Bartonella was present. At the completion of treatment, 7/23 (30.5%) who completed 8 weeks of DDDCT followed by a 5–7 day pulse of HDDCT remained in remission for 3–9 months, and 3/23 patients (13%) who recently finished treatment were 1 ½ months in full remission. In conclusion, DDDCT followed by 6–7 day pulses of HDDCT could represent a novel, effective anti-infective strategy in chronic Lyme disease/Post Treatment Lyme Disease Syndrome (PTLDS) and associated co-infections, including Bartonella, especially in individuals who have failed standard antibiotic protocols.Twenty-five patients with relapsing and remitting Borreliosis, Babesiosis, and bartonellosis despite extended anti-infective therapy were prescribed double-dose dapsone combination therapy (DDDCT), followed by one or several courses of High Dose Dapsone Combination Therapy (HDDCT). A retrospective chart review of these 25 patients undergoing DDDCT therapy and HDDCT demonstrated that 100% improved their tick-borne symptoms, and patients completing 6–7 day pulses of HDDCT had superior levels of improvement versus 4-day pulses if  Borrelia burgdorferi (Bb), is a rapidly growing healthcare problem across the globe. In 2022, the United States (US) had an estimated 476,000 new diagnosed cases of Lyme disease (LD) , vitamin and mineral deficiencies, and sleep disorders) [The most frequent scientific hypotheses to explain chronic persistent symptomatology in those suffering from CLD/PTLDS involve multiple mechanisms, including not only co-infections ,38, but Borrelia ,46,47,48Borrelia . HorowitBorrelia . These isorders) ,59,60,61sorders) , hormonasorders) ,64, Postsorders) , autoimmsorders) ,66, neursorders) , liver dsorders) ,69 and rsorders) . Patientsorders) .Borrelia burgdorferi as a potential cause of persistent infection and ongoing inflammation that could account at least in part for continued symptoms in CLD/PTLDS [Borrelia persists because of a combination of factors. These include immune evasion and changing outer surface proteins [Borrelia [In the past several years, researchers at Johns Hopkins University, the University of New Haven, Stanford University, and Northeastern University have identified stationary, persister, and biofilm forms of LD/PTLDS ,73,74,75LD/PTLDS  and a siLD/PTLDS . Previouproteins ,79, resiproteins  with redproteins , persistproteins , macrophproteins , fibroblproteins ,84, and proteins , changinproteins ,86, resuproteins , as wellproteins . The sciBorrelia  and the Borrelia  may accoBorrelia , as biofBorrelia ,93.Babesia and Bartonella: disulfiram (DSF) and dapsone, diaminodiphenylsulphone (DDS) [Bartonella henselae, and 83.3% reported some clinical improvement, although only two patients achieved full remission with high-dose DSF alone (16.7%), while several patients on either minocycline or azithromycin with rifampin and DSF did not achieve remission [Two repurposed medications have been published to have effects on the persister/biofilm forms of Bb ,75 and ane (DDS) ,95. In ane (DDS) . One patne (DDS) . In anotne (DDS) . Twelve emission . The smaB. burgdorferi biofilm. The 4-drug combo of dapsone, a tetracycline, rifampin, and macrolide (azithromycin) had the most significant effect [Dapsone therapy, using dapsone alone, with a tetracycline and/or rifampin, or with or without azithromycin, has also been shown to be effective against the biofilm/persister forms of Bb . Althougt effect .Bartonella henselae, a facultative intracellular gram-negative bacteria, has been found to have stationary biofilm/persister forms [Bartonella species, apart from B. henselae, have been published to establish long-term stealth infections in immunocompetent persons, including B. vinsonii subsp. berkhoffii, B. bacilliformis, and B. quintana, leading to a chronic, persistent infectious state [B. henselae in culture, methylene blue and rifampin were the most active agents against the biofilm B. henselae after 6 days of drug exposure, whereas both rifampin and methylene blue and azithromycin and methylene blue completely eradicated the biofilm form of B. henselae in culture after treatment for 6 days [Babesia, and chronic bartonellosis, with variable results [Similarly, er forms , accounter forms . Other Bus state . Among 1r 6 days . To date results ,103.Bartonella titers turned positive in this patient after adding pyrazinamide (PZA) to other intracellular antibiotics , where Behçet’s ulcers and granulomatous skin changes resolved for the first time in decades, implicating a potential role for Bartonella in the autoimmune manifestations of Behçet’s [In five separate clinical studies involving more than 365 patients, dapsone combination therapy led to statistically verified improvement in relieving eight major Lyme symptoms in our patients, including sweats/chills, fatigue, joint, muscle, and/or nerve pain, headaches, insomnia, and cognition ,103,104.Behçet’s . erythema migrans (EM) rashes, 100% improved, and 58% went into long-term remission post-DDDCT [Bartonella RNA in their blood and were FISH-positive achieved long-term remission post-treatment with DDDCT. Among 11 patients with a history of Bartonella exposure and no evidence of active infection , 5 (45%) remained in remission, and 6 (55%) improved their underlying symptomatology [Babesia and Bartonella. Of 19 patients (76%) with a history of Bartonella exposure, 15/19 improved (79%), and among 8 patients with proof of active Bartonella infection, i.e., PCR positive, FISH positive, and/or elevated vascular endothelial growth factor (VEGF), 3/8 (38%) remained in remission, with two out of four who were Bartonella FISH positive going into remission (50%). The conclusion of the study was that the higher dapsone dosage, not just the treatment length, positively affected outcomes [A common clinical finding in these dapsone studies for CLD/PTLDS and associated co-infections, similar to studies using DSF, is that higher doses of dapsone showed superior efficacy in putting patients into long-term remission. Double-dose dapsone combination therapy (DDSCT) using dapsone 100 mg PO BID with a tetracycline and rifampin was superior to single-dose dapsone (100 mg QD) with a tetracycline and rifampin, leading to tick-borne symptom improvements in 98% of patients, with 45% remaining in remission for 1 year or longer . In thosst-DDDCT  if all Mmatology . When himatology . A totaloutcomes . Bartonella persisters [Bartonella and Babesia achieved remission after 8 weeks of DDDCT and 4 days of HDDCT. This left us with several essential research questions. We knew that in culture 6 day of treatment with rifampin and/or azithromycin plus methylene blue eliminated Bartonella persisters. Taking these results from “bench to bedside”, would a longer 6–7 day pulse of HDDCT with higher doses of MB result in superior clinical efficacy against the most common co-infection preventing the long-term success of our DDDCT protocol, Bartonella? Would higher doses of methylene blue show increased efficacy against Lyme persisters, based on its identification from an FDA drug library as having anti-persister activity against Borrelia