The Connection Between Lyme Disease and Your Gut

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Today I speak with Dr. Todd Maderis about the connection or the potential connection between Lyme and the gut. The main probe I wanted to explore here was could there be a subset of people with chronic gut symptoms for whom the underlying cause of those gut symptoms is Lyme or some Lyme co-infection? So that is a topic that we explore today, and I was really appreciative of Todd’s perspective on this.

DrMR:

Of course, we discussed the connection between Lyme and the gut, which can be challenging to untangle especially when considering that antibiotics are used to treat Lyme and they may have a carry-over benefit on the gut. It’s also potentially possible that antibiotics could make the gut worse and create gut symptoms in someone who hasn’t well tolerated some of the antibiotics that are used for Lyme. Also, there was a bit of a tie-in with mold, and he helped provide some guideposts, or I guess, hierarchy guidelines for if you have multiple things to pursue. Gut, mold, Lyme, where do you start? Is there perhaps a more efficient sequence that one should be working through?

DrMR:

We also discussed some of the ambiguity in mold testing and his preferred methodology for Lyme testing. I didn’t have a chance to completely vocalize some of my gripes with the Lyme field, mainly because I had another interview scheduled, so I had to curtail or cut some of those. I do want to just quickly plant a few seeds here for the audience. One of the things that’s often said in Lyme which may be true but I question is these infections can be stealth, they can hide, they can be chronic and what have you. I’m not discounting that. That may be true to a degree, but I also have observed that same narrative in GI as it pertains to parasites, to SIBO, to fungus.

DrMR:

In clinical practice, I haven’t really found that to be true. In fact, I have found that with the right support, the symptoms can go away and the labs are not highly correlated, although they do help. And there is validation for PCR stool testing and for SIBO breath testing, but it’s the chronic symptoms in symptomatically non-responsive patients where I don’t know how beneficial more and more testing can be. I suspect it actually fuels this fallacious neuroticism that clinicians should be very careful to avoid and patients should be very careful not to get pulled into.

DrMR:

Another thing that is a bit challenging for me in the realm of gut, Lyme, and the interconnection between the two is a couple of the clinicians who’ve published papers on this. I actually know and I have actually co-managed some patients along with them. One thing was really disheartening to me. I want to share this without sharing any names, because this is not about calling people out, but it is calling attention to things that need to be done better in the field. With one of these clinician researchers in particular, I had more than one patient tell me that let’s say the office visit was 30 minutes. The first 20 minutes was used just getting this clinician up to speed on what was going on with the clinician’s patient.

DrMR:

So clearly a lack of efficient, thorough, and organized note taking. When I combine that with other presentations I’ve seen from this same individual, the presentations were high in theory, and then when it came to the, “Okay, we found ‘X, Y, and Z,’ reinforcing hypothesis “ABC,” then the part that is the most important, which is, “So we treated ABC,” and what did you find? In these presentations, that was glossed over and wasn’t even really addressed.

DrMR:

Now for both clinicians who are looking for other clinicians to learn from, and for people in public or just trying to find clinicians to follow, that’s something very important to cue in on. If someone has a lot of narrative and a lot of story that’s really interesting, compelling, and perhaps very eloquently articulated, but they’re not tying it to, “…and this person saw resolution of their symptoms. They saw improvement in “X, Y, Z,” that is a huge, massive red flag, because that’s the whole point, the whole point of the hypothesis and the saying, “So this suggests ‘ABC’ should be done.” If you don’t then show, “Well, we did ‘ABC’ and we got excellent outcomes,” then if that’s not something that’s important to you, then there’s no mechanism for you to verify or disprove your hypothesis, therefore you are not going to become a better clinician over time. So that’s another thing that has come out of some of the Lyme/gut interconnectivity community that concerns me.

DrMR:

The other thing that concerns me about Lyme and about mold is there maybe this multi-interventional paradigm, which isn’t a bad thing, but at some point it’s incumbent upon the clinician to start breaking these things out into sequential intervention so you can get a sense for, using an analogy that is common for us in the clinic, what’s the effect of low-FODMAP? What’s the effect of probiotics? What’s the effect of immunoglobulins? What’s the effect of elemental diets? We can’t hide behind people being complicated, needing multiple lines of support, and the fact that we’re treating people holistically. True, true, and true. But it doesn’t mean that you can’t, as we do in the clinic, stagger your interventions. Do this for two or three weeks. Then add that.

DrMR:

That gives you a chance to get the feedback from the patient. “Well, when I did the first thing, I saw nothing. Did the second thing, I improved quite a bit.” Okay, great. Do that for six months in a row, and guess what? You can easily cue in on the therapeutics that don’t really move the needle. So my suspicion is somewhat common in both the mold community and the Lyme community regarding treating many things at once, thus reducing the ability of providers in these communities to assess what works and what doesn’t work. And then if that’s combined with the narrative and the expectation that these are chronic conditions that take a long time to improve, then you have the excusing of poor responses, or the accepting of people not demonstrating noticeable improvements.

DrMR:

So those are some of my gripes. I’m not saying that those are directed at Todd. In fact, they’re not directed at Todd, but if we had another 20 minutes, those are the things I would’ve wanted to bandy back and forth. But I’m very appreciative of Todd sharing what he’s doing. I like his perspective of the sequence, and some of the sequence lines up with my clinical experience. Treat the gut before Lyme. To his credit, he made a great point to address mold to the best of your ability before Lyme also.

