What is the difference between chronic Lyme and PTLDS?

Post-Treatment Lyme Disease Syndrome (PTLDS) is the term used by mainstream guidelines for persistent symptoms after a documented, treated Lyme infection. Chronic Lyme is a broader term used to describe persistent infection or symptoms with or without documented prior diagnosis. The clinical reality often blurs the distinction.

Can I get Lyme disease in Philadelphia?

Yes. Pennsylvania has one of the highest Lyme disease incidences in the United States. The Wissahickon, Forbidden Drive, the Pine Barrens, and most green spaces in the Delaware Valley have established blacklegged tick (deer tick) populations carrying Borrelia.

How accurate is the standard Lyme blood test?

For early, acute Lyme (particularly with the bullseye rash), the standard two tier test has reasonable sensitivity. For chronic or late stage Lyme, sensitivity drops substantially, with some estimates suggesting 50% or more of cases are missed. The test is also specific (low false positive rate), so a positive is meaningful, but a negative does not rule out chronic disease.

Do I need IV antibiotics for chronic Lyme?

Most chronic Lyme treatment uses oral antibiotics or herbal protocols. IV antibiotics (typically ceftriaxone) are reserved for specific situations: documented neuroborreliosis with central nervous system involvement, severe cardiac Lyme, and selected refractory cases. IV access carries its own risks (line infections, clots) and is not first line.

How do you handle Bartonella specifically?

Bartonella often requires combination therapy because monotherapy fails. Common pharmaceutical combinations include rifabutin or rifampin plus azithromycin, or a quinolone plus doxycycline. Herbal options include sida acuta, houttuynia, and Japanese knotweed. Treatment courses are typically 6 to 12 months.

How do you handle Babesia specifically?

Babesia is a red cell parasite, treated with antimalarial agents. Standard pharmaceutical regimens are atovaquone (Mepron or Malarone) plus azithromycin, or clindamycin plus quinine for severe cases. Herbal options include cryptolepis, artemisia, and methylene blue (in specialty practice). Treatment courses are typically 4 to 9 months.

Can chronic Lyme cause psychiatric symptoms?

Yes. Lyme and particularly Bartonella are associated with anxiety, depression, OCD, rage, and in severe cases psychosis. The presentation can mimic primary psychiatric disease. We screen for tick borne disease in patients with new onset psychiatric symptoms after exposure history, and we coordinate with psychiatry for medication management during treatment.

What about Lyme and pregnancy?

Active Lyme infection during pregnancy can cross the placenta. We treat acute Lyme promptly in pregnancy with amoxicillin or cefuroxime (doxycycline is contraindicated). Chronic Lyme management during pregnancy is more conservative; we often defer intensive antimicrobial therapy until postpartum and focus on symptom management and supportive care.

How long does treatment take?

Most chronic Lyme treatment runs 6 to 24 months. Some patients need longer. We do not promise a specific timeline because the response varies substantially based on duration of infection, co-infections, immune status, and adherence. We measure progress in 3 month increments.

How do you handle the autonomic dysfunction (POTS) overlap?

We use a 10 minute lean test or formal tilt table to confirm POTS criteria. We apply standard POTS management (salt and volume expansion, compression, recumbent exercise, beta blockers or ivabradine when needed) in parallel with antimicrobial therapy. Many patients see autonomic symptoms improve with antimicrobial treatment as the underlying inflammatory driver is reduced.

What is the role of low dose naltrexone in chronic Lyme?

LDN (1.5 to 4.5 mg at bedtime) modulates microglial activation and provides anti-inflammatory effect without immunosuppression. We use it commonly for the neurocognitive symptoms (Lyme brain), chronic pain, and overall fatigue burden. It is generic, inexpensive, and well tolerated.

What is the C4a complement and CD57 marker, and how do you use them?

C4a is a complement split product often elevated in chronic biotoxin states including Lyme and mold illness. It can rise during Herx reactions and fall with successful treatment. CD57 is a natural killer cell subset often suppressed in chronic Lyme. Both are imperfect markers, but they can be useful for tracking trends. We do not use either as a stand alone diagnostic.

How does Fishtown Medicine coordinate with ILADS trained physicians?

