Wednesday, May 05, 2010

This is Part III of a 3-part essay. Read Part I here and Part II here.

Strays: Part III

Late Spring 2008

Eight or nine months into treatment, as my heart made slow progress on Rifampin, I hunted around the Internet reading abstracts about bartonella and its related cardiac problems. It was hard to find anecdotal accounts of some of the rarer strains in humans. I began mining veterinary articles, which -- perhaps because the subjects were nonverbal -- included more elaborate description of the physical details of the subjects. These were the first articles I found that truly characterized cardiac bartonella. It was around that time that I found a near-description of my own cardiac symptoms in a veterinary article about twelve dogs with heart problems related to bartonella vinsonii subsp. berkhoffii, a strain of bartonella that had known transmission from animal to human. It had been recognized for some time in coyotes, with documented coyote-to-human transmission. On a parallel track, one world-class researcher in Raleigh, NC, Edward B. Breitschwerdt, was on his own obsessive quest to understand rarer strains of bartonella and their impact on human populations. Among other fascinating cases, he has written about a set of twins who seemingly contracted bartonella in utero: one died of a cardiac defect just nine days after birth. His papers on B. vinsonii subsp. berkhoffii in humans were published over a year and a half after I read the article on B. vinsonii subsp. berkhoffii in dogs, and saw my own symptoms in those purebreds and former strays.

B. vinsonii subsp. berkhoffii is a particularly virulent strain when it comes to the heart, at least in dogs. Alarmingly, eleven out of twelve of the dogs in the first article I read, even with treatment, died -- the dog who survived had been on continuous treatment with veterinary Cipro for three years. Clearly, this strain was a different beast from bartonella henselae. The symptomatic notes on the twelve dogs showed an alarming and dramatic infection that seized the dogs quickly, often before they had a chance to get help. A cocker spaniel, a Newfoundland, a coonhound, and two German shepherd were described as having "collapse," whereas a five-year old bull mastiff and a four-year old boxer succumbed to "sudden death." B. vinsonii subs. berkhoffii has also been found in human hearts, and sudden death -- which occurred in the elite orienteers with bartonella elizabethae, another strain that occurs in dogs -- is often an indicator of myocarditis.

Dogs are actually, it turns out, a better model for understanding human diseases than cats. In fact, it is no accident that I found the most descriptive detail of my heart symptoms in veterinary papers and extremely old medical texts, as those patients often had a more comprehensive, intimate relationship with their doctors that involved longer observation periods. In a recent article by Breitschwerdt's team entitled, "Bartonellosis: an emerging infectious disease of zoonotic importance to animals and human beings," the authors state, "it is increasingly obvious that the dog is a natural model for human bartonellosis and vice versa." This same article, published in 2010 -- a year after I was dying in my bedroom in acute respiratory distress breathing with a ventilator as my condition became more deadly, noted that two dogs were diagnosed with b. vinsonii subsp. berkhoffii leading to acute respiratory distress requiring ventilatory support. Other dogs developed "rapid cardiopulmonary decompensation" from this strain. The authors note, importantly, that a limited understanding of bartonella as "cat scratch fever" (bartonella henselae) does not give a clear picture of more damaging, non-self-limiting strains of bartonella in humans. In other words, when it comes to bartonella species, a cat is not a dog.

I was living a parallel reality to those dogs. My infection, after all, had affected my heart with torturous, crushing, utterly debilitating cardiac symptoms just a few days after I was bit. But B. vinsonii subsp. berkhoffii had begun to sound like a ringer for my heart symptoms, even before I remembered and verified the dog bite. For one thing, the technician at the lab that did my blood smear told me he thought I might have a rare strain of bartonella. On my blood slide, the bartonella organisms are bunched in the middle of the cell, whereas in most slides I have seen of bartonella they are clinging to the side. The technician explained this is a visual quirk, that actually the bartonella must be clustered in the concave part of the red blood cells.

I could not find any images of bartonella vinsonii slides, but I did find a slide of b. elizabethae that looked a lot like mine. So both of these became contenders as strains that might have infected me. Because of its lethality and the descriptions of the dogs just collapsing, I felt most strongly that b. vinsonii subsp. berkhoffii was my strain. It is known to cause endocarditis, myocarditis, arrhythmia, uveitis, choriditis, limping, splenomegaly, polyarthritis, and epistaxis in dogs, and endocarditis as well as neurological problems in humans. B. elizabethae, on the other hand, causes lethargy, anemia, and weight loss in dogs, and endocarditis in humans. I called my friend that day and left her a voicemail that said, "I think I've got doggie bartonella!" and I started barking on her voicemail. She reminded me of this message later, when I had my memories about the dog bite.

Around the time of my veterinary readings, unbeknownst to me, Dr. Martin Lerner announced some startling new data from the previous seven years of cardiac observations on ME/CFS patients. At the ME/CFS Conference in Westminster, London, he said that he had identified two distinct groups of ME/CFS patients: one with a herpesvirus illness (EBV, HHV6, HCMV) with no coinfections, and the other with a combination of herpesvirus infections and a co-infection such as Lyme, babesiosis, adult rheumatic fever, or mycoplasma pneumoniae myocarditis. For the first time that I know of, Lerner was publicly acknowledging a subgroup of ME/CFS cardiomyopathy patients whose hearts were likely coinfected with zoonotic, often tick-borne, infections (Lyme, babesiosis). Remember, Dr. Lerner found T-wave inversions and T-wave flattening on Holter monitoring in 90 percent of ME/CFS patients he studied, declaring this heart damage a biomarker. He also found ME/CFS patients to have abnormal tissue biopsies of the heart, and abnormal contraction of the heart indication weakening of the left ventricle. Meanwhile, Dr. John Chia, an infectious disease specialist from California with an interest in enteroviruses, announced his research that showed 135 out of 165 (82 percent) of the ME/CFS patients he tested by stomach biopsy had enterovirus antigens in their stomach tissue, compared with 7 out of 34 (20 percent) of controls, data that validated Richardson's earlier work on enteroviruses with a cardiac-affinity. While Chia's focus was not specifically on the heart (as Lerner's ongoing research has been), both of these raised an interesting possibility: was my heart first infected by a virus, back in 1992, only to be ravaged later by a dramatic attack of virulent bartonella?

In a particularly prescient moment of emailing my home visit doc in 2007 to convince him of my heart infection, I had sent him an article on the latest cardiac understanding of AIDS along with a letter: "Also notable is the attached article AIDS cardiac issues. The fact that pericarditis, pericardial effusion, and all sorts of heart infections are common amongst AIDS patients – and often caused by unusual factors such as staph – leads me to think that this could be a vast untapped area in CFIDS research where the immune parameters and co-infections are so similar to AIDS. Pericarditis leading to cardiac tamponade is one of the only conditions I could find in which chambers of the heart collapsed, which is interesting as Dr. Paul Cheney has found similar heart collapse in upright echocardiograms of CFIDS patients."

Two years after sending that letter to my doctor who thought that having blood like a dead person was not a cause for alarm, after I had been on an antimicrobial regimen for two years, the Whittemore Peterson Institute heralded the discovery of the retrovirus XMRV in ME/CFS patients, and this threw another curve ball. As it turned out, my letter to my hear-no-evil doctor was right on the money: most ME/CFS patients are infected with a retrovirus that seems to pave the way for secondary infections, just like HIV.

In a Q & A in the IACFS Newsletter (Vol. 3, Issue 1, April 2010), lead XMRV scientist Judy Mikovitz answered several questions about Lyme and other coinfections and their relation to XMRV, stating "The hypothesis that chronic XMRV infection creates an underlying immune deficiency is consistent with many co-pathogens including Lyme." She elaborated:

Q; With the known % of CFS patients positive for Mycoplasma species (~60% in multiple studies), Chlamydia pneumoniae (~10% in multiple studies), HHV-6 (~30% in some studies) and other infections, is there any concordance with XMRV positivity?

A: We have only done those analyses on the 101 in the original study, HHV6A was 10%, EBV ~14% and nothing else more than 10%. We are working with several groups at Lyme and those numbers may approach 30%-40 of those tested.

Q: Do you feel that XMRV could act to cause dysfunction of the immune system, allowing opportunistic infections (such as in 4, above), similar to HIV-1 in AIDS?

A: Absolutely that is our working hypothesis

I was correct in asserting to my doctor that ME/CFS patients, initially infected with XMRV, might later present with secondary infections similar to those of AIDS patients, who often get the spirochetal illness syphilis (similar to Lyme) as well as bartonella. I'm not sure why this reality has been obscured for so long in ME/CFS research, but I'm reminded of the sobering article I read about cardiac implications of HIV/AIDS -- about how they were not well tracked in the early years of the epidemic, as patients simply did not live long enough for their heart problems to become full blown. Having a new chronicity brought on a greater understanding of the illness running a progressive course. Funding and ACT-UP tactics, of course, also helped.

