Manly Conference - February 1999
Republic of South Africa
The author, Cécile Jadin, is originally from Belgium, but has been practising in South Africa for the last 17 years. She is a surgeon by profession. In South Africa, in addition to practising as a surgeon, she also assisted her husband in his general practice. For the last 7 years, she has focused on the subject of Rickettsia and her approach has naturally been that of a clinician, and it is in this context that the paper is written.
To understand why she took the Rickettsial approach her background needs to be explained. Her father was Professor JB Jadin, who undertook groundbreaking research on tropical diseases, among them Rickettsial infection, with Professor Paul Giroud in Central Africa, South Africa, the Near East, and in Europe, developing the work started in the Pasteur Institute of Tunis, with Professor Charles Nicolle, who was a disciple of Louis Pasteur. Thus she was familiar with those germs from an early age and her work represents the results of teamwork through the last 100 years.
12 years ago, one of her friends became unable to walk and was diagnosed as having ME. For 4 years Dr. Jadin suggested the diagnosis of Rickettsial Infection, and therefore the Weil-Felix test was performed several times in South Africa, but the results were negative. The friend developed an acute appendicitis. After Dr. Jadin removed her appendix, her serum was sent to Prof. JB Jadin in Belgium to test for Rickettsiae, and the result was positive. Dr. Jadin treated her with Tetracyclines and 3 weeks later, she was riding her horse again. Dr. Jadin was sceptical. But this case brought her 200 patients and the publicity surrounding an investigation of her methodology by the South African Medical Council brought her several thousand more. Thus Dr. Jadin started to focus on the Rickettsial approach.
Research on Rickettsioses was originally developed by French, Polish and Russian scientists. They followed Charles Nicolle's (Pasteur Institute, winner of the Nobel Prize for medicine in 1933) hypothesis, which is that occult diseases are a reality and their cohabitation in the same host will lead to the bankruptcy of the immune system (8). By occult disease Charles Nicolle implies the asymptomatic stage of the disease, where the agent is present in the host, but dormant (3). The emergence of a virus, bacteria, stress or pollution can activate this agent, which leads to the symptomatic stage.
An example of this cohabitation is the infant mortality rate described by J.B. Jadin in Central Africa. Neonates diagnosed with malaria and Coxiella Burnetti all died as opposed to those with malaria only (20).
The numerous publications of these authors are unfortunately all in French, so their circulation was limited. They also, as academics, excluded the media. Therefore the real importance of their discovery is still to be made widely known.
The fairly recently recognised entity of CFS gives us a perfect opportunity to try the etiological route to understand this disease. Along this route we will automatically enter other medical fields, inviting us to consider an infectious etiology in cardiology (4,5,9,11,12), in psychiatry (3,17), in neurology (3,29) and in rheumatology (28), rather than describing the symptoms and gathering them into syndromes (20, 40).
Obviously one germ can cause many diseases depending on a selective topicality for one or more particular tissues as well as one disease can be caused by different germs alone or simultaneously. Therefore we would like to concentrate on the causative agent, rather than on the name of, and the criteria to classify, the diseases.
There are many reasons suggesting the infectious etiology and, more specifically, Rickettsial-like organisms of CFS. Amongst those reasons:
Could these be new names for old diseases?
All of the above highlights the life of a germ as an individual emerging and disappearing in a wave pattern epidemically and historically. Like us, germs have to adapt, producing new variations of themselves, (not new species), that may or may not survive on their own, with or without the help of another germ. This is circumstance-dependent, and these particular circumstances will never reoccur. Some of those variations will acquire specific and consistent characteristics that will allow them to survive. This is their 'civilisation'. We only see them when they succeed, and only then do new avenues of investigation open up, while others are abandoned.