For complex cases requiring extended treatment protocols and specialty experience, we coordinate with ILADS trained physicians who specialize in chronic tick borne disease. We act as the primary care quarterback, manage the day to day, and provide a stable medical home while the specialist directs the antimicrobial protocol.

How do you handle children with chronic Lyme?

We do not see pediatric patients in our practice. For children with suspected chronic Lyme, we refer to pediatric ILADS trained physicians and remain available to coordinate with the family's pediatrician.

What is the Warm Invitation Call?

It is a 20 minute video conversation, free, with no commitment. You tell us your story, what testing has been done, and what is and is not working. We tell you whether the model fits. If we are not a good fit for your specific complexity, we will say so and often help you find a better option.

What is the difference between chronic Lyme and PTLDS?

Post-Treatment Lyme Disease Syndrome (PTLDS) is the term used by mainstream guidelines for persistent symptoms after a documented, treated Lyme infection. Chronic Lyme is a broader term used to describe persistent infection or symptoms with or without documented prior diagnosis. The clinical reality often blurs the distinction.

Can I get Lyme disease in Philadelphia?

Yes. Pennsylvania has one of the highest Lyme disease incidences in the United States. The Wissahickon, Forbidden Drive, the Pine Barrens, and most green spaces in the Delaware Valley have established blacklegged tick (deer tick) populations carrying Borrelia.

How accurate is the standard Lyme blood test?

For early, acute Lyme (particularly with the bullseye rash), the standard two tier test has reasonable sensitivity. For chronic or late stage Lyme, sensitivity drops substantially, with some estimates suggesting 50% or more of cases are missed. The test is also specific (low false positive rate), so a positive is meaningful, but a negative does not rule out chronic disease.

Do I need IV antibiotics for chronic Lyme?

Most chronic Lyme treatment uses oral antibiotics or herbal protocols. IV antibiotics (typically ceftriaxone) are reserved for specific situations: documented neuroborreliosis with central nervous system involvement, severe cardiac Lyme, and selected refractory cases. IV access carries its own risks (line infections, clots) and is not first line.

How do you handle Bartonella specifically?

Bartonella often requires combination therapy because monotherapy fails. Common pharmaceutical combinations include rifabutin or rifampin plus azithromycin, or a quinolone plus doxycycline. Herbal options include sida acuta, houttuynia, and Japanese knotweed. Treatment courses are typically 6 to 12 months.

How do you handle Babesia specifically?

Babesia is a red cell parasite, treated with antimalarial agents. Standard pharmaceutical regimens are atovaquone (Mepron or Malarone) plus azithromycin, or clindamycin plus quinine for severe cases. Herbal options include cryptolepis, artemisia, and methylene blue (in specialty practice). Treatment courses are typically 4 to 9 months.

Can chronic Lyme cause psychiatric symptoms?

Yes. Lyme and particularly Bartonella are associated with anxiety, depression, OCD, rage, and in severe cases psychosis. The presentation can mimic primary psychiatric disease. We screen for tick borne disease in patients with new onset psychiatric symptoms after exposure history, and we coordinate with psychiatry for medication management during treatment.

What about Lyme and pregnancy?

Active Lyme infection during pregnancy can cross the placenta. We treat acute Lyme promptly in pregnancy with amoxicillin or cefuroxime (doxycycline is contraindicated). Chronic Lyme management during pregnancy is more conservative; we often defer intensive antimicrobial therapy until postpartum and focus on symptom management and supportive care.

How long does treatment take?

Most chronic Lyme treatment runs 6 to 24 months. Some patients need longer. We do not promise a specific timeline because the response varies substantially based on duration of infection, co-infections, immune status, and adherence. We measure progress in 3 month increments.

How do you handle the autonomic dysfunction (POTS) overlap?

We use a 10 minute lean test or formal tilt table to confirm POTS criteria. We apply standard POTS management (salt and volume expansion, compression, recumbent exercise, beta blockers or ivabradine when needed) in parallel with antimicrobial therapy. Many patients see autonomic symptoms improve with antimicrobial treatment as the underlying inflammatory driver is reduced.

What is the role of low dose naltrexone in chronic Lyme?

LDN (1.5 to 4.5 mg at bedtime) modulates microglial activation and provides anti-inflammatory effect without immunosuppression. We use it commonly for the neurocognitive symptoms (Lyme brain), chronic pain, and overall fatigue burden. It is generic, inexpensive, and well tolerated.