My life was still circumscribed beyond imagination, and by July of 2008, my cardiac symptoms were still quite severe after almost a year of treatment, even though I had had significant improvements from the previous cardiac torture. "The best I can imagine in life is a slow, progressive anorexia of everything," I wrote on July 22. My heart had still not returned to its pre-Cipro state for any extended period of time, and that was a relief, but it still slipped back to that state with some regularity without homing there, and on November 20, 2008 I wrote in my journal "Tonight the effort of breathing felt like it would end me. Death still feels very close, and still I think of little else but playing the game of survivor." It was a few weeks before my 40th birthday, and I had spent almost all of my adult years too sick to have a life.

On December 1, 2008, after my revelation about the dog bite and its connection to my cardiac symptoms, it occurred to me the local animal control officer might know something about where the white dog was taken, what shelter. I did some research and found the officer's name online -- her name, Candy LaFlam, seemed like a drag queen name more befitting of a flamboyant afghan handler than a small-town rabies monitor. My friend called her for me, since I was too weak to speak on the phone. The officer, a friendly woman who ran a dog-sitting business, had an immediate recognition when my friend described the dog that bit me. She said she was pretty sure she knew the dog personally. The man on Ireland street was actually the owner of the dog, she said, and he was pulling the wool over my eyes about not being the owner and about his intention to contact animal control. The man in fact had found the dog and brought it in to the animal control officer and told her he wanted to keep it, so she was mandated to quarantine it for ten days to make sure it was healthy. The dog had some blindness due to old age, with glazed and glossy eyes. It was about 30 pounds, part "miniature Eskimo dog," with dirty white fur, and partially deaf -- a male. After her ten-day quarantine, she returned the dog to the man. At some point later, she found the same dog dead by the Gorge. She brought the dog's body back to the man, not knowing how it died. My friend got the impression that Candy was somewhat unsure of the man's story then, but if the dog had a lethal strain of bartonella, sudden collapse at the Chesterfield Gorge would have been quite plausible.

Finally, I had my answer. The dog that bit me had been sick enough to die at the same beautiful Gorge where I had escaped to in my early weeks in Massachusetts, before it bit me.

At that point, however, I could not get tested for this strain, and had to be content with my general blood smear showing I had some strain of bartonella. Bartonella vinsonii subsp. berkhoffii is thought to be more likely in dogs from rural populations, where there is more tick exposure, and it is one of only a short list of dog strains of bartonella that also infect humans: B. vinsonii subsp. berkhoffii, B. henselae, B. clarridgeiae (Candidatus B. washoensis), B. quintana, B. rochalimae, and B. elizabethae. Human labs were not doing specific testing for most of these strains, so I tried veterinary labs. One veterinary lab I contacted about testing my blood, Zoologix, offers a panel test for the most common strains of bartonella found in both humans and dogs, but Zoologix refused to process my blood. Just this year, Dr. Breitschwerdt's lab,Galaxy Diagnostics, began testing humans for b. vinsonii subsp. berkhoffii, but since I have been on bartonella meds for almost three years, and since dangerous hypersensitivity reactions can be induced by stopping and restarting my bartonella drugs, Dr. Breitschwerdt agreed in a private correspondence that I would have a hard time getting an accurate test for B. vinsonii subsp. berkhoffii or other dog strains now. He wrote me: "the optimal testing time point is prior to administration of antibiotics. We do get positive Bartonella PCR/DNA sequencing for some patients while taking antibiotics, but this is not optimal as these bacteria are extremely hard to detect and antibiotics suppress the numbers and the growth in the enrichment culture step." I may never know exactly which strain I have.

I do know this: white animals have often been seen in mythological traditions as harbingers. The white dove, for example, is seen as a good omen, and the birth of a white bison is meaningful in many Native American traditions, especially amongst the Plains Indians such as the Lakota, who view it as a symbol of rebirth when the people of the world have fallen upon troubled times. I suspect some species of bartonella will be recognized as some of the most virulent, life-threatening infections of our troubled times. Tragically, Dr. Breitschwerdt experienced this first hand, when his own work quite surprisingly jumped species after his father -- a tough-as-nails former ironworker and WWII vet -- got sick with a bizarre neurological disease. His story demonstrates why it was so hard for me to connect the dog bite with my symptoms for years, and why it's so hard for many people to recognize dangers in their own back yards. Dr. Breitschwerdt, a veteran of zoonotic illness research, did not immediately suspect bartonella, despite the fact that his father had previous tick exposures but a negative test for Borrelia burgdorferi, the spirochete that causes Lyme. Dr. Breitschwerdt describes his father's symptoms as "retrospectively obvious" but, perhaps because of the nearness of the situation, he did not see them clearly right away.

Dr. Breitschwerdt ultimately found evidence of not one, but three strains of bartonella in his own Dad -- B. henselae, B. alsatica, and B. vinsonii subsp. berkhoffii -- and his father was treated and released from the hospital repeatedly, but his condition worsened until he ultimately died in a severely encephalopathic state. Despite appropriate and aggressive antimicrobial treatment for bartonella, and the fact that his son was a leading researcher on bartonella, Dr. Breitschwerdt's father could not fight the infection that had invaded his brain. Many of his symptoms, leading to his death, were identical to mine -- he had a lesion on his eyebrow like the one I had on my finger, he went into a stupor-like state that was described as nearly comatose, he had seizures and jerking movements similar to my myoclonic activity. By his final blood draw, just days before his death, his blood was only showing evidence of one strain of bartonella, thus indicating his antimicrobial therapies had worked against the other two strains. The remaining strain in his blood was B. vinsonii subsp. berkhoffii!

Dr. Breitschwerdt's article about his father, and the veterinary article on the dogs who died of bartonella vinsonii subsp. berkhoffi, are frightening to read. I know, from stopping my meds a few times, that my bartonella infection is not even close to being eradicated. My bartonella drugs are liver-toxic. If my liver conks out, I'll have to stop my only working meds. Many of my symptoms in recent years, as well, hint at an encephalopathic state, and Dr. Breitschwerdt's father demonstrated how bad this can be: he had hallucinations, dementia, symptoms initially thought to be a stroke, tremors, nonverbal states, severe agitation, inability to recognize his own family members, and near-constant confusion. Similar neurological symptoms from bartonella have been observed, it should be noted, in much younger patients, so these symptoms were not related to age. I have had many similar symptoms since contracting bartonella, though I have not detailed them here. As I write this today, however, I can barely read through my own words. I have a constant, maddening thumping on the right side of my head that has been almost continuous for the past year. My hyperacusis is still so severe I cannot listen to music and can handle very little sensory input in general. It is hard to open and close my right hand. I read things on the Internet and have to read the simplest paragraphs over and over again to understand them, as they initially appear nonsensical. These are just my neurological symptoms of the moment.

Had I finished this article on bartonella a year and a half ago when I wrote most of it (including the speculation about B. vinsonii subsp. berkhoffii), had the ice storm not come and thrown me into the hospital, then into increasingly severe neurological, immunological, and other symptoms until I almost died of respiratory distress, I would not have known about Dr. Breitschwerdt, his recent articles, and the death of his father. Most of these articles were only published in the recent months. In a moving departure from the overly-technical tone of most scientific articles, Dr. Breitschwerdt makes poignant observations about death and dying and the human medical system -- from his perspective as a trained veterinarian watching his father die. "In human medicine, unlike veterinary medicine, no physician claimed or accepted the responsibility to be my father's doctor," writes Dr. Breitschwerdt. He adds, "I found the human healthcare system to be frayed, if not broken."

These realities were not lost on me, and I am grateful to Dr. Breitschwerdt for validating my reality -- especially the deep emotional pain I felt when no one would take on the responsibility of my care -- both in terms of practical caregiving responsibilities and medical care -- and the tragic, broken reality when doctors finally did help me. My home visit doc unceremoniously dumped me after I sent him a letter requesting that he stop speaking to my family about my case. He wrote back that I had clearly shown I did not trust him, and that he could not operate in a medical relationship without "trust" (he was not willing to take actions to regain my trust, like admit he had been wrong about my Lyme disease). My LLMD later foisted off my case on a primary care doctor, implying that my condition was so serious and complicated it had become a liability. My own life, post-bartonella, has become more and more broken.

