erythema Nodosum (crohns also)Erythema Nodosum (crohns also)• Granuloma Annulaire (ringworm)Granuloma Annulaire (ringworm)• Thrombocytopenic PurpuraThrombocytopenic Purpura

• Leukoclastic VasculitisLeukoclastic Vasculitis

StriaeStriae

• Endothelial ProliferationEndothelial Proliferation

• Differentiate from stretch marks Differentiate from stretch marks

• in obese or steroid using patientsin obese or steroid using patients

Bartonella Bartonella GI InflammationGI Inflammation

• An Association ShownAn Association Shown

• IL-2, IL-6, IL-10, ElicitedIL-2, IL-6, IL-10, Elicited

Interleuken 6Interleuken 6• Multipotent cytokineMultipotent cytokine

• Elicited by InfectionsElicited by Infections

• Induces inflammationInduces inflammation

NEOVASCULARIZATIONNEOVASCULARIZATION

NEW BLOOD VESSELSNEW BLOOD VESSELS

STEROID EFFECTSTEROID EFFECT

STEROID EFFECTSTEROID EFFECT

SERPINGINOUS RASH = INFECTION

SNAKE LIKE = INFECTION

Helicobacter pylori

BacteriaBacteria

Infects humans onlyInfects humans only

Transmitted - human to humanTransmitted - human to human

H. pylori

• Irritant to stomach liningIrritant to stomach lining

• Cause of gastric, duodenal ulcersCause of gastric, duodenal ulcers

• Lifelong infection unless treatedLifelong infection unless treated

• Predispose to stomach cancerPredispose to stomach cancer

due to chronic irritationdue to chronic irritation

Helicobacter pyloriHelicobacter pylori

NodularityNodularity GastritisGastritis

Eradication of Eradication of H. pyloriH. pylori

Two antibiotics for two weeksTwo antibiotics for two weeks

ClarithromycinClarithromycin

AmoxacillinAmoxacillin

Proton pump inhibitor for a monthProton pump inhibitor for a month

intracellular death of infectionintracellular death of infection

Mycoplasma• Intracellular infectionIntracellular infection

• Rarely in the bloodRarely in the blood

• Worsens Lyme, Bartonella symptomsWorsens Lyme, Bartonella symptoms

• Fibromyalgia, CFS, RA, and Gulf WarFibromyalgia, CFS, RA, and Gulf War

Mycoplasma proteinMycoplasma protein

• Stimulates immune cellsStimulates immune cells

• Proinflammatory cytokinesProinflammatory cytokines

TNFalpha, IL-1, IL-6TNFalpha, IL-1, IL-6

• GI may resemble Crohn’sGI may resemble Crohn’s

Chronicity of MycoplasmaChronicity of Mycoplasma

• Surface antigenic variation Surface antigenic variation

• Supress host immune responsesSupress host immune responses

• Slow growth ratesSlow growth rates

• Intracellular locationsIntracellular locations

• Can take 3 years to eradicateCan take 3 years to eradicate

• Can follow IgM and IgG titersCan follow IgM and IgG titers

Celiac vs Food IntoleranceCeliac vs Food Intolerance

• Celiac is Autoimmune to wheat, rye, barleyCeliac is Autoimmune to wheat, rye, barley

• Gluten, Genetics and EnvironmentGluten, Genetics and Environment

• Intolerance is IgE or non IgE mediatedIntolerance is IgE or non IgE mediated

Inflammation causes Inflammation causes

permeable gutpermeable gut

Foreign proteins to Foreign proteins to

immune systemimmune system

Crohn’s, Colitis, Celiac Crohn’s, Colitis, Celiac

Treatment complications

Candida Albicans

Candida AlbicansCandida Albicans

• Normal Flora YeastNormal Flora Yeast

• Antibiotics kills Normal FloraAntibiotics kills Normal Flora

• Yeast overgrowth occursYeast overgrowth occurs

• Diet to produce lactobacillus, bifidobacteriaDiet to produce lactobacillus, bifidobacteria

• Short chained fructooligosaccharides (FOS)Short chained fructooligosaccharides (FOS)

• Not a casein or gluten related problemNot a casein or gluten related problem

Clostridium difficileClostridium difficile

• C. difficile is normal bacterial floraC. difficile is normal bacterial flora

• Antibiotics kill lactobacilli, bifidobacterAntibiotics kill lactobacilli, bifidobacter

• C. difficile overgrowth occursC. difficile overgrowth occurs

• C. difficile elicits – Toxin A and Toxin BC. difficile elicits – Toxin A and Toxin B

• Pseudomembranous colitsPseudomembranous colits

• Treat with Metronidazole and probioticsTreat with Metronidazole and probiotics

• However, prebiotics help L and B multiplyHowever, prebiotics help L and B multiply

Pseudomembranous Colitis

Foods with sc FOSFoods with sc FOS

• Banana Banana onions onions

• garlic garlic asparagusasparagus

• Barley Barley wheat wheat

• TomatoesTomatoes leeks leeks

ConclusionsConclusions

• Lyme, Bartonella, Mycoplasma occur in Lyme, Bartonella, Mycoplasma occur in

the GI tract of children 5-21 yrsthe GI tract of children 5-21 yrs

• PCR biopsies to document infectionPCR biopsies to document infection

• Consider CoinfectionsConsider Coinfections

• Prevent yeast, c. difficile overgrowth Prevent yeast, c. difficile overgrowth

with prebiotics and probioticswith prebiotics and probiotics