1. A link has been established between Florence Nightingale disease and CFS (21). The fact that she was working surrounded by lice, fleas and ticks, treating soldiers with wounds and with epidemic typhus during the Crimean war, could be a logical explanation as to why she was terribly tired during the last 2 decades of her life; and possibly has relevance to Gulf War illnesses (13). Zinsser has developed the same concept in his classic book "Rats, Lice and History". He contends:
"Soldiers have rarely won wars. Typhus and other infectious diseases have decided the outcome of more military campaigns than Caesar, Hannibal, Napoleon and all generals in history. Depending on the outcome for each warring faction, either the epidemics were blamed for defeat, or the generals were credited with victory." (2). More examples of this phenomenon were reported by JB Jadin (29).
2. Lymphocyte studies conducted on sheep with tick-borne diseases (14), CFS patients (15,16), and patients with Q Fever endocarditis (11) are showing amazingly similar results.
3. Coincidentally, the new name suggested in the Lancet for CFS is PQFS (Post Q Fever Syndrome) in April 1996 edition (22).
4. During the First World War an estimated 25 million Russians contracted Louse-borne epidemic typhus, resulting in 3 million deaths. Why not before or after? It could suggest that the stress factor reactivates the virulence of Typhus Prowazeki (2, 3, 9). In the medical history of CFS patients, stress has often been described as the start of the illness.
5.The symptoms displayed by CFS, Fibromyalgia, RA, and even neurological patients as MS, show the same diversity of symptoms as Rickettsial patients. How many scientists blamed the diversity of symptoms for misleading unprepared practitioners in the diagnosis of chronic Rickettsial infection (30)? That same diversity could have contributed to the delay in recognising CFS. French authors (Giroud, Jadin, Legag) attribute those multiple aspects to a generalized micro-vascular invasion. They widely demonstrated the persistence of Rickettsiae in the vessels (4), (18). The suggestion here is that the well-known, well-documented entity of Rickettsial disease, showing the same symptoms as the newly arrived CFS, might simply, partially or totally be caused by the same agent.
6. The last, but not the least reason, is the success rate of the Rickettsia treatment, Tetracycline, applied on CFS, Fibromyalgia, Depression and MS etc. patients. Dr Phillipe Bottero on 100 patients since 1981, Dr Peter Tarbleton on 300 patients in 1993 in South Africa(17) and myself on a much larger number of patients, maintain an 84% - to 96% recovery rate.
Rickettsiae are transmitted by arthropods (36), except for Q Fever, which does not really need vectors;
They are spread by rodents and birds. Through the centuries, bird migration has been responsible for changing the geographical distribution of disease (27) - but this is nothing compared to the effect of the explosion of these diseases due to the cocktail effect created by distribution through global air traffic (26).
Equally the transport of insects compared to the import and export of livestock - as in the case of the import of 10,000 parrots from Paraguay to Belgium when some 2,000 died, leaving the virus well and alive behind them (27), (identified by my father as Neo-Rickettsia Bedsonia).
This world distribution does not include Antarctica, where they do not survive.
Fish also share this disease, as Erlichioses is, according to breeders, a common problem (Psichi Rickettsia Salmoni, first described in Chile) (31).
3,400 patients presented with CFS, Fibromyalgia, RA, depression and MS have been diagnosed as suffering from Chronic Rickettsial Infection (CRI) after eliminating other diseases as a cause (diabetes, cancer etc.).
The majority of my patients report a flu-like infection, with often an elevated temperature and severe headaches. This lasts for a few days, disappears or reoccurs, and then leaves them with a chronic condition of CFS, Fibromyalgia etc. as mentioned above.
Diagnosis of CRI is established by Giroud's Micro-Agglutination test against five strains of Rickettsiae:
However, the Micro-Agglutination test of Giroud is not our only tool to establish the diagnosis of Rickettsial infections. We find the following blood tests most relevant:
Patients' symptoms most commonly exhibited are:
We find quite a valuable guideline in the physical examination, which often shows
After establishing these 3 cornerstones
treatment is administered:
The treatment consists of 7 to 12 days per month of a specific Tetracycline. The monthly treatment aims to follow the Rickettsial development in the cell.