"Some years ago in a conversation with my mother," writes Dr. Breitschwerdt in the article about his father. "I suggested that the term natural death may well represent an oversimplification of the processes that end a person's life." Indeed, while hundred-year-old cardiology texts can describe the intimate, painful reality of a "natural death," the term natural death is used in modern society as a way of avoiding and anesthetizing the process of dying. This is exactly why a person dealing with a persistent, chronic, potentially lethal infection that invades the heart and brain but evades detection will face denial, derision, and perhaps a grueling and untimely death without a steadfast advocate fighting by her side. I believe there is another reason why veterinarians might be better at this job than human doctors: they are less hierarchical. They don't see a lowly groundhog as unworthy of human interest. They notice, in other words, what is underfoot. By working closely with animals and witnessing the close bond between humans and animals, they don't harbor as strong of an illusion that humans are above animal, and hence immune to insidious little forces of nature crawling up their pant legs. It is the same type of character that makes me admire the often-unlikable Dr. House: when he exhumes a dead cat to save a patient from a zoonotic pathogen, I want him to drive to Ireland Street for me, invade that man's back yard, and dig.

Natural causes are not inevitable. Adolf Hitler once said, "Nature is cruel, therefore we are also entitled to be cruel." It is true that nature is cruel, and that human nature is cruel, but it is Hitler's use of the word "entitled" that gets to me. I think this is what Dr. Breitschwerdt is getting at about natural death. To use that term to diminish the experience of actual death, of death death, is cruel. To walk away from a limping dog, a complicated illness, a person who needs care, is cruel. To not exhume the cat, in its own way, is cruel. It was not, after all, curiosity that killed it -- but rather a lack thereof. Nothing, in other words, entitles us to speed nature along by denying someone's symptoms and then call it a "natural death." Nothing entitles us to deny the complicated, often protracted process of a person dying.

I find it interesting that some drugs, developed for rare medical conditions, are called orphan drugs, and the conditions they treat are called orphan conditions. I wonder when some of us, trapped in the cogwheel of obscure physical realities, will stop being medically abandoned, orphaned, cast astray? Almost as if by vampirism, I have become that dog with the quivering back legs, the dog that tried to wander from its own fate and thought it was being rescued, then found itself dragged back to near where it would die -- yet in one, life-affirming moment, said no with its teeth. I am thankful for the impulse behind that no, the fight that still lives on in me.

This is Part II of a 3-part essay. Read part 1 here.

Strays: Part II

"If a lion could talk, we could not understand him" -- Ludwig Wittgenstein

December 2004- Spring 2008

It is hard to describe the futility of explaining to people a lethal, fringe reality that it outside of their understanding. Wittgenstein had it right when he said "If a lion could talk, we could not understand him." Talking animals only exist in cartoons, and people would balk at the very idea, just as they balk at the idea of homebound, medically disenfranchised patients presenting their own stories. But Wittgenstein was getting at something deeper: language is borne of one's own physical reality, and a lion's words would always be near-misses to humans. Words are, by nature, a way of pinning down the gestalt of experience, but that process does not translate the life of a lion to the life of a human. This is why the Innuit need a hundred words for snow, and the Aztecs needed few to none.

To save my own life as my heart got worse, I tried to translate the lion's roar of my raging infection to a language my doctors might understand. But I was stopped by limited knowledge of bartonella and the fact that dog-to-human strains of bartnonella were so newly recognized that my infection was outpacing the research. It also turned out to be a stroke of bad luck for me that ME/CFS cardiac issues were getting prominent attention just a few months after the onset of my bartonella infection, when well-known ME/CFS expert and recent heart transplant recipient Dr. Paul Cheney began talking about his new theories of cardiac ME/CFS. This new information threw me off the trail of zoonotic infections and distracted me from the obviousness of the dog bite. As I said, I had dealt with serious ME/CFS cardiac issues for years, but they did not resemble my current horror, nor could I find another ME/CFS patient (I tried) with symptoms resembling mine except one Swedish patient who, I quickly decided, might have bartonella too. Yet I did fit the paradigm of ME/CFS heart damage, so I was eager to read Cheney's new work. My Holter monitor test in 2000 had showed T-wave inversions and T-wave flattening, which Dr. Martin Lerner has demonstrated through heart biopsies are indicators of viral cardiomyopathy in ME/CFS patients. Dr. Lerner, like Dr. Cheney, developed a focus on ME/CFS cardiology after his own heart was in danger, quietly treating himself with antiviral drugs for six years until he could resume treating patients full-time and apply what he learned to the ME/CFS community. He expanded upon the work of Richardson and Hyde, fine-tuning his diagnostic technique of using Holter monitoring to detect viral cardiomyopathy, then doing biopsies of heart tissue to prove the existence of the viruses, and lastly treating his ME/CFS cardiac patients with antiviral drugs. Despite a write-up in the Wall Street Journal after he presented his work at a cardiology conference, Dr. Lerner's work is still not well known to most cardiologists, though ME/CFS patients began to take more interest in it when an antiviral drug trial for Valcyte -- an oral verson of the intravenous drug Lerner had used for years -- started on ME/CFS patients at Stanford. In the year after my Holter test showed abnormalities consistent with Lerner's theories, I tried to hand Dr. Lerner's WSJ article to a cardiologist in her exam room, and she simply refused to open her hand to take it, as I were trying to give her a nightclub flier, and walked out the door, pronouncing me "deconditioned." She told me to go home and exercise.

Dr. Sarah Myhill in the UK has explained how ME/CFS patients in fact go into borderline organ failure every time they even sit or stand, due to reduced cardiac output and mitochondrial damage: "in CFS sufferers the drop may be from 5 litres lying down to 3.5 litres standing up. At this level the sufferer has a cardiac output which causes borderline organ failure." My cardiac output, measured on the test Myhill referred to called the Impedance Cardiography (a test I did manage to get -- in a fragrance free doctor's office -- in the ensuing years after my bartonella infection began), was remarkably low upon standing, 3.1 litres per minute which, adjusted by my size, worked out to an even lower number on the cardiac index (1.8 litres/minute) -- that and my other cardiac parameters were similar to those of a 79-year old woman with Class IV heart failure in one published study on Impedance Cardiography that I found on the Internet. It was also significantly lower than what Dr. Arnold Peckerman found in his study on ME/CFS patients, low enough that he would have called it left ventricular dysfunction, whereas Dr. Cheney would have probably called it diastolic heart failure based on his diagnostic criteria at the time. However, since CFIDS heart abnormalities occur at the level of the mitochondria or heart muscle, they do not typically show up on an echocardiogram -- the gold standard for heart failure determination. Diastolic heart failure in general, often called "heart failure with preserved ejection fraction," can be hard to diagnose with echocardiogram alone.

Bartonella vegetations, I later found out, are also quite difficult to detect on an echocardiogram, so diagnoses of bartonella endocarditis take into account risk factors such as body lice infestation (which I don't have) or HIV status. One study reported that "Compared with other cases of infective endocarditis, cases of Bartonella endocarditis are more fibrotic and calcified, less vascularized, with less extensive vegetation and chronic inflammation." (Lepidi, Hubert, MD et al. "Quantitative Analysis of Valvular Lesions During Bartonella Endocarditis"). Myocarditis might not show up on an echocardiogram at all. Myocarditis can be indicated by an EKG, and I showed these indicators, such as Complete Right Bundle Branch Block, on more than one EKG since the dog bite that seemed to initiate my new cardiac problems. Many cardiologists believe this is a marker of myocarditis. "The presence of right bundle branch block or left anterior fascicular block virtually always indicates the presence of significant myocarditis," writes Leslie T. Cooper, Jr, MD in Myocarditis: From Bench to Bedside. This is seconded by L. David Hillis, who writes, "a complete right bundle branch block may be caused by acute myocarditis. . . On occasion, right bundle branch block occurs in patients without underlying cardiac disease" (Manual of Clinical Problems in Cardiology) and also by a book by members of the American Heart Association's Clinical Cardiology Council, which states "Characteristically right bundle branch block or left anterior fascicular block signifies underlying myocarditis." (The AHA Clinical Cardiac Consult by J.V. Nixon, Joseph S. Alpert, etc.). My EKG from a few weeks after the bite also showed something called an RSR Pattern that can indicate a ventricular aneurysm -- a condition that often happens after a heart attack or myocarditis. My doctor at the time told me the test was normal.

In this endemic Lyme area, where I live in an area of dense vegetation, nobody thought to test me for Lyme and coinfections when my heart got so dangerously symptomatic -- which might have included a bartonella test. With my reduced Q -- or cardiac output -- on the Impedance Cardiography, I was squarely in Myhill's category of patients who go into borderline organ failure each time they stand or sit, even without this additional heart infection. But ME/CFS cardiac issues still did not begin to explain what was going on. I had had trouble sitting and standing for my entire course of ME/CFS, but the crushing/squeezing terror was something on a totally different Richter scale, and it had come on suddenly.