DrMR:

So don’t let my gripes with some of the strawmen in the mold and Lyme camp be confused with a criticism toward Todd directly. These are just the criticisms I have at large with the Lyme field. And again, it’s not to single out Lyme. I think these things occur in many areas, including mine, GI, but I just want to voice them so that people understand where and what we could potentially do better.

DrMR:

All that being said, I do not refute that there’s something here that can benefit and likely does benefit people every day. It’s just trying to figure out where is the benefit and where is the excess? The same thing happens in GI. It’s something that at one point in my career I was guilty of. And now that I’m not, I see how much faster patients can improve how they’re feeling at so much of a lower cost to them, not only financially, but also psychologically. Okay, with that long, monologue on the front end here, we will now go to the interview on the gut/Lyme Lyme/gut connection with Dr. Todd Maderis.

DrMR:

Hey everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio, and today I’m here with Dr. Todd Maderis, and the topic de jure is Lyme and the connection between Lyme and the gut. This is something that we talked about a while ago on the podcast, but as I’m sure many of the clinicians here can attest to, you’ll be driving, a thought will hit you, and you’ll be wondering how this may connect. My thought was wondering if there are some patients who have Bartonella that’s manifesting as this symptom that Bartonella has purported to manifest as, which is lower abdominal pain and ache, and I wonder if some patients who are experiencing a feeling of ache or maybe confusing that as bloating may have Bartonella.

DrMR:

We did some searching to see if there was someone who was looking at the connection between the gut and Lyme. We found Todd, and here he is today to discuss this topic. So Todd, welcome to the show. I’m excited to pick your brain.

DrToddMaderis:

Great. Thank you for having me.

DrMR:

Can you give us a little bit about your background and how you found your way into this niche?

DrTM:

Well, probably like a lot of functional doctors listening, you start out with a broad practice where you’re treating most things that people seek out functional medicine doctors for, such as endocrine, adrenal, thyroid issues, digestive issues, and fatigue. I happened to see a patient that had been suffering from fatigue for a long period of time and had seen a whole list of doctors and walked in the door with a stack of lab results. One of those results was a Lyme test. He was unsure what the results had meant, no one had ever gone over them, and I wanted to make sure that I wasn’t on that list of docs that he had seen that couldn’t help him. I didn’t know much about Lyme at the time, but the next thing I knew, I was on a plane to a Lyme conference. This was about a decade ago, and it’s completely changed my practice ever since.

The Lyme-Gut Connection

DrMR:

So let’s start with the high level. There seems to be consensus or agreement, at least from what I’ve been able to parse together. Maybe my bias is why I’m getting this conclusion, so I want to bounce it off you and see if you agree with it. Is there a general agreement in Lyme circles that gut care should be either addressed first or at least at a very early phase before going too deep into Lyme? This is the loose conclusion that some of our prior podcasts online has led us to, which is you may want to get the gut health piece squared away first, or at least at the same time, so that you have better tolerance to some of the Lyme therapies. It’s worthwhile checking to see if that was just a unique perspective, maybe because these were people that were coming on a gut-centric podcast, and therefore perhaps we had a bit of a selection bias. What’s your perspective?

DrTM:

Yeah. I think that Lyme doctors that are more functional in their approach would definitely want to address any underlying GI issues before or at least at the same time as initiating a Lyme protocol. I think there are still a lot of Lyme physicians that are maybe more purists that are just treating infections. If that’s the case, I think they’re missing a big part of addressing underlying gut issues, so that patient may get referred to a GI doctor or the symptoms may not get addressed at all. With the immune system being so proximal to the GI tract, I think it’s important to address any underlying gut pathology that could be skewing the immune system, contributing to more inflammation, that which in conjunction with if antibiotics are prescribed could cause more GI issues.

DrTM:

That being said, I think a lot of my patients that do walk in the door that either have a Lyme diagnosis or suspect they have Lyme are having GI symptoms. Not all, but probably two-thirds of those patients may be experiencing GI symptoms, and so I will do a typical workup with a stool test and maybe a breath test and determine if there is something there that can be treated to just improve their outcome.

DrMR:

Right. I think that’s good for our audience to know if you have Lyme or suspect Lyme that you may want to your feelers out, so to speak, to see if your Lyme doctor is at least inquiring about your gut health. If not, I wouldn’t say that would discredit that doctor’s ability to treat Lyme, but you may want to have someone else on your team who can help with the GI, or maybe get a second opinion from someone who treats both. And I’ll say that at the clinic, that’s one patient type that we’ll see periodically. “Hey, I’m happy with my Lyme doctor and we’re undergoing treatment there, but I feel like no one’s looking at the gut. Can you at the clinic help me in conjunction with the therapeutics that we’re going to be using with my other doctor for Lyme?” And the answer there is always yes. We’re more than happy to support, but one logistical and planning piece to put on the board for people is to make sure that you’re not overlooking your gut health.