burgdorferi [Bartonella, improve long-term outcomes? Would higher doses of methylene blue as well as higher doses of folic acid improve the tolerance of DDDCT and HDDCT by reducing dapsone-induced anemia and its inhibition of the folic acid pathway while further lowering methemoglobin levels, improving tolerability [Babesia and Bartonella). Among 23 patients who completed a full 8-week DDDCT protocol prior to at least one 4-day or 5–7 day HDDCT pulse, 7/23 (30.4%) went into full remission for 3-months or longer, and 3/23 (14%) went into remission for 6 weeks or longer. Methylene blue (MB) was used in both the double dose and pulsed high dose dapsone studies to help lower methemoglobin levels, a known side effect of dapsone , at dosersisters ,101. Onlgdorferi , apart fgdorferi ? Would orability ,110? In We closely examined 25 charts of adult patients who completed the DDDCT and HDDCT protocols.A total of 19 of the 25 patients (76%) had previously completed one course of DDDCT; 2 patients (8%) completed 2 courses of DDDCT; and 2 patients (8%) completed 3 courses of DDDCT before doing one or several courses of HDDCT, which consisted of either a short pulse (4 days) or a longer pulse (5–7 days). Three patients in this chart review had previously undergone one or more treatments with disulfiram and/or DDDCT and had either failed or had an inadequate response to prior antibiotic therapy and/or had relapsed with persistent symptoms after stopping anti-infective therapy. Three patients were also unable to complete the protocol as prescribed. Two patients (8%) did not complete a full 28-day course of DDDCT prior to completing a HDDCT pulse. One was due to a severe Herxheimer flare with neuropsychiatric symptoms secondary to DSF use with DDS, and another was due to viral gastroenteritis. Another patient was unable to complete the 6-day HDDCT pulse as prescribed with 300 mg of MB due to his history of severe neuropsychiatric symptoms with psychosis, requiring a continuation of his psychiatric medicine. Borrelia-specific bands  on a WB [We assessed co-infection status, age, gender, length of illness, and response to treatment, i.e., self-reported improvement in Lyme symptoms, and whether there was remission, percentage improvement, or lack of response to the HDDCT protocol. Full remission was defined as the resolution of all active tick-borne symptoms for at least 3 months post-therapy. Partial remission was defined as the resolution of all active tick-borne symptoms for at least 6 weeks post-therapy since some patients had recently finished the HDDCT protocol. All 25 patients in our retrospective chart review met the criteria for a clinical diagnosis of Lyme disease supported by a physician-documented erythema migrans (EM) rash and/or positive laboratory testing, including a positive ELISA/enzyme immunoassay (and/or C6 ELISA), immunofluorescent antibody (IFA), Centers for Disease Control and Prevention (CDC) positive IgM and/or IgG Western Blot (WB), PCR,  on a WB ,112, andSaccharomyces boulardii, were used to help prevent antibiotic-associated diarrhea [All patients signed informed consent forms that outlined the proposed benefits and the potential risks of treatment. Patients volunteered to take the high-dose pulsed dapsone protocol at our medical practice based on our prior research illustrating the benefit of dapsone combination therapy in the treatment of CLD/PTLDS ,103,104 diarrhea ,124.In order to minimize potential drug interactions with methylene blue, including serotonin syndrome/toxicity , patientDietary restrictions were also instituted, avoiding foods high in tyramine, which can potentially produce a hypertensive crisis in the presence of MAOIs and/or higher doses of methylene blue . PatientBorrelia [Several patients took disulfiram (DSF) in combination with HDDCT if they had previously failed to have an adequate clinical improvement with either drug regimen used alone or in combination, utilizing higher dosing if they failed prior combination therapies. The patients signed a consent informing them of the potential benefits and risks of DSF, including increased fatigue, brain fog/cognitive dysfunction, worsening psychiatric symptoms, liver function abnormalities, and/or increased neuropathy ,97. TheyBorrelia , along wBorrelia . All patBorrelia .Borrelia burgdorferi [Borrelia [Although both dapsone and disulfiram have demonstrated some efficacy against resistant biofilm/persister forms of gdorferi ,94,104, gdorferi , Biocidigdorferi , essentigdorferi , as wellgdorferi . Rarely,gdorferi , was congdorferi . If patigdorferi ,140. GraBorrelia ,142.Institutional Review Board approval was not required for this work since this was a retrospective review of a convenience sample of patient charts. A convenience sample of 25 adult patient charts was chosen for inclusion in our study out of a patient population of 50 patients offered HDDCT. Protocol 1 with Protocol 1. Medication and Nutritional Supplementation Protocol Sheet for Double Dose Dapsone Combination Therapy and High Dose Pulsed Dapsone Combination Therapy for CLD/PTLDS.Diet: Avoid aged cheese, liver, avocados, beer, wine, overripe fruit, raisins, sauerkraut, sour cream, soy sauce, yeast extracts, etc. since a low histamine diet will help protect against any increases in blood pressure while on higher doses of methylene blue (MB). Those with high blood pressure (hypertension) should have a home electronic blood pressure cuff and intermittently check their blood pressure while taking MB. Stay on a low-carbohydrate diet and avoid simple carbohydrates to avoid promoting yeast/candida overgrowth. Take tetracyclines with a full stomach and 8 oz glass of water, sitting up for one hour post-ingestion to avoid reflux esophagitis; do not mix dairy and minerals within one hour of use; and avoid more than several minutes of direct sun on tetracyclines  since they can cause a sunburn. Use of a 65-sun protection factor sunscreen on all exposed areas  is advisable, even while driving in the car.The patient should be Glucose-6-Phosphate Dehydrogenase (G6PD) positive (an enzyme needed to help red blood cells work properly) without significant iron deficiency anemia or vitamin deficiency  before starting this protocol. Moreover, before instituting methylene blue, all psychiatric medications that could interact should be tapered and stopped (except benzodiazepines). The patient should provide a list of all medications and supplements for the healthcare provider to review, as medication interactions can occur  and may require a dosage adjustment in medications . Coordination with a psychiatrist may be required, depending on the number and types of psychiatric medications. Protocol 2. Two-week HDDCT Protocol Medication and Nutritional Supplementation Sheet for CLD/PTLDS.Bartonella). This protocol is primarily for patients who have completed an 8-week DDDCT in the past (months or years) with or without a course of HDDCT and have ongoing resistant symptoms attributable to tick-borne disease  had been ill for more than 20 years, 40% (n = 10) had been ill between 10 and 20 years, 24% (N = 