Once I became so incapacitated it was inconceivable for me to get to a doctor, I could not get anyone to treat me. Finally, more than a year and a half after the dog bite when I landed a home visit doctor, he was so incompetent he only held a stethoscope to my chest once or twice, and ignored the dramatic change in my symptoms and the fact that my EKG tests were abnormal -- nor did he help me, despite my pleas, to get a cardiologist interested in my case. I begged him to try and get me access to hand-held echocardiogram equipment so we could test my heart at home, and he wrote it in his notes then did nothing as far as I know. I emailed cardiologists and telemedicine doctors all over the country during that time, desperate for answers. My doctor was so useless that, one day when a nurse was putting in an IV and saw that my blood had turned coal black in the tubes, he didn't call me back for 48 hours, even after speaking to his colleagues who told him they had only seen blood like that in patients who were "already dead" -- and then he just brushed it off and offered me no help, nor offered an explanation for the blood he had called "markedly de-oxegenated." He conveyed all of this in a cheerful voicemail message, that he had only heard of blood as de-oxygenated as mine in corpses. The nurse who had taken my blood said she had never seen blood that color before.

It's hard to describe what it's like to muscle through medical miasma with hardly any strength at all. I was desperate for someone to understand the cardiac horror I was going through. But descriptions of cardiac illness had really staled in the era of sports medicine and defibrillators. I scoured the Internet trying to find others with these symptoms, and though I found some near-comrades in people with ill-defined cardiac symptoms who fit into diagnoses like Cardiac Syndrome X and variant angina, their symptoms were not quite like mine. However, these conditions of unusual cardiac pain both seem related to endothelial dysfunction, and bartonella is known to impact endothelial cells.

Ultimately, the accounts I found of symptoms that most matched mine were in old homeopathy and eclectic medicine and cardiology texts from the 19th and early 20th century -- texts predating the invention of antibiotics and invasive cardiac testing, when illnesses ran a natural course. A homeopathic reference for the remedy Spigelia antheilmia, for example, describes a subset of heart patients with a "crushing sensation" in the chest, "shooting pains" that "stab through the heart," and "a sense of suffocation," all of which are aggravated by "motion." It associates these symptoms with pericarditis and notes that the patients "are often anxious about their heart, their pains, and what the future might hold." The Eclecic Practice of Medicine by Rolla L. Thomas, M.S., M.D., 1907, describes endocarditis patients (many of whom also have myocarditis and some pericarditis) as having "great oppression or a sense of constriction in the chest," and "distress in the precordial region" along with shortness of breath. "In the more aggravated cases, the patient will lie on his back," notes the test, "or incline to the left side. There will be distention of the veins of the neck, with marked cyanosis." Interestingly, this book also notes that "great care must be taken to secure rest and quiet. The patient should be placed between blankets, and all company, or anything that would tend to excite the patient, must be forbidden." My heart symptoms would worsen from the slightest interaction with company, or any stress, to the point that I had to limit human contact to almost nothing, and still do or my condition worsens. Until I read that text, I had no way of explaining to people how I would have increased cardiac symptoms from a simple conversation with someone.

In Dr. O. Phelps Brown's The Complete Herbalist, pericarditis is described as causing "pain, oppression, weight, palpitation, . . . debility, restlessness, and great nervous irritability." With endocarditis, "there is at first pain about the heart, whose disordered action may be violent" and "in dangerous cases there is extreme anguish." Thomas also describes myocarditis: "If, however, there is a sense of constriction of the chest, some palpitation, more or less dyspnea attended by slight pain, and the pulse is rapid, small, and easily compressed, evidences of cardiac enfeeblement, myocarditis would be suggested." Additionally, he writes, "There may be dilatation of the cavities, and if there has been localized myocarditis, weakening the tissues, partial aneurism may result. In the localized or circumscribed form there are areas of necrosis, which are followed by abscess formation. These abscesses may open into the cavities of the heart, and thus enter the blood-stream, giving rise to abscess formation in other portions of the body. A favorite location for an abscess is in the interior wall of the ventricle near the apex and septum. They may empty into the pericardium, resulting in suppurative pericarditis. When they perforate the heart cavities, in addition to poisoning the general blood with an accompanying septicemia, they often give rise to malignant endocarditis. This form usually terminates fatally, though, in rare cases, nature throws a covering around the abscess, the pus is incapsuled, and undergoes caseation or calcification." As for prognosis, Thomas writes, if "the patient can refrain from severe mental or physical exertion, can live in an equable climate, and be much in the open air, the life may be prolonged to its allotted period. Where frequent attacks of angina occur and the cerebral circulation suddenly fails, death may occur quite suddenly." To recover, Thomas recommends "Absolute rest must be enforced in every case; the reclining position should be observed, and nutrition maintained."

In contemporary literature on the heart, it was rare to see mentions of cardiac conditions in which lying down improved the patient's condition, even though for me this was the only thing that helped. Nor could I find any mention of slight mental exertion, visitors, excitement, or other things that made my own heart condition worse. Contemporary descriptions of cardiac illness rely upon measurements -- METs (metabolic expenditures), echocardiographic parameters, electrocardiograms -- with little attention given to the patient's pedestrian habits that seem to help or worsen the condition, except for contemporary habits such as eating artery-clogging fast food. The exception to this is sometimes found in veterinary texts, where behavioral observation is not seen as a suspicious practice, as it now is in human medicine except in cases where patients are shamed for being inactive or fat. With human conditions, behavioral qualities whether they are socially sanctioned or just plain odd are more often shuffled into psychiatry. This has to do with the dualistic focus on cure or death, with chronicity and adaptive technology still seen as largely relegated to an arena outside of medicine.

My family had gone into an increasingly distant orbit, and I could not get the practical caregiving I needed to maintain the continuous bedrest that was the only thing keeping my heart from dramatically declining, though I kept begging my family members for help. Nobody else seemed to comprehend how bad it was except for the rare witnesses I had in my space, who saw a catastrophic situation. As I declined further and further, and was later bitten by a tick in the summer of 2007 that gave me confirmed Lyme and probable babesia, I began a new strategy recommended by a friend of a friend who was a pediatrician. I began writing letters to my home visit doctor so as to create a paper trail, and asked for stronger antibiotics than the Augmentin he had prescribed for tooth pain I was having (my trigeminal nerve had apparently been attacked by the Lyme). Reluctantly, he finally gave me Cipro -- which miraculously eased my heart symptoms by about twenty to thirty percent in a matter of weeks. It was, in a Dr. House-ian drama, the kind of bullseye that completely re-routes a medical investigation.

As I wrote in my journal on 11/3/07, "Cipro has given me a reprieve from death for now, though it is probably damaging my tendons. Nevertheless, this drug is a miracle: the crushing, suffocating sensation in my heart, what a comparable patient described as a horse kicking her in the heart -- has relented, and I can sit up for spells without the symptoms thudding through my body and crushing the life out of me." My home visit doctor admitted to me on the phone around the time of that entry (I took notes) that the only explanation for this was that "a bacterial infection was affecting my heart and Cipro was treating it," even though he had previously written in his medical notes "Pt is fixated on an occult or cardiac or systemic bacterial infection. She is already on Flagyl and Augmentin with broad coverage. I told her that it is very unlikely she is having endocarditis or pericarditis but of course can't prove that since she cannot/will not get tested." (Sept. 13, 2007). In the same day's notes, he writes that he "will comply w/ her request to try a diff/ antibiotic." He notes I'm having "chest heaviness/squeezing, chills, etc." What he does not write is that I had just penned my will, and I had written him letter after letter begging for help in the months before that. He also does not write that he would not help to get me testing at home, to "disprove" my "fixation" on endocarditis or pericarditis, that I was having shaking chills so bad my teeth were chattering, that right then I was so delirious I could not speak in whole words but just grunted out sounds, rocking back and forth as my friend desperately called the emergency room and asked if they would do anything at all to accommodate my severe chemical sensitivities. Within a couple of days of that hospital call, I got the Cipro my home visit doctor had reluctantly prescribed. At first, it gave me a Herxheimer reaction so severe I was briefly almost psychotic from neurological die-off.