DrTM:

Agreed. Generally speaking, whether it’s thyroid issues as well or if someone has a mold exposure, whatever it may be, if you cast that broad net and can identify as many of the underlying pathologies that are causing symptoms, then you’re clearly going to have a better outcome than just staying focused on the infection.

Bartonella and Abdominal Pain

DrMR:

Sure, absolutely. More of a global and holistic treatment approach. So I spent a couple of years treating Lyme, and it wasn’t something that I fell further into for reasons that maybe we’ll get into later. But one of the things that was on my radar screen was Bartonella and its association to abdominal pain. I don’t think I had the sophistication or the methodology earlier in my clinical practice to really be able to tease out that association. I know this is a very, very specific question, but do you have any sense if those with Bartonella have a higher degree of abdominal pain or this lower abdominal ache, as I know it’s sometimes described? Perhaps you don’t agree with that at all, just whatever your perspective is, I’m curious for your honest take on that.

DrTM:

That’s a good question. I haven’t heard or seen any literature that correlates Bartonella with lower abdominal pain or discomfort. A lot of times my patients that have tick-borne infections will have multiple infections. It’s rare. We say the rule is that ticks are multi-infected and really you just get one. Testing for the human has gotten a whole lot better in recent years, and so we’re picking Bartonella up a lot more using a Bartonella Western blot, which looks at four different species. In years past, I’d suspect a Bartonella patient would have all the signs and symptoms, but the testing would show up negative. I might put them on a protocol, they’d improve, and that would kind of confirm my suspicion. But in recent years, the testing has improved.

DrTM:

And then seeing multiple infections, is there abdominal discomfort from Lyme? Is it from Bartonella combination? I’m not sure, but I definitely do see it in patients at times. Bartonella tends to have an affinity for the nervous system. We’ll probably segue into this in a little bit, but with the enteric nervous system, or if the Vagus nerve is affected by one of these infections or multiple infections, you’re going to get sort of a neuropathy that contributes to something, whether it’s constipation or gastro-paresis, and then that leads to SIBO. That may be the case, again, because of Bartonella’s association with the central nervous system.

DrMR:

Is there an association that you’re seeing between abdominal pain improve from Lyme, if you’re able to break that out from what might be happening? I’m assuming some of these abdominal symptom cases are improving as we’re giving antibiotics, and those antibiotics may be addressing other things in the GI like SIBO or dysbiosis. Again, this is probably something that’s pretty challenging to untangle from a clinical observation perspective, but do you have any sense on that?

DrTM:

Of course, the antibiotics we use are typically a little different than what we’d use for SIBO, but people occasionally do report their GI symptoms do improve. The results may not last. I tend not to use many oral antibiotics any longer just for a variety of reasons, including causing more digestive issues. So I’d say I probably prescribe Xifaxan more often than I prescribe antibiotics for Lyme disease. Orally, at least, I use some IV antibiotics to bypass the gut. But yeah, it’s definitely a possibility where someone gets put on, say, Doxycycline for the Lyme and their GI symptoms improve. Maybe it’s temporarily, but that might clue you into some GI dysbiosis.

Antibiotics for Lyme Treatment

DrMR:

Is the thinking in the Lyme world that the IV antibiotics are going to be more effective at getting these bloodborne illnesses and also bypassing the gut? Is there a degree of this that’s intentional to get around the gut so as not to have so much impact via absorption in the GI? In my Lyme training, I didn’t really get much of an answer on that, although I wasn’t really asking why there is more of a lean on IV. I mean, it would make sense that if it’s a bloodborne infection, you go to blood administered antibiotics, but what’s the thinking there?

DrTM:

Historically, I think the use was really to just get high blood levels or high concentrations of the antibiotic in the bloodstream. You’ll still see it used in hospitals, especially when people have what we call neuroborreliosis. And so more of a neurological manifestation of Lyme, if it has penetrated the central nervous system, then those higher concentrations are necessary to get into the central nervous system. I don’t think anyone is really looking out for the gut early on, but maybe more so now physicians have realized there can be a detrimental effect from the orals. I tend to pulse if we do use IV antibiotics. I tend to use a pulsing method so they’re not on it daily, which is also nice.

DrTM:

You know, these infections are stubborn, they’re stealth. They like to hide in tissues and joint spaces. That creates a real challenge. Oftentimes they get into what we call immune privileged sites. Their goal is survival, so they’re not typically floating around in the bloodstream, but they might be in tissues, organs, or joint spaces. It makes it really challenging to treat them, especially if biofilms are formed. So I think at the end of the day, a lot of times it’s sort of a balance. With of a lot of the symptoms we see with tick-borne infections, there’s almost like two silos. You have this bacterial load when that happens, and then you get this immune response that tries to match that bacterial burden. And a lot of the symptoms we see are actually a result of the immune response. So it’s not just about knocking down the bacterial burden.

DrTM:

One of the most common questions I get at one of the first visits when maybe someone gets a diagnosis of Lyme disease, they’ll say, “Well, can you ever really get rid of all the bacteria?” I think the conclusion is that we really don’t. There’s always going to be some level of bacteria in our body. We’re full of viruses, bacteria, some good, some bad, but it’s really a biome. And if we can knock down the pathogenic bacterial load low enough and get the immune system working properly, regulated, that’s when people become asymptomatic and can go on and lead normal lives.