6) had been ill between 5 and 9 years, and 12% (n =3) had been ill for less than 5 years in duration. Eight percent of patients (N = 2) had physician-diagnosed EM rashes and therefore met the criteria for PTLDS. Another patient had multiple red rashes 22 years ago, prior to getting ill; however, the diagnosis of Lyme disease had not been established by a physician. Among these 25 participants with CLD/PTLDS, 44% (11/25) had CDC-positive IgM Lyme immunoblots, and one patient out of 25 (4%) had at least one co-infection; 2 patients (8%) had at least 2 co-infections; and 22 out of 25 patients (88%) had three or more co-infections. Five patients (20%) had positive titers for Relapsing Fever Borrelia (TBRF), 3 patients (12%) had antibody titers to Borrelia miyamotoi, and 16/25 patients (64%) had exposure to Babesia species, with several patients having more than one species present ; 1 Babesia divergens). Five out of 25 patients (20%) had evidence of active Babesia, as they were Babesia FISH positive. Twenty-one patients (84%) tested positive for one or more Bartonella species. These included: 11 patients with Bartonella henselae; 7 with Bartonella quintana; 6 with Bartonella elizabethae; 6 with Bartonella vinsonii subspecies; 1 with Bartonella koehlerae; 1 with Bartonella bacciliformis; and 4 with Bartonella spp. (genus) without specific spp. identification. Seventeen patients (68%) had evidence of active Bartonella, with 11 patients (44%) being positive by Bartonella FISH and 7/25 (28%) having evidence of active Bartonella via elevated vascular endothelial growth factor (VEGF) or changes in striae. Other co-infections included 20% of patients with evidence of Ehrlichia (5/25), 16% (4/25) with Anaplasma, 24% (6/25) with low positive tularemia titers, 16% (4/25) with Rickettsia spp., 16% (4/25) with low positive titers to Brucella spp., 72% (18/25) with prior exposure to Mycoplasma pneumonia, 12% (3/25) with Chlamydia pneumonia, 96% (24/25) with evidence of exposure to herpes viruses 1, 2, 6, and EBV ; 20% (5/25) with Cytomegalovirus (CMV); 8% (2/25) with West Nile virus (WNV) exposure; 52% (13/25) with COVID exposure before, during, or after DDDCT and HDDCT; 32% (8/25) were positive to Coxsackie/Parvovirus B-19; and 60% (15/25) had evidence of Candida/hypoglycemia.Among the 25 participants, 15 were men and 10 were women. The age range was between 18 and 63 years old . A total of 68% were less than 50 years old, and 32% were older than 50 years old. The mean length of illness was 14.7 years. A total of 24% of patients ; Trichothecenes, 11/25 (44%); Aflatoxins, 8/25 (32%); Gliotoxins, 11/25 (44%); Zearalenone, 9/25 (36%); Citrinin/Dihydrocitinone, 1/25 (4%); exposure to 8 heavy metals (Mercury (Hg) 10/25 patients (40%); Lead (Pb), 11/25 (44%); Arsenic (As), 3/25 (12%); Tin (Sn), 1/25 (4%); other: Cesium (Ce), Uranium (Ur), Thallium , Antimony (Sb), 7/25 (28%); Inflammation/Autoimmune markers: 20/25 (80%); Immune Deficiency (CVID), 5/25 (20%); Other immune abnormalities  cells, ↑ IgM antibodies), 5/25 (20%); Leaky Gut/Food Sensitivity/Mast Cell Activation Syndrome (MCAS), 15/25 (60%): GI Microbiome Abnormalities, Gastroparesis, 6/25 (24%); Liver Abnormalities, i.e., Non-alcoholic Steatohepatitis (NASH), ↑ LFT’s, 11/25 (44%); Liver Abnormalities, Low Alkaline Phosphatase, 6/25 (24%); Detoxification Abnormalities, Low glutathione (GSH), 7/25 (28%); Vitamin and mineral deficiencies, 22/25 (88%); Hormonal abnormalities, low adrenal function, 20/25 (80%); Hormonal abnormalities, low testosterone (men), 6/25 (24%); Hormonal abnormalities, absent pituitary function, 1/25 (4%); Hormonal abnormalities, elevated insulin/Polycystic Ovarian Syndrome (PCOS), 1/25 (4%), Hormonal abnormalities, low thyroid function, 7/25 (28%); insomnia/sleep disorders , 17/25 (68%); POTS/dysautonomia, 8/25 (32%); Psychiatric disorders , PTSD, Schizophrenia), 14/25 (56%); Mitochondrial dysfunction, 6/25 (24%); and genetic abnormalities , 10/25 patients (40%). Babesia and/or Bartonella. Three out of 23 patients (13%) also had a full resolution of their Lyme and tick-borne symptoms for 1½ months or longer, having recently completed the full protocol 6 weeks prior; among those three patients, patient number 10  had improvement in their tick-borne symptoms. Of 23 patients who completed a full 8-week course of DDDCT prior to one or several courses of HDDCT, 7/23 (30.5%) had a full resolution of their Lyme and tick-borne symptoms for 3 months or longer, even if there was prior evidence of co-infections, including A total of 2/25 patients (8%) were EM rash positive with a history of PTLDS, and 1/2 (50%) went into remission for 3 months or longer. Patient 5 had an EM rash 21 years prior, and although DDDCT in 2019 helped to relieve the vast majority of symptoms for several years, it was not until completing a 4-day course of HDDCT 3 years later, in December 2022, that residual fatigue, joint pain, irritability, insomnia, and word recall issues resolved 100% for 6 months or longer.Babesia FISH positive remained in remission, although 4/6 of them (66.6%) were greater than 30% improved and 2 patients were somewhat improved (range of 0–20%). The last patient, patient number 25 (see Of the sixty-four percent (16/25) of patients with babesiosis, 18.8% (3/16) were in full remission. None of the 6 patients who were r 25 see , was funBabesia. It was well tolerated in 5/6 patients (83.3%), and DSF needed to be stopped in one patient due to a neuropsychiatric flare with anxiety. Disulfiram was taken with dapsone for the treatment of resistant Babesia in patient number 4 (B. duncani), patient 13 , patient 17 , patient 18 (Babesia FISH+), patient 21 (Babesia duncani), and patient 25 (B. duncani), and the combination therapy was helpful in relieving symptoms of babesiosis, i.e., symptoms of sweats, chills, flushing, air hunger, and/or a cough. Regimens for Babesia apart from using dapsone and DSF included rotations of atovaquone with or without azithromycin and/or clindamycin [Artemisia annua) [Cryptolepis sanguinolenta) [Scutellaria baicalensis) and Japanese knotweed (Polygonum cuspidatum) [Babesia symptoms, except for patient 21. None of the patients who had active Babesia (FISH+) who took dapsone and DSF with or without the above antimalarial medications and botanicals, however, remained in full remission.Six out of 25 patients (24%) took DSF in doses varying between 62.5 mg alternating with 125 mg, up to 500 mg per day, for up to 6 months at a time, during their course of therapy with dapsone for the treatment of Lyme disease and ndamycin ,148, atondamycin , tafenoqndamycin , with orndamycin  and Malandamycin , low dosndamycin , and bota annua) , with ornolenta) , as wellpidatum) . Five ouBartonella exposure, 100% improved their underlying symptomatology after at least one course of DDDCT and one or several courses of HDDCT pulses (4 days or 5–7 days). Four out of 21 patients (19%) went into long-term remission for 3 months or longer; 3/21 patients (14.3%) went into full remission for up to 6 weeks; and 14/21 patients (66.6%) improved. Of those patients not in full remission, symptom