A few weeks after getting Cipro, I convinced a Lyme literate doctor (LLMD) to take my case, and finally I found a doctor who listened to me. In the week before I first talked to the LLMD, my home visit doctor wrote in his notes, "Cipro is helping her heart sx's substantially" (this is one of the first times he did not put "heart" or "heart symptoms" in quotes, as if the pharmaceutical suddenly proved their existence). "She can sit up, crushing heart sx's [two arrows pointing downward to indicate reduction], chills gone" (10-25-07). In our next conversation (11-6-07) he notes "Cipro helps her "heart" sx's but now developing tendonitis." Cipro and other fluoroquinolone can cause severe and permanent tendon damage, so tendon problems often force people off the drug, and my tendons were in so much pain they did feel like they might rupture. He then told me he was taking me off the Cipro and would not give me an alternative broad-spectrum antibiotic with similar action. At that point I almost lost it. I was still very symptomatic, and I was terrified of the relapse that would inevitably result if he did not provide an alternative and I had not yet had a full interaction with my new LLMD. He wrote "Plan: Stop Cipro which pt resists saying it is the only thing that has relieved her "heart" sx's & that she is willing to risk permanent tendon damage which is against my medical advice." At this point, in a life-saving moment, my new LLMD ordered a repeat Western blot for Lyme -- which was positive -- and a later blood smear for bartonella -- which was positive. I sent the positive Lyme test to my home visit doc, but by the time I had gotten a copy of his medical notes and the records in his file on me, he had conspicuously removed that positive test from his files. I had had an earlier Western blot, performed just a couple of weeks after my tick bite -- a time frame often considered too early to get definitive results. That test, which had positive and equivocal Lyme-specific bands, was negative, but my doctor said nothing about a retest and Lyme is a clinical diagnosis, based on symptoms and tick bites as well as tests. I had also, at that point, had a positive IFA test for Lyme. In his notes on 10-25-07, before my positive test,Western blot, my home visit doc wrote "pt now absolutely convinced [big circle around "convinced"] she has chronic Lyme disease (although she's never had it & her - [negative] testing)." This notation came a couple of weeks before my positive Western blot for Lyme.

My first test for bartonella by my Lyme-literate doctor only tested for bartonella henselae and not the other strains. It was not until April, 2008, that I finally got a positive blood smear for bartonella, but my LLMD had been steadily treating me for the presumed bartonella infection. She had already rendered a clinical diagnosis of bartonella, based on my bartonella-typical symptoms such as pain on the soles of my feet, myoclonic seizures, and odd rashes -- and my positive clinical response to antibiotics that target bartonella such as Cipro and Rifampin.

It is painful to read through my home visit doctor's notes and feel his obvious derision that nearly ended my life. Throughout his notes, he almost never put the names of other organs or systems in quotes, only "heart" and "heart infection" as if he was taking a medical history of the Grinch, or of someone too dumb to locate the thing beating in her own chest. He wrote down the phone numbers I had given him for hand-held echocardiogram equipment over a year before he gave me the Cipro, equipment that would have enabled heart testing at home, but wrote nothing about follow-up action on those number. He wrote many notes about my crushing and squeezing "heart" symptoms, and my obvious distress over how bad my symptoms had gotten, but he was treating me like a hysteric.

In the Spring of 2008, as I made slow progress on my medications for bartonella, I was still fighting the Lyme and probable babesia that had infected me the summer before, and it was an uphill battle. The Winter before that was treacherous and long, characterized by forced stillness as I tried not to backslide. After a brief stint with Rifampin once I had to stop Cipro due to tendon issues, my liver enzymes were elevated so I had to stop my bartonella-specific antibiotics for two months, and during that time I was slowly relapsing, trying everything I could imagine to cleanse my liver so that I could resume treatment. My heart was getting worse again, the crushing sensation returning. Meanwhile, I took high-dose Amoxicillin for Lyme and a slew of herbal remedies for all three infections. I wrote on January 25, "My heart has been really bad this week and all of January I have slid downhill again. I'm afraid my heart is going to stop. Please God stop the terror and let me have those health gains. Let me keep sitting up for my meals -- a luxury I've waited for for 3 1/2 years, in hell, my heart crushing me." The odd lesion on my right ring finger had reappeared, cracking into an open painful wound that would not heal: a sign that seemed to come and go as bartonella treatments succeeded and failed. In early February, finally, I was able to restart my bartonella meds and my heart again began to experience some relief.

But neuro Lyme started running rampant, just as some of the bartonella symptoms were tamped down. In February, my vision had suddenly and dramatically diminished in my right eye, then gradually returned with acupuncture treatments. An opthalmologist suspected it to be optic neuritis, a sign that Lyme or bartonella had gone neurological. My Lyme doctor agreed to switch me from oral antibiotics for Lyme to Bicillin injections, which are thought to better target neuro Lyme. Soon after that, with the re-addition of another drug, Flagyl, I woke up one day, tapped my fingers lightly on the refrigerator door, and felt lightning-like pain shooting up my arms. I stuck my hand under water and the water felt scorching, like liquid fire. I could not pick up a piece of paper without excruciating pain. I had suddenly developed peripheral neuropathy. For a few weeks, it was unbearable, with water feeling like fire and the task of making a sandwich feeling like someone sticking needles under my fingernails, but the magnitude diminished in time over the next few months. Still, it was debilitating, and once again I was helped by my acupuncturist, who would come into my living room, quietly walk around me as I laid on a mattress on the floor, and stick needles right into the tips of my fingers until they sometimes bled, joking that she felt like both a Geisha as she padded around the mattress with no shoes, entertaining me with stories and tending to my needles, and a torturer.

I had had bartonella for almost four years at that point, and it was not going down without a fight, and in fact was just barely controlled. I still had seizures, coma-like episodes, difficult opening and closing my right hand, and other neurological symptoms, as well as constant reminders that the infection was eager to resume a tighter grip on my heart. The white dog had receded into my memory, along with an entire landfill of former cognitive functions. Bartonella, Lyme, and probable babesia had turned my remaining gray matter into a useless slurry. Aside from the myoclonic jerking, peripheral neuropathy, vision loss, and other obvious neurological symptoms, my brain was less functional than ever. I would often lapse into a stupor-like state that felt like my cerebral vasculature was a series of narrowing mine shafts filled with noxious gas: my brain, as best I can describe it, was just barely wakeful. A sense of complete unfamiliarity would frequently overcome me, so things I once seemed to "know" filled me with a sense of amnesia. I watched TV and could no longer understand social cues, or what motivated the characters. Writing became impossible. Worst of all, the emotional content of language seemed to have been removed as if by a paint stripper, its vibrant hues replaced by a factory-applied gray. Words no longer had the same texture. I also felt irritable all the time, and I experienced hyperacusis. My movements were off. My right eyelid twitched regularly, accompanied by a vibrating sensation in my right temple. I would have lightning bolt sensations, or vibration sensations, course through my body. My brain got stuck in what felt like internal tics, odd jerking sensations in my thoughts that I tried, with great effort, to push to the next frame. I had a pervasive sensation of wanting to flee the cinema of my life: I knew the heroine had very little chance of escaping her predicament alive. Continue to Part III.

Sunday, May 02, 2010


Since May is Lyme Disease Awareness Month, I am posting in three parts a long essay I started before the Ice Storm about my infection with the Lyme coinfection bartonella (which is frequently tick-borne, and people are often infected with bartonella at the same time they get Lyme), and it's interaction with XMRV, ME/CFS, and cardiac issues. I have now been in treatment for both Lyme and bartonella for almost three years but have not been able to edit this essay until now. This is Part 1.

September 2004

Finding the answer to my medical puzzle in Massachusetts was like trying to narrate a fabulist bestiary out of zoomorphic clouds. It was impossible to articulate. One week I was lying on my porch as raspberry-eating chipmunks squatted on rocks to grasp berries from the bushes, and the next week I was fighting for my life against a zoonotic pathogen that had entered my heart.

My first drive down Ireland Street had seemed like jailbreak, as the side windows of my Volvo framed weather-beaten New England capes. The Hilltowns housed the tougher stock. Ireland Street goes most of the way to the Gorge, until the turn-off by a llama and alpaca farm. I had just moved to Western Massachusetts at the end of July, 2004, from Providence, where I had spent years too ill to walk fifty feet to the end of the block, mostly bedridden and confined to a tiny ten foot by twelve foot room where I had a cot-sized futon, a computer and a 13-inch TV. Even though Rhode Island is the smallest state in the Union, small enough to be spanned in an hour, I only got to enjoy its scenery in my early years there, when I was less sick. An hour was further than I could typically travel after that: fifteen minutes was further than I could travel. Though I promised my dog Rowley until the day he died that we would one time return to the Jamestown lighthouse along the Southern coast, he saw that I never went anywhere. My life was characterized by constriction and constant pain. It took years to marshal the strength to make my move across the state line.

When I first saw the perfectly-carved masterpiece of water and rock known as the Chesterfield Gorge, I started crying. It was emotional for me to be out of my old apartment, at this pristine and barely-trafficked spot. I had this feeling that maybe I was going to escape my hell, even though my heart was thumping out of my chest from the effort of walking from the parking area to the railing overlooking the drop-off, and I had to lie down on the trail to recover. It's hard to describe what it is, after so many years of being so ill and so punished for any motion with horrific symptoms, to dare to feel hope, but I thought I might be recovering a little bit now that I was in cleaner air. People with severe chemical sensitivities sometimes do recover if they are put in a pristine environment, and several people had spent over a month making my house on five acres very green so I could live in it. The Gorge was the my first post-prison landscape. It was like a first slice of blue after years of barred windows.