DrMR:

That’s something I definitely want to circle back to because it’s a finding or a philosophy that I have found to be very much true in GI.

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GI Symptoms of Lyme Disease

DrMR:

Let’s go a little bit further and outline a bit more of the GI connection before we go to some of these philosophical pieces that I have that I’m quite interested to actually unpack. You had sent over a few notes about common GI symptoms in Lyme disease. Let’s go over some of those, just so people are in possession of some of this knowledge in case they feel this is an area in need of investigation.

DrTM:

Clinically what I’ll see is patients that have classic SIBO symptoms. They might have gas and bloating, abdominal discomfort, maybe more constipation than diarrhea. Patients also might be reactive to foods. They could hardly eat much otherwise they react. Is that a food allergy issue, a leaky gut issue, or a mast cell issue? That’s where I think testing comes in handy, but I’d say the nausea, vomiting, and abdominal discomfort tend to be really common. Constipation is also a really big one. Probably like you and your practice, the goal of everything we at least want to do is get to the underlying cause. If you keep asking, “but why?,” eventually you’ll get there.

DrTM:

Constipation just seems to be one of those that I see a lot in the tick-borne infection world. There was a study that came out earlier this year from a GI practice down in Southern California, Dr. Rahbar, who is a gastroenterologist, but began testing some of his patients for Lyme probably almost seven or eight years ago. And every year he’s tested more and more folks, but they ended up doing this retrospective chart review of 270 patients. These are patients that had come to their clinic because of sort of refractory SIBO, and what they determined was that about half of those patients had tick-borne infections. They also tested them for SIBO, and of the people that had SIBO, about half of them were the Lyme infected folks and the other half were not. So not all cases of Lyme disease cause SIBO, but it’s definitely something that should be screened for. I think the purpose of their study was to bring awareness to these difficult, chronic, unexplained digestive conditions that don’t get better. Could there be an underlying pathology that’s contributing to that?

DrMR:

You mentioned constipation. Is there some ability of Lyme to impact the nervous system and the gut? Is this a theoretical or is this something that is a fairly strong clinical observation? I’m sure our audience is curious to know a little bit more about that, because that’s the first I’ve heard of this potential constipation, slowing of motility potentially associated to Lyme.

DrTM:

Again, one of those things that probably hasn’t been studied. I’ve seen an article written by a physician named Virginia Sherr. The title of the article is “Bell’s Palsy of the Gut.” Of course, Bell’s Palsy is a facial paralysis that occurs, and the nerve that’s affected there is the seventh cranial nerve. As you know, the Vagus nerve is the 10th cranial nerve and it innervates the gut. So there have been associations, and the suggestion is that these tick-borne infections can essentially cause a neuropathy of the Vagus nerve that then contributes or interferes with the migrating motor complex, and then we see constipation form, which of course with any motility disorder can contribute to bacterial overgrowth in the small bowel.

DrMR:

I’m assuming that you’re seeing some Lyme cases improve from antibiotic therapy or herbal equivalent therapy, but it’s again probably challenging to know if this is causal or associative.

DrTM:

Right. So while I’m treating the systemic tick-borne infection, especially if they test positive on a breath test, they’re going to get two weeks of Xifaxan. I like to use prokinetics a lot, so I typically try to start with a natural prokinetic and I would say it works in maybe half the cases, but if that doesn’t do trick, then I put them on a prescription prokinetic and try to keep their bowels moving so the SIBO doesn’t return while we’re focused on the underlying tick-borne infection that may be contributing to the central or the Vagus nerve dysfunction in the first place.

The Treatment Sequence for Lyme

DrMR:

And speaking of Lyme, I know this is probably a loaded question or a lot to speak to, but is there a certain structure or hierarchy that you will use with Lyme patients? Just as one quick example, we often start with diet and lifestyle. It sounds simple for our patients, but a reminder that someone who let’s say is overly stressed and has a heightened degree of emotionality or might have some limbic imbalances, support there can be huge in reducing their GI symptoms combined with getting them on the right diet. Someone may be eating a really high-FODMAP diet and has no clue that even though they’ve been trying to change their diet for five years, they haven’t uncovered this one FODMAP piece.

DrMR:

We’ll kind of start there. That could be loosely described as a level one, and then see how they respond. And level two might be probiotics. Level three might be a short-term elemental diet reset. Level four might be antimicrobial therapy. Level five might be immunoglobulins. So there seems to be somewhat of a successful sequence to follow and to personalize. Is there something similar that you’re using with Lyme?

DrTM:

It’d be great if there was a real black and white roadmap for tick-borne infections, but unfortunately there really is not. I tend to look at each patient individually, and if we do a lot of testing to identify all those underlying issues, each scenario is a little bit different. For example, if someone has both tick-borne infections and mold, I strongly believe you have to address the mold successfully before you can go on and treat the tick-borne infections. Mold is very immunosuppressive, and if mold is part of someone’s picture, then they’re just not going to get better by treating the tick-borne infections alone. And not every case of Lyme is one where someone also has mold, but a fair amount of people do.