improvement for all Bartonella patients was at levels ranging from 15% to greater than 70%. Examining the differences in treatment response between a 4 day pulse and a 5–7 day HDDCT pulse for the treatment of Bartonella, 6/21 patients (28.5%) who took at least one course of DDDCT and one 5–7 day HDDCT pulse went into remission, and no patients who took DDDCT with one or several 4 day HDDCT pulses went into remission if Bartonella was active. An 8-week DDDCT followed by a 5–7-day HDDCT pulse was therefore superior to a shorter 4-day HDDCT pulse for those with CLD who also had chronic active Bartonella. Among the 8 patients with CLD and Bartonella who took one or several 4-day HDDCT pulses without a 5–7 day HDDCT pulse, there was nevertheless significant improvement in underlying symptomatology. Symptoms of bartonellosis that improved with either DDDCT followed by 4 day or 5–7 days HDDCT pulses with MB included 8 major Lyme symptoms, i.e., fatigue, joint pain, myalgias, neuropathy, headaches, sweats, chills, cognitive functioning, mood, and insomnia, but also included improvement in pain in the soles of the feet, striae, and Bartonella pseudo seizures  [Among 21/25 patients (84%) who had a history of eizures) .Bartonella. Three patients who did one course of DDDCT and one course of HDDCT for 4 days  went into long-term remission, and none of them had evidence of exposure to Bartonella. The 4-day HDDCT pulse after 8 weeks of DDDCT was therefore adequate for treating chronic LD/PTLDS if Bartonella was not present. All patients except patient 23 took PZA during DDDCT + HDDCT.An 8-week DDDCT followed by a 4-day HDDCT pulse was, however, effective in putting several patients into long-term remission with CLD/PTLDS if there was no evidence of exposure to Bartonella FISH positive, and patients 14 and 21, who had elevated VEGFs, consistent with active Bartonella. Patient number 10 did her first HDDCT pulse with 100 mg of methylene blue (MB) PO BID, and she was one month symptom-free before relapsing. She therefore did a second 4-day HDDCT pulse, using 200 mg PO BID of MB, which improved symptomatology but was insufficient to put her in full remission. A third HDDCT pulse for 4 days with 300 mg PO BID of MB was therefore instituted, which resulted in her being symptom-free for 2 months, her longest time without a relapse. She recently finished her first 6-day HDDCT pulse using 300 mg PO BID of MB after doing 3/4-day HDDCT pulses with lower doses of MB and has remained 100% symptom-free (approximately 2 more months in remission). Patient number 24 suffered from Lyme disease (C6 ELISA positive), active Babesia (FISH+), active Bartonella (FISH+), and multiple MSIDS abnormalities, including hypopituitarism, POTS, CVID (on IVIG), small fiber neuropathy, severe resistant insomnia, anxiety with PTSD, inflammation, multiple vitamin and mineral deficiencies, and Morgellons’s disease. She had conducted 2 courses of DDDCT, 3 courses of HDDCT for 4 days, and one course of HDDCT for 6 days. Earlier courses of pulse HDDCT were for 4 days and used a lower dose of MB (100–150 mg PO BID). The last 6-day HDDCT pulse used 300 mg of MB. Although there was temporary improvement in symptomatology with DDDCT and three four-day pulses of HDDCT with lower dose MB, it was not until the last course of six days of HDDCT with 300 mg PO BID of MB that she noticed persistent and sustained improvement in energy, myalgias, neuropathy, and cognitive impairment for five months. Patient 21, after 3 courses of DDDCT and 3 courses of HDDDT for 4 days, where the last round used a higher dose of MB at 300 mg BID, resulted in sustained improvements in energy/endurance, headaches, decreased joint pain, decreased neuropathy, dizziness, and some movement of paralyzed muscles of the lower extremities during the past 4 months. The lower doses of MB used in 4-day HDDCT pulses did not result in sustained improvement or movement of paralyzed muscles in the lower extremities. Finally, patient 14 had 3 spp. of Bartonella , an elevated VEGF, implying active Bartonella, and a Bartonella granuloma on her right hand. She also suffered from severe depression and anxiety with POTS, similar to the other patients with multiple species of Bartonella and Babesia. After 2 courses of DDDCT and one 6–7 day course of HDDCT with minocycline, rifampin, azithromycin, and pyrazinamide in December 2022, along with a higher dose of MB at 300 mg PO BID, she noticed a marked improvement in clinical symptomatology, going from 25% to 87% of normal functioning, with improvements in fatigue, chills, joint pains, and cognition. Her joint pain and swelling decreased, and the Bartonella granuloma on her right hand decreased in size by 80%. See Methylene blue (MB) dosage, apart from the length of HDDCT pulses, affected the efficacy and tolerability of the protocol. Earlier regimens of 4-day HDDCT used 100 mg of MB PO BID (twice a day). These doses were subsequently increased after patients relapsed post-therapy, with evidence of increased methemoglobin. The MB dose was therefore increased to 150–200 mg PO BID, and if symptom relapses persisted with elevations in methemoglobin, the dose was increased to a final dose of 300 mg PO BID while using HDDCT. Examples of increased efficacy of higher doses of MB were seen in patients 10 and 24, who were both Age, length of illness (LOI), and gender were also evaluated to determine their effect on the treatment outcome. Neither age, LOI, nor gender affected remission rates or levels of improvement. Among 17 patients less than 50 years of age, 4 patients went into full remission for 3 months or longer; one patient went into remission for 6 weeks or longer; 5 patients improved greater than 50% of normal; 1 patient improved by greater than 45% of normal; 2 patients improved by 30% of normal; 3 patients improved by 15% of normal; and 1 patient improved by 5% of normal. In the 8 patients who were greater than 50 years old, 3 patients went into full remission for 3 months or longer, 2 patients went into full remission for 6 weeks or longer, and 3 patients improved their baseline functioning by greater than 50% of normal. Although there were fewer patients (8 vs. 17) greater than 50 years old, equal numbers (5 patients in each group) went into remission, and all patients had significant improvement.Length of illness and gender also did not affect remission rates or clinical improvement. Sixteen patients (64%) were sick for 10–20 years or longer, and 8/16 (50%) were in remission, with 8/16 (50%) showing significant clinical improvement. Among 5 patients who had been ill for more than 20 years, 1 was in full remission (3 months or longer), 2 were in remission for 6 weeks, one patient had improved by 30%, and another patient had improved by 15%; Eleven patients were sick between 10 and 20 years old, and 5 went into full remission; 4 were improved by greater than 50% of normal; and 2 patients were improved by 15% of normal. Eight patients were sick between 5 and 9 years, and one was in full remission; one was in remission for 6 weeks; 3 improved by 50% or greater; 2 improved