I was driving down Ireland Street a month or so later -- on September 8, 2004 -- when I saw a frail white dog limping slowly down the middle line, stopping occasionally to wobble like a confused drunk. I slowed my car but the dog showed no signs of leaving the road, waving its butt like a surrender flag. Its eyes were big bowls. When I see its image in my head, I can picture the diseased eye. I think only one eye had signs of not functioning, and the dog's skin looked bad. Its fur was thinned out and the visible flesh was irritated and pink. When I got out of the car, the dog didn't try to run. It could barely hobble. It was on the verge of collapse and seemed terrified, as if an illness had seized it suddenly or it had just been abandoned there. It had a collar but no tags. Its bones were not sticking out so it probably had not been away from food and shelter that long. I recognized some of myself in that dog. For example, it seemed to be avoiding exertion, which is a symptom found in those with mitochondrial dysfunction or cardiac problems, who have excruciating symptomatic payback or even death from the exertions normal people take for granted. In retrospect, I think the dog could have had a damaged heart, because it was not suffering obvious weakness from malnutrition and dogs will attempt exertion until they are in severe pain or will just collapse from it -- or that it was simply at the end of its days. Severe pain did not seem to be this dog's worst problem, as it did not flinch from being handled or wince when it jumped in the car, and it was not panting from distress, as dogs will often do in acute pain. It didn't seem to have the energy for panting. I had a thought the dog might have been attacked, and perhaps that's why it was avoiding the woods and staggering down the road, but it had no scratch or bite marks. It was a scruffy little dog, sweet and scared.

I'm very allergic to all dogs but a few hypoallergenic breeds, so I did not want to put the dog in my car. The nearest house was close to the next turn in the road, and I couldn't run or walk either, so I herded the dog toward my car door. Once the back door was open, I shoved the dog's butt a little so it would jump and it didn't resist, just seemed so weak in its shaky back legs. I had grown up in a family that often picked up strays. I remember my sister, when we were kids, building a habitat for a shivering little mouse out of cardboard boxes so it would not freeze to death beside the grocery store where she found it. My Mom once brought home a cat she found at a donut shop that we named (originally) Donut, and we owned a couple of second-hand dogs before my allergies worsened. Now, I can see the citified hubris of assisting a sick dog that staggers out of the tick-ridden woods, but I was not thinking about a 19th century death. I had lived, for so long, a disability of postmodernity and chemical culture.

I found help at the second house -- a place with a trailer in the yard. I think it was then, when I shuttled the dog out of the car and it began to realize I was going to abandon it and a man appeared in the doorway, that the dog snarled and nipped at me and bit down hard enough to break my skin. I downplayed the bite because I was concerned that if the dog appeared vicious it would be put down. In fact, I did not remember this detail until I found the email I had sent my then-partner about the incident. It was a huge fact to forget all these years. The man at the door had on a wife beater and pants, and I could see movement in the dark space behind him, though he was filling the doorway with his stance, obscuring my view. I heard his wife's voice from somewhere in the din, and suddenly she appeared with a bowl of water. The man had a big charming smile, and he reassured me he knew the animal control officer and would try to get the dog medical care. I decided to trust him, plus I really had to get out of there. I was growing sicker from the dog's dander and also from the laundry fragrances on the man's clothes. I deposited the dog and went home where I wrote the email I later found:

Sent: Wednesday, September 08, 2004 5:17 PM
I just had a sad dog experience. I saw this lost dog who looked really sickly weaving along the road. I picked him up and drove him to two different nearby houses, until the second guy took him in and offered to call animal control. I couldn't keep him or bring him home -- I was having a massive allergy attack and wouldn't have even taken him in my car but I just knew he would get hit. He also snapped at me and broke the skin a teeny bit, so I hope he didn't have rabies or anything. . .

I forgot this crucial biting clue because my cognitive problems prevent me from keeping a steady narrative sometimes. I had learned in over twelve years of illness that few doctors were interested in crucial clues unless they turned over the stones themselves, and I had also lost most of my functional memory. The dog bite should have been memorable, since I have only been bitten by dogs twice in my life and they were both little white dogs -- the other was a vicious, child-hating poodle owned by Great Uncle Leonard and it left a tiny heart-shaped scar on my left hand. But this bite was not a big deal to me at the time. I did not connect the dog and the claw hands and the horrors that followed, not until more than four years later, after hovering close to death most hours in between. This fight for my life is still hard to talk or write about, especially since I am still battling cardiac symptoms that finally feel, after years, that they are not imminently lethal all the time.

When I finally made the connection that the dog might have been the reservoir of disease, I realized how skewed my sense of time had become. I had come to associate my new, screamingly life-threatening level of disability with the state of Massachusetts, since it started here, but actually my first few weeks here were hopeful. Reading the emails from the weeks before the bite, I can't believe how alive I sounded in my first month in this new state, how I could luxuriate over words and how expansive the hours seemed. In the pit-and-pendulum years that followed, all time seemed to be crushed into a thimble, and I could only think of one repeating thought as I dragged my dying body from hour to hour: how was I going to stay alive? How could I get anyone to help me live? There were barely enough hours in the day to choke down one meal, to do some research online to try and save my own life, to beg yet another numb-eared person for help and be rejected like a mangy stray. And sleep: sleep was a long, long poem channeled through a Ouiji board.

I was waking up every day with a crushing, suffocating sensation in my heart that worsened as the day went on, and became excruciating at night, when my heart became as intrusive and violent as a jackhammer. I was desperate for answers, and desperate to stay alive. In one episode of House, a man at gunpoint takes Dr. House and some others in the hospital hostage, demanding that they get to the root of his deadly illness and save his life. As the weeks wore on and my cardiac symptoms became more torturous, I was almost that desperate for some route to viable treatment. Like Dr. House, I kept turning over stones and ruling out diagnoses, but doctors often view such persistence in a patient as a kind of madness, and dying without help brings its own kind of madness. It was clear to me I had no chance to stay alive if I didn't fight, yet I had much less stamina than that dog, who used the simple strategy of throwing himself into the bright light to get noticed. I had to follow that dog's courage in facing more abandonment and rejection as he fought for his own life. I had to throw myself into the light, even if people interpreted my illness as disheveled desperation.

I made very little progress over time, because I was just too sick to do much of anything but try to stay alive. I told a friend it was a "rock hammer pace," to refer to the scenes in the Shawshank Redemption when a prisoner chips away at a wall with a rock hammer to escape. It took a year of antimicrobial medications before I had enough memory to consider the significance of that dog. After a month and a half on a new anti-malarial drug in the Fall of 2008, I began to have vivid flashbacks of scenery from my childhood. To feel momentary luster, even though still horribly ill, gave me a glimmer of hope that my brain was starting to revive. Right then, the sick white dog started to insert himself in my mind with totemic significance. I saw his face very clearly. One aspect of my many years of myalgic encephalomyelitis (ME/CFS) is that I have had some degree of facial agnosia. In the early years of ME/CFS, when I lived in San Francisco, I was one of two witnesses to an armed robbery that occurred at 4:30 in the morning at an all-night grocery store, but I was such a terrible witness that, after bringing me in to look at a lineup, the cop dismissed me as useless, since I could not remember the criminals' faces. I remember they were running with a box, but could not recall their hair color or the hue of their car. My memories are often vague, boxy. Faces slip away, yet they can suddenly reappear in crystal focus, so acute it's as if a synapse just activated, which is what happened with the dog. Though I could not remember the date that I picked up the dog, I did remember I wrote an email about it.

So I ran a search of my saved emails on the word "dog."

And then a search on the words "claw hands."

See, my severe cardiac problems had started the night of the claw hands, and I knew if I picked up the dog before the claw hands there might be a causal relationships between the two events. My new partner and I had just started fooling around. Suddenly, I had ripping pains across my chest and an iron-jawed squeezing around my actual heart. My arms froze and my hands formed into claw shapes -- I could not pry the fingers apart and they were clenched tightly together and turned inward. I wanted to shout for my partner to get off of me but I had suddenly lost the ability to speak and could not even grunt out sounds. My body was rigid. I thought I must be having a heart attack. Though I had had chest pains with much of my sexual activity in the previous decade, this incident was different and absolutely terrifying. From that moment on, for years of incomprehensible terror, I was barely alive with wrenching, suffocating cardiac symptoms. When I reviewed my emails from that period around the dog bite, I learned something remarkable: the claw hands incident had happened three days after I picked up the sick dog. I had described the whole ordeal to a friend, and in my email box there are a string of responses with joking titles like "claw hands puppet theater." On Sept. 12 I wrote to her "I'm glad that 'claw hand sex' is a genre now. But yes, attempted claw hand sex should be a crime. I should be put into some kind of clawcuffs pronto." On Sept. 21 I told her I had an episode of "claw foot" too. While we had a pattern of making fun of our most bizarre symptoms, I was absolutely terrified about my heart and these new symptoms. Something was horribly wrong, and there was nothing funny about it.