DrTM:

We didn’t give the disclaimer in the beginning, but what we’re typically talking about here is chronic Lyme, not the acute tick bite where someone gets a bite and within 10 days, they have symptoms. We’re talking about people that have long-term or what we like to call late stage Lyme disease. For some people, they might’ve had a tick bite that occurred 10 or 15 years before the onset of their symptoms. Then something happens, some event happens that triggers their symptoms. And then someone runs a Lyme test and they go, “We’ve figured it out, it’s Lyme disease.” But again, maybe it was a dormant infection for 10 or 15 years. Maybe it was some stressor, a gut infection, mold exposure, whatever, that triggered the onset of what is basically an inflammatory process.

DrTM:

Clearly you have to go after the infection at some point, but it’s like the saying if you’ve got 12 nails in your foot and you find one and remove it, you still have 11 nails in your foot. So there’s no straight forward hierarchy given that everyone is a little bit different. I do believe you’ve got to get the immune system working properly. You’ve got to address the underlying digestive issues, address any other toxins, whether it’s mold or heavy metals, before you’re going to have success treating a tick-borne infection.

DrMR:

Okay. So then there are some higher-level sequences, which would be gut before Lyme. Again, loosely, but gut before Lyme, mold before Lyme, which I definitely think would make sense if there’s ongoing exposure due to the chronic immune reactivity and therefore likely immunosuppression. Anything else? Maybe when we get into the Lyme, do you start with, I think it’s Buhner’s protocol? There are some herbal protocols, or there’s whole line from Byron White, these herbal formulas. Do you start there, reevaluate, and then consider escalation antibiotics? Are there some general guiding principles within how you’re applying the Lyme therapeutics specifically?

DrTM:

If someone’s immune system is really unstable, I know that they’re going to be reactive to whatever I put them on. It could be one drop of an herbal tincture for tick-borne infection and they might react. And so if we have to clean them up first, detoxify them, get their immune system modulated, I tend to take that approach. If someone has more of what you might call a clear infectious presentation where they’re maybe having fevers, night sweats, and almost classic flu-like symptoms, then it sounds like the bacterial or infectious burden is really what’s driving the bus. Maybe they’re going to need an anti-microbial early on.

DrTM:

So it really depends on how sensitive a patient might be, but I really like to focus on that immune response too. I use a lot of low-dose naltrexone in my practice. I use a therapy called low-dose immunotherapy. We use transfer factors and a variety of other things that help to modulate and improve that immune response, because at the end of the day, these symptoms are really a by-product of this inflammatory cytokine response. A lot of people are familiar with cytokines now since COVID and hearing about the cytokine storm that was really causing symptoms in folks. Well, the same thing has been happening in these chronic tick-borne infections.

Mold Treatment

DrMR:

With the mold, how are you determining if someone does or does not have mold? Is it history, home testing, perhaps something like an ERMI or having an IEP examine their residence? Is it some type of urine test? Is it cytokines in the blood? How are you trying to make that ruled in or ruled out?

DrTM:

That’s a big question in the mold world. I’m in a mold group of physicians and there’s always a little ongoing debate about what works and doesn’t work. Typically I’m focused on the patient, and I will refer them to an IEP if we suspect there’s a current exposure, but historically I would look at some of those inflammatory markers also known as those Shoemaker markers or CIRS markers. They can be elevated when people have mold exposure, but they can also be elevated from other causes. As we say, they’re non-specific. You might have an elevated TGF-beta that’s caused by something else. I still like that marker, but I don’t think a lot of the other markers really give you a whole lot of clinical data.

DrTM:

I did urine testing for a number of years and would see kind of mixed results. The first urine test might come back with one elevated mycotoxin. I’d treat someone for two or three months, repeat the test, and then see two or three other mycotoxins elevated. It wasn’t because they had a new exposure. I think their body had maybe cleared that first mycotoxin, and now they’re excluding the remaining. And then about a year or year and a half ago, I started using mycotoxin antibody testing. So blood testing that looks for antibodies against 12 different mycotoxins, both IgE and IgG, that tells us if someone’s immune system is reacting to the mold. It really makes a whole lot more sense to me to know whether or not someone’s immune system is being triggered.

DrTM:

In fact, I have a family right now where one of the children have elevated mycotoxins. A mother and a daughter don’t; they all lived in the same house, but their immune systems are just not being triggered. To me, whether or not their immune system is reacting to the toxin is more important. I’ll still run urine tests in conjunction with a mycotoxin antibody, especially if someone is more of a pure mold case, but clinical history is what guides that, and then of course the testing confirms it.

DrMR:

Well, I actually really like that perspective. As I’ve been learning more about mold and we’ve been interviewing various experts, I’ve had the pleasure of living in two homes with mold, treating more and more patients with mold, and using testing. I think our audience knows that I’m about 50% convinced that everything in the field is awesome and 50% convinced that everything in the field is crap. And so it really keeps me questioning things so that only the best ideas are left standing. The way I’m starting to think about mold is that while there are rare exceptions where someone will have a highly-toxic form of mold, I suspect what’s far, far more common is a degree of mold overgrowth occurring in certain climates like that of Austin fairly commonly, but only some people are sensitive, just like some people are only sensitive to grasses and pollens.