between 30 and 45%; and one improved by 5%; and finally, one patient was sick for 0–4 years and was in full remission.Borrelia burgdorferi [Gender also had no effect on clinical improvement or rates of remission. Although there were more men (15) than women (10) who took DDDCT and HDDCT, equal numbers of men and women  were in remission. Among those who did not go into full remission, 60% of women (3/5) and 53.3% of men (8/15) also improved by 30% or greater, with 2 women and 2 men both having improvements ranging from 5–15%. In a recent study by Johnson et al., using self-reported clinical data from 2170 patients in the MyLymeData patient registry , the autgdorferi ,158,159.Babesia spp. and several Bartonella spp. simultaneously, these patients were some of the sickest and most resistant patients. Four out of five of these patients (80%) with multiple species of Babesia and Bartonella (80%) were Bartonella FISH-positive. One patient who was Bartonella FISH+ and had Bartonella striae suffered from psychosis with auditory hallucinations, and clinical characteristics shared among the other patients included severe neuropsychiatric symptoms  as well as resistant neuropathy . Patient 11 had chronic inflammatory demyelinating polyneuropathy, i.e., CIDP on IVIG; patient 21 had small fiber neuropathy and was on IVIG; and patient 23 also had CIDP and small fiber neuropathy. Patients 11, 17, 21, 23, and 24 had resistant neuropathic symptoms of tingling, numbness, burning, or stabbing sensations, and patients 11, 21, and 23 had severe POTS/dysautonomia, a form of autonomic neuropathy. The species of Babesia and Bartonella that were found in these 5 patients , and patients 15 and 23 had evidence of 3 species of Babesia . Patients 11 and 21 had evidence of 2 spp. of Bartonella , patients 12 and 14 had evidence of 3 spp. of Bartonella , and patients 15 and 23 had evidence of 4 spp. of Bartonella . Patients who simultaneously had two or more species of Babesia and Bartonella oftentimes required psychiatric medication to help control their depression/anxiety and medication (gabapentin (Neurontin), amitriptyline (Elavil), pregabalin (Lyrica), and/or duloxetine ) to control neuropathic symptoms [Bartonella (Bh and Bq) with elevated VEGF and low positive tularemia and Brucella titers, which both can cross-react with other intracellular pathogens [Examining the clinical symptomatology and difference in response rates of those patients who had evidence of exposure to several ents see  includedsymptoms ,162,163.symptoms , midodrisymptoms , droxidosymptoms , Beta blsymptoms , and ivasymptoms , she wasathogens ,170.Despite changes in a number of laboratory values during the course of treatment described here, all patient values returned to normal at the end of treatment . Laboratory values with a CBC, CMP , and methemoglobin levels were monitored before, during, and after DDDCT and HDDCT. For some patients, there were temporary changes in white cell counts , platelets (3 patients had mild thrombocytopenia), transient elevation in myelocytes and metamyelocytes (4–5 patients), regular decreases in hemoglobin (Hb) and hematocrit (Hct) and expected rises in the mean corpuscular volume (MCV) while on dapsone, due to the drug’s effect as a folic acid inhibitor, affecting bone marrow production . There wThe details of the changes in laboratory parameters were as follows: White cell counts remained WNL for 84% (21/25) of patients , with a mean WBC count of 5.57 per µL (median 4.75 µL). Four patients (16%) had temporary episodes of leucopenia (minimum 2.36 µL) and one patient had a temporary episode of leukocytosis (maximum 18.5 µL). All WBC values returned within normal limits post therapy. Hemoglobin (Hb) values   were monThe last laboratory parameters we monitored before, during, and after DDDCT and HDDCT were liver functions, including aspartate transaminase , alanine transaminase , alkaline phosphatase , and total bilirubin  ,186. ASTBabesia and Bartonella, with some patients reactivating underlying viral infections . Our cohort of CLD patients also had other overlapping sources of inflammation on the 16-point MSIDS map contributing to their persistent illness, including environmental toxins , microbiome abnormalities, leaky gut with food sensitivities/mast cell activation syndrome (MCAS), sleep disorders, and vitamin and mineral deficiencies [Babesia and active Bartonella played a major contributing role in driving chronic symptomatology. Sixteen out of 25 patients (64%) with CLD/PTLDS had exposure to Babesia spp., and 21/25 patients (84%) tested positive for one or more Bartonella species. The 3 patients with CLD/PTLDS  who went into long-term remission with 8 weeks of DDDCT and one 4-day pulse of HDDCT had no evidence of active Babesia or Bartonella, despite an LOI between 11 and 21 years. None of the 6 patients who had active Babesia by FISH went into full remission, requiring multiple rotations of anti-malarial medications, and those patients who had evidence of exposure to multiple species of Babesia and Bartonella were some of the sickest patients with resistant neuropsychiatric symptoms and peripheral/autonomic neuropathy (POTS). In those Lyme and Bartonella patients who were FISH+ (and/or had an elevated VEGF and/or striae with granulomas) with a history of Babesia exposure (FISH negative), a longer course of HDDCT (5–7 days) was required post-8 weeks of DDDCT to achieve full remission. Seven out of 23 patients (30.5%) with CLD/PTLDS with Bartonella and Babesia who completed 8 weeks of DDDCT followed by a 6 to 7 day pulse of HDDCT remained in remission for a period of 3–9 months, and 3/23 patients (13%) recently completed the protocol and so far have been in remission for at least 1 ½ months. Although 100% of all 25 patients had an improvement in underlying symptomatology with DDDCT and HDDCT, and 43.5% of patients were in remission at the time of submission of this publication, overlapping MSIDS factors interfered with many patients who did not go into full remission. These factors primarily included inflammation/autoimmune phenomena (80%), due to not only chronic infections but also environmental toxins with mold and heavy metals (88%), immune dysfunction with CVID and CIDP (36%), hormonal abnormalities with low adrenal function, low testosterone (low T) (80%), leaky gut/food sensitivities/microbiome abnormalities/MCAS (68%), hypoglycemia/candida (up to 52%), vitamin and mineral deficiencies (88%), detoxification abnormalities including low glutathione (28%), liver abnormalities, including non-alcoholic steatohepatitis (NASH) (56%), resistant insomnia (68%), POTS/dysautonomia (32%), and severe neuropsychiatric symptoms (56%). Establishing a broad differential diagnosis among those suffering from CLD/PTLDS and screening with the 16-point MSIDS map is essential from our perspective, since many of these MSIDS factors can cause resistant fatigue, pain, cognitive difficulties, insomnia, and neuropsychiatric symptoms resembling chronic Lyme and tick-borne infections, yet their treatment and resolution do not involve antibiotic therapy.Lyme