1. A high dosage is required (4,5) with the limitation of:
Safety (32) Goodman et al (33) highlights irreversible hepatotoxicity in intravenous administration only. Our experience was that when liver functions were normal to start with, they stay normal. If they were abnormal, they will improve during treatment and generally return to normal. Cases of fatty acid depots (as shown by liver scan, before and after 6 months to 1 year of treatment) have disappeared (1 MS, 4 ME). This confirms the fact that Rickettsiae are more hepatotoxic than Tetracyclines.
The gastric intolerance will be successfully prevented by using a gastric pump inhibitor during and if necessary before and after the administration of the Tetracyclines.
1) The Tetracyclines are alternated because:
2 )The Tetracyclines are combined with Quinolones, Macrolides or Metronidazole (7), because Rickettsiae present a wide heterogenicity of susceptibility to different drugs (4).
3) The treatment is often long due to:
3. Antimalaria has been found efficient to improve Rheumatoid symptoms and Rheumatoid biological findings (see patients' files). Christopher Columbus knew it in the 15th century, as he gave tree bark containing quinine to his crew to prevent malaria and also mysterious body pains. The Imperial army of Queen Victoria did the same and so was born Indian Tonic water.
4. Adjuvants such as Vitamin B complex and acidobacillus are also used.
5. Cortisone is avoided as much as possible as it is known to weaken the Immune System in general (3) and also to reactivate the disease in experiments on guinea-pigs (39). Cortisone has been accused of interfering with the diagnosis of Rickettsia by masking the antibody level (4).
6. Exercise is recommended, for the following 3 reasons:
7. Hot baths are important to eliminate toxins via the skin, produced by Rickettsiae antigens when liberated in the bloodstream by antibiotherapy.
8. Reinfection may obviously occur. Reactivation (called so rather than relapse) may also happen due to the interaction of bacteria, virus, stress, pollution, etc. causing the Rickettsiae forms' to change to active from dormant (35).
Patients are seen monthly to judge progress on:
1. Symptoms
2. Activity increase (From bedridden to back to exercise or back to work)
3. From being treated by painkillers, antidepressants, sedatives, cortisone to none
4. Medical examination
5. Biological investigation: from having:
· LFT |
· RF raised |
· CRP raised |
· ANF raised |
· KFT raised |
· Thyroid antibodies raised |
· Iron |
Back to normal, or nearly so
Based on this assessment, the treatment is prolonged or stopped (3 months to 2 years: 8 months on average). However, as previously mentioned, the length of treatment is not directly correlated to the length of illness:
Therefore patients can be divided into 2 categories:
1. Fast progress - their illness was mainly Rickettsia
2. Slow progress - their illness was Rickettsia plus other factors (20).
"La santé est comme une mongolfière: il faut parfois lâcher du lest"
Health is like a hot air balloon. You have to get rid of excess burdens to keep it in
the air. Rickettsia is the easiest one to lose
Appendix 1: CFS - Rickettsial Infection: Sources of References
References |
Authors |
|||
1 |
CFS in Incline Village |
1991 |
Mauff & Gon RSA |
|
2 |
Annals New York Academy of Sciences |
1990 |
Preface |
|
3 |
Acta Mediterranea di Patologia. Infectiva e Tropicale. |