DrMR:

As one example of this, when I first moved to Austin, I bunked up with a buddy of mine, and there was clearly mold in that home. Now that I’ve been in two places that have had mold, I know exactly the sort of reaction that I have. And he and his girlfriend had zero ill effects from being in that home. So I look at that and I say it’s not that there’s this boogeyman lurking that is in some houses and not others, but it’s rather just like you wouldn’t feel weird or abnormal if you were labeled as someone with an allergy to pollen, I look at that as some people are allergic to mold and therefore they have to be extra diligent about where they live.

Levels of Mold Sensitivity

DrMR:

So that cues in with what you’re saying about the antibodies, but there’s also something else here that I just want to make sure our audience captures, and grain of salt here because this is just my hypothesis. There’s no real hard data to affirm this yet, at least not that I know of, but I think we can start looking at some of mold, I would argue speculatively, most of mold, as not there being something wrong with you, per se, but just looking at it like how some people have seasonal allergies. I have a seasonal-like allergy to mold, and so I have to be a bit extra diligent about making sure this is not in my environment. Not framing it as this chronic inflammatory boogeyman, limbic trigger, emotional trigger, not good for you from a psychological standpoint. So I’m not sure if you would agree with that or tear some of that down, but that’s at least how I’m starting to think about it.

DrTM:

I think it’s an important point you bring up. For some people, they can spin out because they think every environment does have some level of mold. At the end of the day, I think what some of the pioneers in environmental medicine world would says is that it’s total load. It’s total burden. And I often use that analogy with patients. It’s like you have a bucket, we’re all born with a certain size bucket. It may be different based on genetics, and some people can withstand a lot and others not so much, but once that bucket is full and then you have an added exposure burden, it’s going to tip over or flow over and contribute to symptoms.

DrTM:

I think an important distinction to make with mold is that there can be mold allergies. That’s the kind of test you get from a regular Labcorp, Quest reference laboratory where they’re looking for antibodies against the actual molds. What I referenced earlier was the mycotoxin antibody testing, which is performed at a specialty lab, and they’re truly looking at antibodies against mycotoxins. So the mold spores produce a toxin, and that’s what we’re more concerned with. So you’re right. There are a couple of different levels of mold reactivity someone can have. They can be mold sensitive or have a mold allergy, and then there’s mold toxicity. And I think that’s an important clinical piece to be able to identify.

DrMR:

And would you agree that we can look at this as some people being allergic to the mold while other people are allergic to the mycotoxin? At the end of the day, I guess you could say you’re allergic to the dog, maybe a bad example there, but if you could be allergic to the dog or the dog hair, it’s a similar analogy. Or is there something there that I’m not factoring into that?

DrTM:

I mean, you’re triggering antibodies in either scenario. That’s important to know, but the toxin itself is what I think causes a lot of the pathological damage in the body and inflammation. I’ve got a folder on my computer of various studies on various mycotoxins. There’s a plethora of research out there; it’s overwhelming. I’ve been compiling and adding papers to this folder of mycotoxins for a while now.

DrTM:

In the agricultural world, they’ve studied a lot of these mycotoxins because it affects the food and how it’s transported and stored. There’s a lot of evidence out there that these toxins that can be in foods as well, particularly grains, can cause GI issues when we ingest them. There are a number of studies out there that associate these various mycotoxins and leaky gut syndrome, which is a funny word. I like to call it intestinal hyperpermeability, but most people know it as leaky gut. There’s some hard evidence that supports that these mycotoxins can break down tight junctions and contribute to gut inflammation.

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Review of Mold Studies

DrMR:

For our audience, because I know of late there a few review papers that have been quite comprehensive in their scope reviewing and chronicling some of this evidence that I think you’re referring to, Joe Mather from our office underwent the significant undertaking of reviewing that paper and the references. And this is something that I need to read, because I know Joe put in a lot of work reviewing these references. But one of the things that was interesting about this paper was there seemed to be a lot of emotionality amongst one paper in particular. It almost seemed as though the conclusion was reached at the beginning. I have a feeling that reading Joe’s writeup and objective analysis of this paper is going to be really enlightening for people in the mold field.

DrMR:

One of the things I credit Dr. Joe with is as someone who suffered from mold himself and had quite sizable personal hardships because of the symptomatic burden he was under, he’s still very level-headed in not wanting to fall into various circles of dogma. The invade GI, the invade thyroid, Lyme, mold, everything. So I’ll just point that out to our audience. I apologize that I have not yet read it. That means that I’m both a bad friend and a bad co-worker for not having had read it yet, but what I suspect people will get there is a good balanced perspective on some of this literature.

DrMR:

The reason why I mentioned this in particular is that I’ve become increasingly sensitive to this over the past few years when we hear some of these toxins are prevalent. It can really lead people to, as you said earlier, spin out. I’ve just been trying to offer people as many lifelines as I can to prevent them from spinning out, and using myself as an example, I’m clearly sensitive to mold, yet I have no food reactivity. Pretty much zero. So for me, one way if I’m framing this as negatively as possible, I could interpret my observation that living in a home with mold-caused symptoms could be then I need to be on the lookout for it being in my coffee, in certain grains that I’m eating, or in too high of a level in certain fermented foods?