disease has reached epidemic proportions in the United States and worldwide, with an estimated global Bb seroprevalence of 14.5% . Althougciencies ,102,103.ciencies ,70,71. WBabesia duncani, and Bartonella vinsonii subspp., had been vaccinated and boosted several times against COVID-19, and contracted COVID-19 seven times during the course of her illness due to her job, which required regular travel across continents. Despite 7 episodes of COVID-19, one course of DDDCT, and 5 courses of 4-day pulses of HDDCT, her health significantly improved, with each pulse of HDDCT removing a resistant symptom. It was not until she did one 7-day pulse of HDDCT with 300 mg of MB for Lyme and Bartonella that she went into full remission for 3 months or longer.Long COVID also has overlapping symptoms resembling CLD/PTLDS, including chronic fatigue, muscle/joint and nerve pain, insomnia, “brain fog” with cognitive difficulties, neuropsychiatric problems, chest pain, shortness of breath, palpitations, and dizziness secondary to POTS . One wayp-value < 0.00001), where DDS decreased the incidence of Alzheimer’s disease exacerbation [Borrelia burgdorferi has been found in the CNS in patients with Alzheimer’s disease [Dapsone (DDS) alone or in combination with other antibiotics (doxycycline) has been proposed as a potential treatment for those with COVID-19 due to the drug’s combined effects in blocking inflammatory storms and suppressing the production of cytokine signatures including IL1α, IL8, IL1β, IL6, and IL8 and tumor necrosis factor-α ,198. DDSerbation . The poserbation . Althoug disease ,207,208,Borrelia after standard courses of antibiotics, increasing inflammation [Borrelia “persisters” in biofilms [Seven of the factors found on the 16-point MSIDS factors in those suffering from CLD/PTLDS due to ongoing inflammation and downstream effects have been reported in the long COVID-19 syndrome, i.e., viral persistence (coronavirus), viral reactivation (EBV), autoimmunity, mitochondrial dysfunction, POTS/dysautonomia, dysbiosis of the gastrointestinal tract, and MCAS ,214,215.ammation . The scibiofilms ,90,217, biofilms  in biofibiofilms ,91,219, biofilms .Borrelia can persist after standard courses of antibiotics [Borrelia has similarly been proven in the animal model [Borrelia. Although 1–2 courses of high-dose DSF have been shown to have some clinical efficacy in patients with CLD and associated co-infections, resulting in remission rates of up to 36.4% with 6–18 months of use [B. burgdorferi persisters was shown to lack efficacy  46.3%) [Borrelia burgdorferi stationary phase persisters in biofilms, both as a single drug and in combination [B. burgdorferi in these sulfa drug combinations” [Borrelia persisters in culture after evaluating dapsone as a single agent or in combination with tetracycline, rifampin, and azithromycin [Borrelia persisters; however, the efficacy against the persister/biofilm forms of Bb increased as antibiotic combinations were added. Dapsone in combination with doxycycline (2-drug combo) was more effective than dapsone alone, and dapsone + doxycycline + rifampin (3-drug combo) was more effective than the 2-drug combination. The most significant effect in reducing the mass and viability as well as the protective mucopolysaccharide layers of B. burgdorferi biofilm was, however, using the 4-drug combination of dapsone + doxycycline + rifampin + azithromycin [Borrelia persisters using multiple antibiotic combinations [There are multiple scientific studies showing that ibiotics ,221,222,ibiotics ,224, ligibiotics , fibroblibiotics ,84, intribiotics , endotheibiotics , skin [2ibiotics ,227, eyeibiotics , and cenibiotics ,230, witibiotics . Persistal model , in miceal model , dogs [2al model , horses al model , and macal model , as wellal model ,235; howal model ,97 and dal model ,103,104.) 46.3%) . Dapsonebination . They conations” . Dr. Evahromycin . The conhromycin . The stuinations . To dateinations , which cinations .Bartonella [Bartonella FISH positive (seven patients) or PCR/biopsy positive (two patients) using lower dose dapsone went into remission [Babesia and Bartonella. The aim of this study was to examine the effect of higher-dose dapsone pulses in the treatment of resistant Lyme and associated co-infections as well as the effect of methylene blue (MB). In that study, using a 4-day HDDCT pulse with 100 mg BID of MB had some efficacy against Babesia and Bartonella but was insufficient to put most patients with active co-infections in full remission. “Among 11 patients who were Babesia FISH positive, three (27%) remained in remission, six improved (55%), and two (18%) had no change in sweats, chills, flushing, or dyspnea. “Among 19 patients (76%) with a history of Bartonella exposure, 15/19 improved (79%), and four patients (21%) had no change in symptoms” [The three-drug combination of a tetracycline, rifampin, and dapsone (100 mg BID), i.e., DDDCT, was shown to have clinical efficacy in the treatment of CLD/PTLDS, demonstrating tick-borne symptom improvements in 98% of patients, with 45% remaining in remission for 1 year or longer if they didn’t have active rtonella . In thatemission . Clinicaymptoms” .Bartonella. Research in the past several years has shown that Bartonella, such as Borrelia, can form persisters in biofilms [Bartonella-mediated endocarditis, representing a potential reservoir for the persistence of these bacteria [B. henselae to identify more effective treatments for persistent Bartonella infections [Bartonella henselae in vitro [Bartonella, with no viable bacteria detected after 6-day drug exposure [Bartonella, one of the primary co-infections interfering with the success of DDDCT and HDDCT [Bartonella persisters (the Hopkins study did not identify medication dosing) but would also have the advantage of helping to lower methemoglobin levels resulting from the use of higher dose dapsone [Bartonella who took higher doses of MB (300 mg BID) during their pulse therapies vs. lower doses (100–200 mg) noticed improved clinical results. Patient 23 noted sustained improvements in energy, muscle and joint pain, neuropathy, and muscle strength  with a higher dose of MB. Patient 24 similarly noticed for the first time sustained improvement in energy, myalgias, neuropathy, and cognitive functioning after using a 6-day HDDCT pulse with MB 300 mg PO BID. Patient 10 became 2 months symptom-free for the first time after a 4 day HDDCT pulse and 300 mg PO BID of MB, whereas lower doses of MB with 4 day pulses  helped decrease symptoms of fatigue, pain, neuropathy, brain fog, and Bartonella “pseudo seizures”  for a maximum of one month before relapsing during her menstrual cycle. She is now in full remission several months after doing her first 6-day HDDCT pulse with 300 mg PO BID of MB.Our present protocol was the first dapsone combination therapy to regularly use a 4-drug combination of dapsone with a tetracycline (minocycline or doxycycline), rifampin , and azithromycin. A 5th antibiotic, pyrazinamide, i.e., PZA (or rarely macrodantin if there was an intolerance to PZA), was also added in resistant