1984 Vol 3 1986 Vol 5 1987 Vol 6 no 3 |
JB Jadin, Ph. Bottero |
P213 |
4 |
Bulletin Societé de Pathologie Exotique |
1963 |
J. Gear Monteiro S. Nicolau J.G.Bernard N.R.Grist A. MasBernard Roche |
P588 P680 P691-714 P758-793 P684-687 P714-724 P724-740 |
5 |
Clinique de la Résidence du Parc |
1986 |
||
MS |
P. Le Gag |
|||
Relationship between protozoa, virus & bacteria |
J.B. Jadin |
|||
Psychopathies |
Ph. Bottero |
|||
Buerger Disease |
C. Bourde / Delanoï |
|||
Dermatology |
Aymard |
|||
6 |
Extrait Bull. Acad. Nat. Médecine |
Vol 158 No 1 |
P. Giroud & J. Jadin |
|
7 |
European Journal of Epidemiology |
1991 |
D. Raoult |
P276 |
8 |
Academie Royale des Sciences d'Outre Mer |
1963 No 6 |
J.B. Jadin |
P1128-1129 |
9 |
Ann. Soc. Belge Med. Tropic. : Au Sujet des Maladies Rickettsiennes |
1962 Vol 3 |
J. Jadin |
P321 |
10 |
Infectious Diseases and Medical Microbiology |
2nd Ed. |
Braude |
P810-814 |
11 |
Arch. Int. Med.: Chronic Q Fever |
March 8 1993 Vol 153 |
T. Brouqui et al. |
P.643 |
12a |
Department of Pathology SA |
April 1992 |
Alan Shore? |
|
12b |
Update: Does Infection Cause Coronary Disease? |
Nov. 1997 |
P. Welsby |
P15 |
13 |
International Journal of Medicine |
Garth Nicholson |
||
14 |
Res. Vet. Scient.: Lympho. Subpopulations in Peripheral Blood of Sheep Experimentally infected with Tick-Borne Disease |
July 1991 |
Woldehiwet |
|
15 |
Journal of Clinical Immunology (US): Lymphocytes Phenotype and Function in the C.F.S. |
Jan. 1993 13 (1) |
Strauss et al. |
P30 |
16 |
S. Maryland Clin Immunol. |
Jan 93 13 (1) |
P30-40 |
|
17 |
Affidavit: "To Whom It May Concern" to the SA Medical Council |
January 1995 |
Dr P. Tarbleton, |
|
18 |
Bulletin Acadèmie Nationale de Mèdècine 1979 |
No 6 Masson Ed. Paris |
Paul Giroud |
P163 |
19 |
Maladies Infectieuses |
1976 Ch 41 |
J. Orfila |
|
20 |
Arch. Inst. Pasteur Tunis: Les Infections Superposées Sont à la Base des Faillites de L'Humanité |
1986 Vol 63 |
P. Giroud J.B. Jadin |
P 97-99 |
21 |
Study Annales Internat. Med.: CFS: May 12: F. Nightingale's Birthday Comprehensive Approach |
1994 - 121 |
T. Hennessy |
P953-959 |
22 |
Lancet |
Vol 347, April 1996 |
P977,978 |
|
23 |
Bulletin Acadamie Nationale Medicine |
Vol 163 No 6 1979 |
||
24 |
Bulletin Societé Pathologie Exotique |
January 1952 |
||
25 |
Lyme Disease CDC |
|||
26 |
Rickettsiae and Rickettsial Diseases |
1973 |
Brezinia |
|
27 |
Bulletin Societé Pathologie Exotique |
1969 |
JB Jadin |
|
28 |
Annales of Internal Medicine |
January 1995 |
||
29 |
ASBMT |
Vol 3 1952 |
JB Jadin |
|
30 |
EEG report of 18 year old Epilectic |
February 1998 |
CL Jadin |
|
31 |
An Emerging Group of Pathogens in Fish |
1997 Oregon S U Synopsis |
JL Fryer M. Mauel |
|
32 |
SAMJ Tetracycline in ME - fad or fact? |
Vol 82 1992 |
Bettina Schön |
|
33 |
Pharmalogical Basis of Therapeutics |
1991 |
Goodman et al |
|
34 |
In vitro susceptibilities of Rickettsiae |
1997 |
University of NC |
|
35 |
Relation entre Protozoaires, Virus et Bacteries |
1984 |
JB Jadin |
|
36 |
Arthropods |
|||
37 |
Martindale |
6th Ed 1995 |
P314-318 |
|
38 |
Rickettsial Disease - Review of Medical Biology |
Ch 21 1980 |
Jawetz |
|
39 |
8th Congress of American Rickettsioses Society |
1990 |
M. Drancourt. P Levy |
|
40 |
Académie Royale des Science d'Outre-Mer |
1991 |
JB Jadin |
Reprint in Full-Text with Permission of Dr. Cecil Jadin
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