DrMR:

At least my observation doesn’t necessarily track with that. It’s not to say that’s not the case for some people and probably could be true for some early in their healing journey when their immune system is reacting to everything. But just to point to that piece of balance, if people want to go through Joe’s review on one of the more recent and comprehensive reviews on mold toxicity, I would offer that. And that’s in our clinicians’ newsletter so it won’t be on our website at large, just for our audience. But if you are a subscriber to the FFMR, you’ll see that. I think it was June of 2021, so this year’s June research review. Todd, anything there that you want to respond to?

DrTM:

I agree. I think everything has to be balanced out. I always think of the patient that I see that can only eat white rice and sweet potatoes and if they deviate something goes wrong. In my mind, it’s not about the diet, it’s about something else that’s underlying that you have to identify and heal. Regarding these mycotoxins and leaky gut, I think the research is fairly robust and it’s fascinating. And clearly not everyone that ingests wheat, because actually a lot of these mycotoxins tend to be associated with wheat storage. It begs the question that maybe that’s more of the issue than the gluten or gliadin, but the point is that the research really does make a correlation between various mycotoxins and gut inflammation, or I should say tight junction breakdown. I’d be happy to share those studies with you to link to the show notes.

DrMR:

If you send over a few of those, they would be great to have. These are studies that are mainly in stored grains that show after consumption humans are experiencing more permeability?

DrTM:

Yeah, there are a couple in particular that are review articles that highlight all the research that’s been conducted here. One is called “Mycotoxin: Its Impact on Gut Health and Microbiota,” by Liew. Another one is titled, “The Compromised Intestinal Barrier Induced by Mycotoxins.” So there’s a variety of them, and they just look at the mycotoxin load and then tight junction breakdown in various studies, whether it’s rodent studies or human studies, but there’s a variety of them out there.

DrMR:

Well, the one sniff test that I’d want it to pass is just to make sure that this isn’t animal data or human cell culture data, meaning we’re not having humans ingest a certain food. Do you know what extent the evidence is, I don’t want to say clinical trial, but at least observational trials in humans and not something that’s consolidated to human intestinal tissue in a Petri dish or to animal data?

DrTM:

I think a few of them were looking at population studies. So different demographics that consumed high amounts of certain grains that looked at the mycotoxin content in the grains. Again, there’s a variety of them and some of them may be rodent studies and others not.

DrMR:

Yeah, it’s a lot to parse. If you would send that to me, I think what we’ll do is a review of a couple of those papers just because I’m sure there is some more human level evidence there that we could weigh for people and help give them a summary to take away. So, yeah, that’d be great.

DrTM:

And to your earlier point, you’re trying to keep everyone level-headed and not fly off the handle and think that if they consume a grain they’re going to end up with mold or mycotoxin illness and leaky gut. I hear you. Clearly information is empowering to everyone. And at the end of the day, what I like to do is test the patient. Not all tests are perfect, but some are pretty good. I prefer to do zonulin testing in the stool and not blood tests. I was just reviewing some labs in my inbox before we logged on here. I had three stool results and all three of them had elevated zonulin levels. That just happened to be what came in today. So there are a variety of causes, but if it’s there, I think it has to be treated.

Lyme Testing

DrMR:

Pivoting regarding the testing, because I want to make sure that we get your perspective on Lyme testing, specifically Lyme and Lyme co-infection. This is something that seems to be somewhat contentious where some are trying to adhere to more of the CDC Western blot guidelines, and then there are some who do it based upon looking at you and reading your aura and tell you if you have Lyme. So somewhere in between, I’m assuming we have the sweet spot of sensitivity and specificity but what are you finding with the Lyme testing accuracy and what are some of your preferred tests?

DrTM:

It’s always a big loaded question because we tend to default to the CDC and their recommendations. In the Lyme world that I live in, I’m part of an organization called the International Lyme and Associated Disease Society and a lot of the physicians in that organization use specialty laboratories because the evidence regarding these national reference labs is that the sensitivity of the testing is just not very good. As I mentioned earlier, Lyme bacteria don’t like to hang out in the bloodstream. They like to get into tissues. When we do the testing, we’re most commonly using what we call indirect methodology where we’re looking at the immune system to see if the immune system has seen the bug. Of course, if the immune system hasn’t seen the bug, then we’re not forming antibodies or low-level antibodies. That’s not going to turn a test positive.

DrTM:

So that makes it challenging. But your Labcorp or Quest is typically what’s called a two-tiered test. First an ELISA test that has very low sensitivity, they say less than 50%. But if it is positive, a Western blot test gets run, which has greater sensitivity and specificity. So it’s going to confirm that ELISA. I’d say the most advanced test available is what we call an immunoblot. It’s a little bit more sensitive than the Western blot. That’s primarily the test that I prefer to run.

DrTM:

The direct methodologies, such as PCR testing, which is looking for the DNA of the bacteria, again, because it’s not floating around in the bloodstream, it tends to be difficult to see a positive PCR. if you do get one or a positive direct visualization with a tests like a FISH test, which is Fluorescence Institute Hybridization, then if it’s seen or you find the DNA in the blood, then clearly that’s a slam dunk. The antibody testing is more sensitive, but sometimes the immune system has not made antibodies or doesn’t see the infection. So there are a lot of specialty labs on the market, and I still use the tried and true IGeneX laboratory that’s here in the bay area where I’m located. They’ve been doing nothing but tick-borne infections for about 25 years.