cases, using longer courses of high-dose dapsone (5–7 days vs. 4-day regimens) with higher doses of methylene blue (up to 300 mg PO BID) for the treatment of CLD/PTLDS and associated co-infections, including biofilms ,239, andbacteria . Johns Hfections  and evalin vitro . Their cexposure . We, thend HDDCT ,103. Usi dapsone ,172, whi dapsone . SeveralBartonella in the majority of our patients based on the drug’s efficacy in mycobacterium infections, another bacterial “persister.” PZA has been published to help shorten the course of mycobacterium therapy by demonstrating efficacy in latent infections, phenotypic resistance, or tolerance [Bartonella published several years ago in a patient with Behçet’s disease, a severe autoimmune illness, demonstrated that dapsone combination therapy along with PZA had efficacy against a stealth infection with Bartonella, helping to relieve resistant symptoms [Bartonella. Among those patients who had CLD and Bartonella and who took 8 weeks of DDDCT and a 5–7 day course of HDDCT with PZA, 7/23 patients (30.5%) remained in full remission for 3 months or longer, and 3/23 (13%) were in remission for up to 6 weeks. Due to the small sample size and lack of a similar comparison group, we cannot conclude whether PZA increased response rates to Bartonella. Among three patients in our cohort with a history of CLD  without evidence of Bartonella who did not use PZA, 100% (3/3) went into long-term remission with an 8-week course of DDDCT and one 4-day HDDCT pulse. The 4-day HDDCT pulse was only effective in inducing long-term remission in those patients without evidence of active Babesia or Bartonella. This included patient 5, who met the criteria for PTLDS after having had an EM rash 21 years prior. He had low-grade symptoms for several years after doing an 8-week course of DDDCT. He improved significantly; however, symptoms would come and go. Relapses included several 10–14 day cycles per year, with a return of joint pain, irritability, insomnia, and word recall issues that would then spontaneously resolve. It was not until doing a 4-day HDDCT pulse with 300 mg PO BID of MB three years after taking one course of DDDCT that he went into full remission for over 6 months’ time (see Protocol 2). A double-blind, controlled, randomized trial using DDDCT followed by a 4-day HDDCT pulse needs to be conducted to confirm whether this protocol will lead to long-term remission in those patients with CLD without associated co-infections, as it did in patients 5, 6, and 7.We added Pyrazinamide (PZA) for the treatment of resistant olerance . A case symptoms . It was Bartonella  with striae and 3 species of Babesia  and had been sick for over 10 years before doing dapsone combination therapy. He had an EM rash in 2008 (meeting the criteria for PTLDS) and had previously failed 7 years of antibiotics before seeing us, including IV doxycycline for two months and IV azithromycin, as well as a short course of DSF. No antibiotic protocols during the 7 years of treatment had resulted in any significant sustained improvement. He did one course of DDDCT and two seven-day courses of HDDCT and had a 15% improvement in symptoms, including decreased muscle/joint pain, neuropathy, tinnitus, and improvements in cognition. Rotations of Babesia medications  along with dapsone were required to help decrease his sweats and air hunger, classical symptoms of Babesiosis. Dapsone’s benefit in this patient was in part from its antimalarial effects, i.e., antimicrobial as well as antiprotozoal effects, making it useful as an adjunct treatment of Babesia [Bb [Regarding potential side effects of the medication regimen, one patient, patient 23, was unable to take PZA due to a transient rash that developed on the medication. It was promptly resolved using H1 and H2 blockers  . He had  Babesia ,102,104; Babesia , with ef Babesia ,245; as esia [Bb  with excesia [Bb .Bartonella and multiple species of Babesia, like patient 23, were the sickest individuals in this cohort with the most severe, resistant symptoms. This may be due to the overlapping effects of Babesia and Bartonella each increasing inflammatory cytokine production [Borrelia and Babesia increasing inflammation, where each pathogen affects the other microbe directly or indirectly by influencing the host immune response [Bartonella species and Babesia species in CLD, where patients also had other overlapping sources of inflammation with downstream effects (MSIDS variables). There are presently over 36 species of Bartonella that have been identified, of which at least 17 have been associated with an expanding spectrum of animal and human diseases [Bartonella henselae (associated with a virulent form of cat scratch fever and culture-negative endocarditis), Bartonella quintana , Bartonella elizabethae, Bartonella vinsonii subspp., and Bartonella koehlerae  [Bartonella bacilliformis . Clinical manifestations of these Bartonella species include a broad range of eye problems , cardiac problems , peripheral neuropathy, central nervous system neurological disorders (Pediatric acute-onset neuropsychiatric syndrome (PANS), hallucinations, psychosis, encephalopathy, transverse myelitis, radiculitis, cerebellar ataxia), [Bartonella species have also been associated with breast cancer [Patients with multiple species of oduction ,246, as response . To the diseases ,36. We ftations) ,249, andataxia),  rheumatoataxia), , chronicataxia), . Recentlt cancer ,253,254 t cancer , a highlBartonella can overlap those of CLD, including fevers, fatigue, joint and muscle pain, headaches, cognitive difficulties, eye problems, and mood disorders [Bartonella may be present include severe neuropsychiatric symptoms with striae [Bartonella is present. We believe that Bartonella infections in our study interfered with the long-term efficacy of HDDCT, as did multiple Babesia species, necessitating a differential diagnosis and laboratory testing for multiple species of each infectious agent. Several of these Bartonella species have been associated with immunosuppression. These include B. bacilliformis, B. henselae, and B. quintana [Bartonella had Chronic Variable Immune Deficiency (CVID), i.e., patients 1, 8, 11, 22, and 24, and patient 23, who had 4 species of Bartonella , had Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). Considering the high incidence of immunosuppression in 5/25 patients (20%) as well as neuropathy  with neuropsychiatric symptoms among this cohort of patients, any patients presenting with CLD and associated co-infections with the above clinical symptomatology warrant initial laboratory testing for Bartonella species and immune deficiency. This evaluation should include an immunoglobulin panel  with IgG subclasses [Bartonella species is reasonable in this clinical setting, as well as other co-infections and MSIDS variables, since not only has Bartonella been associated with immune deficiency [Anaplasma [Babesia [Bartonella, which can lack adequate sensitivity [Bartonella spp. [Bartonella immunoblots [Bartonella FISH testing [Bartonella species. We found Bartonella FISH testing (IgeneX laboratories) to