What is the C4a complement and CD57 marker, and how do you use them?

C4a is a complement split product often elevated in chronic biotoxin states including Lyme and mold illness. It can rise during Herx reactions and fall with successful treatment. CD57 is a natural killer cell subset often suppressed in chronic Lyme. Both are imperfect markers, but they can be useful for tracking trends. We do not use either as a stand alone diagnostic.

How does Fishtown Medicine coordinate with ILADS trained physicians?

For complex cases requiring extended treatment protocols and specialty experience, we coordinate with ILADS trained physicians who specialize in chronic tick borne disease. We act as the primary care quarterback, manage the day to day, and provide a stable medical home while the specialist directs the antimicrobial protocol.

How do you handle children with chronic Lyme?

We do not see pediatric patients in our practice. For children with suspected chronic Lyme, we refer to pediatric ILADS trained physicians and remain available to coordinate with the family's pediatrician.

What is the Warm Invitation Call?

It is a 20 minute video conversation, free, with no commitment. You tell us your story, what testing has been done, and what is and is not working. We tell you whether the model fits. If we are not a good fit for your specific complexity, we will say so and often help you find a better option.

The Lyme & Chronic Fatigue Strategy

TL;DR30-second take

Chronic Lyme disease and persistent symptoms after Lyme infection often involve co-infections (Bartonella, Babesia, Anaplasma), biofilm formation, and immune dysregulation. The Strategy covers improved testing options (IGeneX, T-cell assays), biofilm disruption, pulsed antimicrobial therapy (herbal and pharmaceutical), and the supportive care needed for recovery from a chronic tick-borne disease load.

Read Time: 20 Minutes
Clinical Focus: Borrelia, Co-Infections (Bartonella/Babesia), Biofilms

You might remember a tick bite ten years ago. You might not. What you have is "the aches." It feels like the flu, but it never goes away. Your knees hurt today, your shoulders hurt tomorrow. You have air hunger or night sweats. You have been told your standard Lyme test is negative, so it must be something else.

Standard ELISA testing misses up to 50% of chronic Lyme cases. The bacterium hides in tissue, covers itself in biofilm, and dodges the immune response. The Lyme and Chronic Fatigue Strategy is the playbook for patients with persistent post-tick syndromes: better testing, biofilm disruption, pulsed antimicrobial therapy, and the supportive care needed for actual recovery.

Why are standard Lyme tests inadequate for chronic disease?

The standard two tier ELISA and Western blot tests look for the immune response (antibodies) to Borrelia burgdorferi. They were designed and validated primarily for acute, early Lyme disease. They fall short for chronic and persistent infection for several reasons.

Antibody response is variable in chronic disease: Patients with long standing infection often have suppressed or atypical antibody patterns.
Strain diversity: Borrelia has many strains and species (B. burgdorferi, B. mayonii, B. miyamotoi). Standard tests do not cover all of them.
Co-infections are not screened: Standard Lyme panels do not test for Bartonella, Babesia, Anaplasma, Ehrlichia, or Powassan virus.
Biofilm and persister cells: Borrelia can form biofilms and persister cells that evade both immune detection and antibody testing.

How do co-infections complicate the picture?

Ticks are dirty needles. They do not just carry Lyme.

Bartonella: Causes "stretch marks" (striae not from weight gain), foot pain, anxiety, rage, and cognitive disturbance. Often missed.
Babesia: A red cell parasite (similar mechanism to malaria). Causes night sweats, air hunger, headaches, and worse fatigue.
Anaplasma and Ehrlichia: Cause fevers, chills, low white blood cell counts, and elevated liver enzymes. Often present in early disease and missed.
Powassan virus: A neurotropic virus transmitted in minutes after tick attachment. Less common but increasingly recognized.

If you treat Lyme but miss Babesia, you do not get better. The co-infections often need separate treatment, and the order of operations matters.

What does the diagnostic workup look like?

We layer testing rather than relying on a single result.

Standard Tier

Two tier ELISA and Western blot: We still order it because positives are diagnostic. We just do not use a negative to rule Lyme out.