DrTM:

There are some new labs on the market. I think time will tell how accurate they are. I think it’s important in medicine not to just jump on the next bandwagon or the latest and the greatest until it’s proven itself in the marketplace. Sometimes it requires multiple tests. I just saw a study published last week that someone was negative on a Lyme test and they seroconverted after antibiotic treatment, which is not uncommon, meaning they received microbials which stir the pot and liberates the bacteria. And then the immune system sees it and the person became positive. This was in a conventional hospital, but the point there is for Lyme at least, it’s always been considered a clinical diagnosis by Lyme literate doctors. And the tests are confirmatory. They’re much better now than they used to be.

DrTM:

A lot of my patients have been to a number of specialists. They’ve seen neurologists and rheumatologists. They’ve had MRIs. They’ve been worked up for MS or some other autoimmune condition. And when all of that has come back negative and when another diagnosis hasn’t been confirmed, that’s really helpful because you’ve ruled out a number of things. And then if Lyme is suspected, then of course there’s that clinical picture confirmed by labs.

Finding Root Causes

DrMR:

Gotcha, gotcha. Yep. I think that approach of not hanging your hook on any one lab in particular and correlating with the individual is really the best way to unify both the patient’s symptoms and history and the lab testing so that we’re not just looking at one completely to the exclusion of the other.

DrTM:

We see this a lot because Lyme is known as the great imitator, meaning these infections can cause a multitude of symptoms. Lyme is sort of a distant cousin of syphilis, which was originally known as the great imitator. If you look at the myriod of symptoms, it could be everything from joint aches and pains to fatigue, cognitive impairment, headaches, mood disorders, anxiety, depression, and insomnia. Pick a symptom, whether it’s depression, but they also have fatigue or they also have joint aches and pains, then I think it raises another level of suspicion that it’s not just a pure depression. You have to look a little bit deeper and determine what’s also causing the fatigue and the pain. There could be a common thread that if it’s addressed will take care of all three of those symptoms.

DrMR:

I think that’s the route that we often try to look for in the clinic. It’s an analogy we often use with our patients, which is patients will oftentimes be very concerned about this array of branches or symptoms. What we’re really trying to do is trace that down to what is the one, two, or few root causes that if addressed will ameliorate these 10 symptoms that may be seemingly unrelated. So obviously the root cause approach is really the way to go. It’s sometimes easier in theory than it is in practice, but that’s the aim.

DrTM:

It’s very rewarding and I also think it’s much more sustainable. Conventional medicine really doesn’t have an answer for complex illnesses. You see people going from specialist to specialist. You see someone that focuses on the elbow and then the next person that focuses on the liver. They’re not going to connect the dots. And really the approach that we all take in functional medicine is to look for the common threads and look at the patterns. Could these five or 10 symptoms be caused by one or two common commonalities? And the answer is, yes, they probably could be, if you look in the right location. Sometimes people will say they went to a great university hospital and saw some wonderful physicians but they couldn’t find anything. And the joke is, well, maybe they didn’t look in the right location.

DrMR:

Fully agreed, and also as you actually said a few moments ago, it’s great that you’ve had those things ruled out. And it is; that’s not just a platitude. It’s great. You’ve ruled out a bunch of stuff, so now we can rest assured that it may not be something that’s more in the conventional box that could be more life-threatening because usually the deeper you go into the conventional box, the less you want to be someone who’s receiving a diagnosis there from that specialist. And now we can go to work in looking in the sphere of focus that we will look at.

DrMR:

So yeah, I think it’s important for patients to realize that even though you’ve seen a bunch of specialists, it doesn’t mean that another doctor may not be able to find the cause, especially if you’re going to a different paradigm. And it’s also good that you’ve had those evaluations and I wouldn’t feel defeated or frustrated, although a degree of that would be understandable. That is constructive in the sense that you’ve crossed things off of the list.

DrTM:

Correct. We’ve had great advances in conventional medicine, whether it’s imaging or some of the other blood testing that we can do. And it’s great to rule out some of those obvious conditions, but sometimes we need to cast a broader net and look at other areas that could also be causing those symptoms.

DrMR:

Well said.

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Episode Wrap-Up

DrMR:

Well, Todd, where can people find you online if they wanted to track you down or learn more about the good work that you’re doing?

DrTM:

My website, which is where I like to write articles to educate people especially on everything we just discussed today, because I think there’s not a lot of great information. My website is DrToddMaderis.com. And then the other location is on Instagram which is DrToddMaderis as well. So those are probably the two best locations to track down the information that I like to write about related to tick-borne infections, mold, and mast cell issues.

DrMR:

Great. Well, thank you for taking a little bit of time here to discuss Lyme with us. It’s been a while since we’ve broached this topic. I’m glad that we were able to provide our audience with some reminders and hopefully some tips for navigating this if it’s something that you think is part of what’s going on with yourself and therefore needed in order to feel your best. So I just really appreciate it again, Todd. I hope you have a great rest of your day.

DrTM:

Great. Thank you for having me.

Outro:

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What are some important aspects of Lyme treatment

• GI before Lyme
• Mold before Lyme 
• Dampen reactivity before Lyme, in those who are sensitive

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