In the weeks and months that followed, I also began to have seizure-like episodes of myoclonic jerking, would go into a terrifying, coma-like state where I could not move or speak -- often after seizure activity, and I had a swollen lymph node in my left armpit that would not go away. My partner would often massage the migrating sore nodes in my neck and pelvis, but the single armpit node was huge and unyielding. I also had two odd, scaly patches of skin -- one on my breast and one on my arm -- that did not go away for about a year. Additionally, I had a small, rounded, painful lesion on one finger that soon began to crack, bleed, and refuse to heal. My cognitive problems had also worsened, but the most marked thing was that I simply could not safely do anything for myself -- even the slightest motion would cause excruciating cardiac symptoms, and it was so dangerous for me to try to get food, get to the toilet, make a phone call, eat, or even slightly lift my head.

But the problem -- really, the problem I have had since I became chronically ill -- is that I could not get enough practical help to get through my days, let alone fight the medical system. And having a medical record is like having a police record. New symptoms are more often viewed as suspicious new crimes than important details in a larger puzzle. While Dr. House has a whole team of people to write and cross off postulations on a whiteboard, ravenously searching for an answer to a medical mystery, the real experience of chronically ill patients tends to be much different from this. The chronically ill are the ones who have to sleuth around for answers. They are also the ones who have to prove their own innocence, and assert repeatedly that they deserve some quality of life beyond the status quo. The years of my horrific cardiac symptoms, in fact, mark a period of epic neglect from my health care providers. At the time of the claw hands, I had just begun care with a new physician, and he ignored my abnormal EKG, then later refused desperate requests for a home visit as I grew too ill to get to his office. In my medical file, there are repeated notations of calls from people advocating for me that say things like "She is going into a 'coma-like' state. Can't talk, can't move. Feels that she is close to death" (1/19/05) and "Pt has been 'crashing badly' with CFIDS/MCS. Blood pressure is low and pt is too weak and sick to come to office for IV." (4/7/05). When I finally got a home visit doctor, he was much worse than the other doctor. I barely survived his care. His care was, at best, verging on murderous. When I read his medical notes, I actually do feel like someone confronting an attempted murderer at a trial: I'm filled with the most terrifying sensation that this man tried to kill me, that he ignored my pleas for help until I was seconds from death. Throughout his notes, he writes the word "heart" in quotation marks (which he doesn't do with other, unvalidated symptoms), as if talking about a speculative sighting of Jesus on a tortilla, not talking about the organ pumping life through my body. I can hardly bear to think about those months in his "care."

I had had ME-related cardiac problems that had been documented since the year 2000 even though they went back to 1992, including signs of cardiomyopathy, orthostatic intolerance, tachycardia, chest pains, and post-exertional worsening of symptoms. I had anxiously awaited every bit of attention given to ME/CFS cardiac issues, and my abnormalities were consistent with theories that ME/CFS starts as a viral cardiomyopathy, especially since my onset began as a flu-like illness. Dr. John Richardson of the UK was perhaps the most long-standing ME/CFS doctor studying cardiac causes of ME/CFS. Richardson spent 40 years examining enteroviruses along south bank of the Tyne, following them through generations, with a particular focus on coxsackie viruses, which are known for both ravaging neurological symptoms and devastating effects on the heart (particularly myocarditis, but also pericarditis and valvular dysfunction). Richardson strongly believed enteroviruses could explain the multi-system and organ damage relating to the broad symptoms of ME/CFS. He also found that coxsackie could be easily passed from a mother to an unborn child, leading to fibroelastosis or maldevelopment of the heart, or structural abnormalities of organs including the brain. Right before his death in 2002, Richardson finally published these findings in his book, Enteroviral and Toxin Mediated Myalgic Encephalitis/Chronic Fatigue Syndrome and Other Organ Pathologies (Haworth Medical Press 2001). His work interests me not only because my Mom's father had a valve in his heart replaced, but more importantly because my Mom had polio as a child, and polio is perhaps the most notorious enterovirus. If an asymptomatic mother could pass coxsackie on to an unborn child, why not another enterovirus such as polio? It is possible that I was born with neurological or cardiac weaknesses that went undetected. My mother and I joke about my childhood maladies, such as my insomnia that started soon after birth, well before Kindergarten nap time, or the chronic headaches and flu-like symptoms I began to have at the age of 7. I was mostly a healthy child, but I have noticed some childhood consistencies with other ME/CFS patients who are friends of mine. For example, some of us could not run long distances when we were children or young adults, even if quite physically fit. We would experience sudden weakness or faintness upon running around a track, and shortness of breath that made us different from the other kids. I often tried to train myself, in fact, to run longer distances but I never was able to succeed. It seemed odd that, despite my efforts to physically condition myself through cycling and frequently-used gym memberships, and my steady workout schedule that gave me toned muscles and an enviable resting heartrate, my long-time smoker friend in college was easily about to take a class in cross-country running and push herself to run a mile, whereas I could not do distance running no matter how fit I was.

Canadian ME/CFS doctor Byron Hyde took an interest in Richardson's work when most ME/CFS doctors were more interested in neurology and immunology. "I have found that during the first years of acute onset ME/CFS disability," writes Hyde in the Handbook of Chronic Fatigue Syndrome (Jason, Fennell, and Taylor, eds.), "the incidence of pericardial effusion is unusually high. This seems to settle down with no apparent short-term problem, and after a year, the cases of pericadial fluid decrease considerably. However, the incidence of valvular disease in people in their 30s and 40s appears to be higher than in the normal population." He also notes "several cases of elevated right heart pressure, significant septal defects, and increased myocardial wall thickening," then adds that "Dr. Richardson has identified more than several hundred cardiopathies in his ME practice." These tidbits on ME would have been helpful when, as I fell into acute-onset ME/CFS in 1992, I immediately experienced chest pains and shortness of breath as well as orthostatic hypotension upon exertion (and my doctor did not even do an EKG), but the new symptoms that began with the claw hands brought on a level of ongoing terror and disability that defies description. It was violent and constant and totally new.

It is known now, from research on ME/CFS deaths, that ME/CFS patients die earlier than they should, and cardiac deaths are one of the top three causes of death, but little is known about the exact nature of these deaths, since extensive autopsies are rarely performed. The family of Casey Fero, a 23-year old ME/CFS patient in Wisconsin who died of ME/CFS-related myocarditis, tried to remedy this by starting a tissue bank where ME/CFS patients could donate their bodies to science. Fero had been found on autopsy to have viral myocarditis, but his heart also showed fibrosis, or scar tissue from past infections. Patients with Lyme and coinfections die suddenly and tragically as well, many of cardiac deaths. One example of this was the untimely and eerie death of Leslie Wermers, a 41-year old Lyme patient who died of heart failure in her sleep. Before her death, she had been videotaped for inclusion in the Lyme documentary Under Our Skin, and those videos show her speaking at a memorial for another Lyme patient, saying, "She shouldn't have had to die." In another scene, she talks about how she knew the illness would kill her one day. Could she have done anything to convince doctors of this? I know what she knew in her own body, and I am still fighting to save my own.

Most people would call 911 or go to the ER with a terrifying, life-altering cardiac incident like I had with the claw hands, but I could do neither of those things. It's a basic fact of people with severe chemical sensitivities: emergency medical care is just not an option. Because I had suffered angina-like pain in my chest before, I hoped this was that type of pain on a new level, though it felt completely different. It felt like a momentary heart attack that later turned into a constant heart attack. The cardiac distress was of a greater magnitude than I had ever experienced or ever heard of, and my hands had never frozen into claws like that. It wasn't until years later, when Under Our Skin showed a neurologically-impaired Lyme patient with similar hands, that I saw any example of what had happened to me. The tremendous crushing sensation in my heart started right after that. In my journal, I wrote of the crushing sensation as a trash compactor, those giant steel jaws in the back of a garbage truck that casually and crushingly smashes the cargo. The sensation was horrendously crushing, but not a tree on top of my heart -- more of a heart-shaped lead encasement wrapped completely around the heart, and being screwed tighter and tighter around the organ. I could not imagine anyone feeling this and not dying from it immediately, and I felt like I was imminently going to die. Most of the time, most hours of most days, there was no way to distract myself: the pain was so immediate, demanding, and extreme. It was absolute cardiac agony, all day long, with almost no respite. The only slight relief came when I would lie in an inverted position, with my butt on a pillow and my legs up on a wall. Inversion helped me somewhat, but then, going upright at all -- even to lift my head for a minute to drink some water, wound amplify the crushing sensation tenfold, so that I might spend hours after that one exertion feeling as if a steel-toed boot was kicking me in the heart. I spent most of my days in that inverted position all day. I ate my meals like a sick dog, lying on a mattress on the floor with my body flat and the plate on the floor so that I could lean over and scoop the food into my mouth, since lifting my head even the slightest bit would increase my heart symptoms, sometimes for hours. The level of impairment was bad enough, but the actual physical sensation was incomprehensibly bad. It felt continuously like descriptions I have read of heart attacks. I was often in screaming agony, with a squeezing and crushing around my visceral heart combined with an odd vibrating/rustling sensation of the heart laboring to beat as my neck veins bulging out and global hypoxia filled my body. It was like a corset, boning around my heart, tightened to the point of suffocation, a feeling of constriction beyond description, a small box of hell I cannot adequately depict. All I can say is this: there's no way I survived that. There is no way a person could survive that level of cardiac agony for that long.