Specialty Testing

IGeneX or Vibrant Wellness Lyme panels: Look at additional bands and species not covered by standard testing.
T-cell based assays (like LymeSpot or T-Lab): Detect cellular immune response to Borrelia, often positive when antibody tests are negative.
Co-infection panels: Bartonella IgG/IgM, Bartonella PCR or FISH, Babesia IgG/IgM, Babesia PCR for B. microti and B. duncani.
CD57 marker: A specific natural killer cell subset that is often suppressed in chronic Lyme. Not a stand alone diagnostic but useful as a trend marker.
C4a complement: Often elevated in chronic biotoxin states including Lyme.

Supportive Workup

Inflammation: hs-CRP, ESR, ferritin, fibrinogen.
Hormonal: Full thyroid, AM cortisol, DHEA-S, sex hormones. Chronic infection drives endocrine dysfunction.
Mitochondrial markers: Lactate, pyruvate, organic acids when indicated.
Autonomic: 10 minute lean test for orthostatic intolerance (POTS overlap is common).

What is the strategic roadmap for chronic Lyme treatment?

Phase 1: Provocation and Testing

We complete the workup and identify the dominant pathogens and downstream effects. We also stabilize basic systems: sleep, nutrition, hydration, and electrolyte balance. Many patients are in a fragile state, and starting intensive antimicrobial therapy in an unstable patient causes severe Herxheimer reactions.

Phase 2: Breaking the Biofilm

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

Start your intake

You cannot clear the bug if you cannot reach it. Biofilm disruption is often the difference between a year of failed antimicrobial therapy and actual progress.

Stevia leaf extract: Lab evidence supports antibiofilm activity against Borrelia.
Cistus incanus tea: Polyphenol rich, used for biofilm disruption and as a daily preventive.
Lumbrokinase or serrapeptase: Enzymes with biofilm disrupting and fibrinolytic activity. Used under supervision because of bleeding risk.
Monolaurin: A coconut derived fatty acid with broad antimicrobial activity.

Phase 3: The Antimicrobial Phase (Pulsed)

We pulse therapy because Borrelia has a slow replication cycle (several weeks) and switches between active and dormant forms. Continuous treatment can drive the organism into persister states. Pulsed treatment catches the spirochetes when they emerge.

Pharmaceutical options: Doxycycline, azithromycin, cefuroxime, dapsone, and others. Selection depends on the dominant pathogen, prior treatments, and patient tolerance.
Herbal options: Cryptolepis, Japanese knotweed, cat's claw, andrographis, sida acuta, alchornea. We often prefer herbal protocols for long term use because of the lower side effect profile.
Co-infection specific therapy: Bartonella often needs combination therapy (rifabutin or rifampin plus a quinolone or azalide). Babesia needs antimalarial agents (atovaquone plus azithromycin, or cryptolepis based herbal protocols).
Pulsed schedule: Many protocols use 4 days on, 3 days off, or 2 weeks on, 1 week off. The schedule depends on the specific medication and patient response.

Phase 4: System Repair and Supportive Care

Clearing the pathogens is only part of the work. The downstream damage needs repair.

Mitochondrial support: CoQ10 (ubiquinol), PQQ, NAD precursors, magnesium.
Detoxification support: Binders (activated charcoal, bentonite clay, cholestyramine in select cases), glutathione, NAC, milk thistle.
Hormonal restoration: Thyroid, adrenal, sex hormone optimization based on labs.
Autonomic regulation: Salt and volume expansion, compression, recumbent exercise.
Mast cell support: Many chronic Lyme patients develop mast cell activation that needs separate stabilization.

Actionable Steps for Suspected Chronic Lyme

Get the right testing. Standard Lyme panel plus IGeneX or Vibrant Lyme panel plus co-infection panel (Bartonella, Babesia, Anaplasma).
Address the foundations first: sleep, nutrition, hydration, electrolytes, basic mitochondrial support. Many patients improve substantially before starting antimicrobials.
Find a physician who knows the literature. The standard infectious disease community remains divided on chronic Lyme. We work alongside ILADS trained physicians for complex cases.
Plan for a long course. Most chronic Lyme treatment runs 6 to 24 months. Quick fixes are not realistic.

Scientific References

Aucott, J. N., et al. (2013). Post-treatment Lyme disease syndrome symptomatology and the impact on life functioning. Quality of Life Research, 22(1), 75-84.
Feng, J., et al. (2020). Identification of essential oils with strong activity against stationary phase Borrelia burgdorferi. Antibiotics, 9(3), 128.
Theel, E. S. (2016). The past, present, and (possible) future of serologic testing for Lyme disease. Journal of Clinical Microbiology, 54(5), 1191-1196.
Horowitz, R. I., & Freeman, P. R. (2019). Precision medicine: retrospective chart review and data analysis of 200 patients on dapsone combination therapy for chronic Lyme disease/post-treatment Lyme disease syndrome. International Journal of General Medicine, 12, 101-119.
Kullberg, B. J., Vrijmoeth, H. D., van de Schoor, F., & Hovius, J. W. (2020). Lyme borreliosis: diagnosis and management. BMJ, 369, m1041.

Conclusion

This is a marathon, not a sprint. But you can get your life back.

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Fishtown Medicine | Playbooks

2418 E York St, Philadelphia, PA 19125(267) 360-7927 hello@fishtownmedicine.comHSA/FSA Eligible

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Frequently Asked Questions

Common Questions

The mainstream Infectious Diseases Society of America (IDSA) and ILADS (International Lyme and Associated Diseases Society) interpret the literature differently. IDSA emphasizes that prolonged antimicrobial therapy after standard Lyme treatment lacks evidence of benefit. ILADS emphasizes that patients have persistent symptoms not explained by other causes and respond clinically to longer courses. We acknowledge the debate, treat the patient in front of us, and use the best available evidence.

A Herxheimer (Herx) reaction is a temporary worsening of symptoms when antimicrobial therapy clears bacteria and releases their toxins faster than the body can remove them. Symptoms include increased fatigue, headache, joint pain, brain fog, and flu-like feeling. Mild Herx reactions are expected with effective treatment. Severe reactions require dose adjustment, additional binders, or pause and restart.

For chronic disease, herbal protocols (Buhner protocol, Cowden protocol, Klinghardt protocol) have a different risk-benefit profile than long term antibiotics. Some lab evidence shows specific herbs (cryptolepis, Japanese knotweed) have direct antiborrelia activity. Patients often tolerate herbal protocols better for the long courses chronic disease requires. We use both approaches and often combine them.

Deep-Dive Questions

We map the dominant pathogens and the downstream system effects first. A patient with prominent Bartonella features (rage, anxiety, foot pain, striae) needs different therapy than a patient with prominent Babesia features (night sweats, air hunger, severe fatigue). A patient with significant POTS overlap needs autonomic stabilization in parallel with antimicrobial therapy. The personalization is not about which one supplement to add. It is about the order of operations and the rate of treatment intensification.

Many chronic Lyme patients develop mast cell activation as the immune system stays chronically primed. The clinical presentation includes new food sensitivities, flushing, anxiety after eating, orthostatic intolerance, and worsening reactions to environmental triggers. We screen with tryptase and 24 hour urine N-methylhistamine. We treat with H1/H2 blockers, mast cell stabilizers (cromolyn, ketotifen), and dietary low histamine support when needed. Mast cell stabilization often allows more intensive antimicrobial therapy without intolerable Herx reactions.

Killing bacteria releases endotoxins and biotoxins that the body must clear. Binders (cholestyramine, activated charcoal, bentonite clay, chlorella) bind these toxins in the gut and prevent enterohepatic recirculation. We use binders strategically during antimicrobial therapy, particularly when Herx reactions are problematic. We dose binders away from medications and supplements to avoid binding the active treatments. Glutathione, NAC, milk thistle, and adequate hydration support phase 1 and 2 liver detoxification.

Many patients we evaluate for chronic Lyme have concurrent mold exposure or biotoxin illness (CIRS, chronic inflammatory response syndrome). The symptoms overlap substantially. We screen for water damaged building exposure, run urine mycotoxin panels when indicated, and address mold concurrent with Lyme when both are present. Treating one without the other often leaves the patient in a chronic inflammatory state.

Variable. Patients with shorter duration of illness and clear pathogen identification often have substantial recovery within 12 to 24 months. Patients with multi-decade illness, multiple co-infections, and significant downstream organ damage have a more difficult course. We aim for substantial functional improvement, not always complete cure. Many patients reach a stable, manageable baseline that allows full life participation, even if some maintenance care is needed.

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