So for three years I lived like this. Even with my legs inverted, the crushing around my heart was continuous, squeezing all of the oxygen out of my body, and getting up for water or urination was terrifying as it would make my symptoms so much worse. The distress was so bad I would often spend hours at night just lying on the floor screaming, sometimes calling my family and begging them to not let me die, knowing none of them were going to come and help me as they had lapsed into a chilling denial. I was just in complete terror, the life being violently squeezed out of my body. I had watched my own dog die of bone cancer that had metastasized to his lungs, filling them with fluid that was drowning him from the inside out, and I once knew a guy who was almost murdered by an escaped convict trying to strangle him to death, until his eyes bulged out and his neck was bruised. The sensation in my heart had that feeling of imminent suffocation. I was dying a violent and horrible death, and I could not get sufficient practical help or medical care and was for the most part too ill to help myself, especially since I had to spend almost all day in an inverted position and could not risk exertion as it would cause my cardiac symptoms to worsen so intensely. I had so little oxygen traveling to my tissues. This fact was palpable and maddening. I have read accounts of drownings or suffocation and it had that level of desperate struggle to it, of a person trapped in a car underwater breathing the last dregs of a tiny air pocket as every cell scrambled desperately for life. I could feel it in my brain, my organs, my limbs. My neck vein felt like it would pop, so bloated from trying to compensate for my heart's failings. It was, like cardiac syphilis, a violent cardiac death -- with "violent" being a very important qualifier.

Though patients describe both angina and heart attack (MI) as "severe," "heavy," "squeezing," and "crushing," the difference is often the magnitude and the length of the attack. Myocardial infarction is also described as "deep and visceral" and "the worst pain someone has ever experienced." Women, in addition, often have a "feeling of impending doom" with heart attacks, but of course this "feeling," though an actual symptom, often gets them written off as anxiety sufferers rather than intuitives. However, while an myocardial infarction might last longer than angina and be more severe, neither of these are ever described as continuous. I had these same symptoms -- a severe, heavy, squeezing, visceral, crushing around the heart -- with a feeling of impending doom -- but with few breaks: my attacks were not episodic but rather the breaks between them were episodic. I had, in fact, symptoms of a heart attack nearly all the time. I know this probably sounds inconceivable, but some people have daily migraines too. It was beyond belief. And it was happening to me.

By late 2008, as long as I was lying down and rarely exerted myself at all to do daily tasks, and took several different antimicrobial drugs that I had been on for a year, my heart did not spend all day at that level, but was still quite bad, much worse than it was before I moved to Massachusetts, and with an ongoing tone of threat -- since my crushing symptoms returned with some frequency, and I feared they could again become constant. That was, of course, before the ice storm that pushed me to an even worse state of illness. On proper antimicrobial drugs, my heart was finally getting better -- the same heart my doctor had put in quotes as if I was making it up. My parenthetical heart, on the other hand, was devastated from years of terror.

I now know that the infection causing my heart symptoms is a bacterial infection known as bartonella. Before 1990, only two bartonella species, B. bacilliformis and B. quintana, were known to exist in pathogenic forms, but since 1990, at least 22 bartonella species have been described in the medical literature, and at least half of these are considered human pathogens. Many of these are known to have an affinity for cardiac tissue, both in humans and in dogs. I do not have the most commonly-tested species, bartonella henselae, as I tested negative for it on PCR, but I do have one of the other species, as proven by a positive blood smear that depicts a vivid image of the bartonella bacteria clinging to my red blood cells. My heart has also responded to bartonella-specific antibiotics, which my Lyme-literate doctor knew to be a clinical sign that bartonella had invaded my heart tissue. Bartonella infections of the heart are frequently lethal -- almost always lethal without prompt treatment, and they can be particularly virulent in the immune-compromised, mostly those with AIDS although clusters of bartonella heart deaths have also been found in elite orienteers, IV drug users, and the homeless. Links between ME/CFS and AIDS immunology are well-established and have been written about eloquently by many researchers and writers, so its no surprise I would be vulnerable to bartonella's invasion of my heart.

Since this essay was originally written, and the link between ME/CFS and the retrovirus XMRV was found by the Whittemore Peterson Institute, it is quite possible that bartonella might be more virulent in someone with ME/CFS and behave as it does in AIDS patients. Studies have found bartonella to be associated in AIDS patients with bacteremia, endocarditis, aseptic meningitis and dementia. Interestingly, one recent paper in Medical Hypotheses postulated that acute bartonellosis itself can behave like AIDS: "We speculate that the pathophysiology of the acute phase of human bartonellosis resembles AIDS, with a period of immunosuppression following the infection and later, clinical manifestations of immune reconstitution subsequent to treatment." Constrictive cardiac conditions such as cardiac tamponade and constrictive pericarditis are seen in AIDS patients, from secondary infections. However, and this is important to note, if tamponade (a state where the pericardium fills with fluid and chokes the heart) is appearing in ME/CFS patients, it may go unnoticed unless a patient dies and a proper autopsy is conducted, as patients with hypovolemia often have a different presentation of cardiac tamponade called low pressure tamponade with more mysterious (and less detectable) clinical signs. Streeten and Bell found that most ME/CFS patients have chronic hypovolemia, sometimes with less blood in their veins than someone who has bled to death.

Bartonella is known to cause endocarditis, myocarditis and pericarditis, but its most common cardiac complication is endocarditis, which is where the valves of the heart fill with vegetations. An infected pericardium can also constrict the heart, if it fills with fluid and clamps down. Myocarditis can cause left ventricular dysfunction or even aneurysms that can in turn become infected and might lead to a squeezing or crushing sensation and reduced cardiac output, or just dramatic cardiac weakness and death. I finally got a positive bartonella test, but only 3 1/2 years into the infection. I don't know that anyone else has lived that long without treatment from an active bartonella and highly symptomatic infection in the heart. In fact, most strains of bartonella have been identified in humans after the patient has died and the tissue examined. Attention to this growing public health threat has been slow-growing, but a recent slew of articles compared bartenella rochalimae -- a strain spread by rat fleas -- to the Black Death. "Bacteria that can cause serious heart disease in humans are being spread by rat fleas, sparking concern that the infections could become a bigger problem in humans. Research published in the December issue of the Journal of Medical Microbiology suggests that brown rats, the biggest and most common rats in Europe, may now be carrying the bacteria." ("Rat Fleas Spread Heart-damaging Bacteria" California Science and Technology News, November 25, 2008).

The cardiac involvement was beyond obvious in my case, but my doctors would not listen. With gravely reduced cardiac output, and little oxygen transported to my organs, I could feel every function in my body failing each time I lifted my head to take a drink of water. It was like being trapped under a tree where nobody notices the tree. I even said this to my Mom, who at one point was trapped on her side under a car that had to be lifted off by many neighborhood men. She had a crushed pelvis, and my sister and I had to run and get help when I was only six years old. I asked Mom why she could not see that I was crushed under a car, why nobody would lift the car off of me, and she didn't say much. No metaphor, no literal language, could get through to anyone in my life. I tried to use the simplest phrase to communicate with my sister that I was dying from this. "Please don't let me die," I begged her. "Please come out here and help me."

"We just don't understand what you mean by death," she responded.

"I mean death death," I said.

My father came out to assist me temporarily, but would not stay longer and help me though I was begging him for more help. I was pleading my case to him with tears running down my cheeks, as if before a judge, but I knew I would not be acquitted. I wrote in my journal, a week before he left, "In between bouts of heart terror and rage: near-death sensations in my chest, venous pressure in neck again, heart failure big time. And there is no one and nothing to bail me out." As he stood in the doorway ready to go, my stepmom waved to me from the car. Dad was telling me about the stray she had brought along with her -- a bitch she had rescued from a puppy mill. His face lit up when he talked about this, about the dog making a steady recovery and getting socialized after years of neglect. Then the door slammed and he was gone. Continue to part II