be positive in 11/25 patients (44%) and helpful in proving an active Bartonella infection as a cause of persistent symptoms when other serological methods were negative. The vascular endothelial growth factor (VEGF) test was also useful as an indirect marker of active Bartonella [The symptoms of isorders , potentih striae   have been shown to induce VEGF-mediated vasoproliferative disease in immunocompromised or immunocompetent animals  and humans [B. vinsonii subsp. berkhoffii, B. henselae, and other Bartonella spp. have developed survival mechanisms that allow for low-level intravascular and intracellular persistence [Babesia microti (1:320+), and Bartonella  with a history of severe fatigue, joint pain, sweats, and shaking chills (Babesia) with severe memory/concentration problems, depression, and panic attacks. She had been on high-dose morphine sulfate years ago before seeing us due to her severe pain, which was still not controlled by narcotics. She did two courses of DDDCT in the past several years, which improved her health and allowed her to stop all her narcotics as her pain levels decreased. She recently did one 6–7 day course of HDDCT with 300 mg of MB PO BID at the end of December 2022, several years later. After having a severe Herxheimer reaction, she improved from 25% to 87% of normal functioning, and a Bartonella granuloma on her hand decreased in size by approximately 80% . She did one 8-week course of DDDCT in August 2022, followed by a 6-day HDDCT pulse in March 2023, and had significant improvements in arthritic joint pain, energy, sleep, and cognition. She started at 23–30% of normal and was now functioning at 80% of normal as of May 2023. Finally, patient number 20 had a history of CLD, Babesia microti (1:64+), an indeterminate Bartonella immunoblot with Bartonella henselae (1:256+), and elevated VEGF. His primary symptoms in 2017 included severe fatigue, myalgias, rib pain, headaches, neuropathy, lightheadedness, cognitive difficulties, and mood swings. He did one 8-week course of DDDCT in March 2019 with doxycycline, rifampin, azithromycin, and pyrazinamide, and although he improved, one year later, in April 2020, symptoms relapsed after being treated for cellulitis with Augmentin when Bartonella striae emerged  and went from 50–60% normal to 95% normal functioning. He would have been counted as in remission if not for his occasional word-finding problems and sleep issues. This patient had multiple overlapping MSIDS variables affecting his resistant symptoms.fections . At leasd humans , as B. vsistence . We foun 80% see . She felrged see . The DDDBartonella in CLD, which is controversial, and whether it is definitely a tick-transmitted pathogen. Bartonella spp. can be transmitted from mammals to humans via cat fleas, sand flies, keds, mites, and human body lice [Bartonella via ticks, red ants, and spiders [Bartonella transmission by ticks, although one study in Europe with Ixodes ricinus ticks confirmed their ability to transmit a species of Bartonella, B. birtlesii [Bartonella from ticks, which have been shown to contain different Bartonella spp. [Bartonella [Bartonella henselae [Bartonella species. These included: 11 patients with Bartonella henselae; 7 with Bartonella quintana; 6 with Bartonella elizabethae; 6 with Bartonella vinsonii subspp.; 1 with Bartonella koehlerae; 1 with Bartonella bacciliformis; and 4 with Bartonella spp. (genus) without specific spp. identification. The MyLymeData patient registry of about 4000 participants highlighted the large heterogeneity of treatment responses for those with CLD [Bartonella and Babesia, undiagnosed/untreated MSIDS factors, as well as the large variability in treatments, including newer persister drug regimens, accounted in part for the large diversity of treatment outcomes.There are several unanswered questions regarding the etiology and role of ody lice . Recent  spiders . Furtherirtlesii . Whetherlla spp. ,274,275 rtonella ,102,103.henselae . In our with CLD . Based owith CLD ,105, it Babesia, a malarial-type parasite found in ticks [Babesia microti; 10 had Babesia duncani; 2 had Babesia odocoilei (FISH); 1 had Babesia divergens; and 20% (5/25) had evidence of active Babesia, i.e., were Babesia FISH positive. The primary symptoms present in those with active Babesia included day sweats, night sweats, chills, flushing, an unexplained cough, and “air hunger”, which are questions 1 and 22 on the HMQ-validated Lyme questionnaire [Babesia were more resistant to treatment, and none of the 6 patients (24%) who were Babesia FISH+ remained in full remission. Although the range of a B. microti lineage has been known to be expanding in the Northeastern US [the Southeastern US [B. divergens and Babesia venatorum [B. microti and B. duncani. Babesia duncani has also been increasing its range from the Western US to the Eastern US [Ixodes ticks is B. odocoilei [B. odocoilei has been found in ticks from Canada to Texas [B. odocoilei were found by Scott et al., implying that the parasite can be pathogenic in humans [B. odocoilei serologically cross-reacts with Babesia duncani [eight most prevalent Babesia species reported in humans from different parts of the globe include B. bigemina, B. bovis, B. crassa-like, B. divergens, B. duncani, B. microti, B. odocoilei, and B. venatorum [Babesia spp. have the highest prevalence in Europe, lower middle-income countries, and among individuals with a history of tick bites and other tick-borne diseases [in ticks , which cin ticks , maternain ticks ,280, andin ticks , was fouionnaire . Those pstern US  as well stern US , it has enatorum . Patientstern US ,285 as wstern US , and shodocoilei ,288,289.to Texas , and recn humans . Since B duncani , it is penatorum . These Bdiseases .Babesia oftentimes required multiple rotations of antimalarial therapies, including clindamycin [cryptolepis sanguinolenta, Scutellaria baicalensis (Chinese skullcap), Polygonum cuspidatum (Japanese knotweed) [B. microti, which has been implicated in a few cases of human babesiosis, all of them found in Europe [B. microti [Patients with active ndamycin , atovaqundamycin , atovaqundamycin , tafenoqndamycin , with orndamycin , lumefanndamycin , and botnotweed) , as wellnotweed) . Oftentinotweed) ,296; hownotweed) , and reqnotweed) . Clofazin Europe ,300. The microti . Many of microti ,302,303.Babesia microti has become resistant to standard therapies  [B. burgdorferi infection depends on a Th2 CD4+ T cell response within regional lymph nodes, and co-infection with B. microti may influence T cells toward a TH1 response [Babesia spp. may also complicate the course of DDDCT and HDDCT, as clinically they can result in hemolytic anemia [Babesia infections [medications’ side effects includes elevated levels of methemoglobin [Babesia  may also cause hemolytic anemia, it is incumbent on the physician to determine whether one or several etiologies are present. Although mild hemolytic anemia is common following dapsone treatment, it rarely warrants a change of therapy, as increased hemolysis usually only occurs in patients with glucose-6-phosphate dehydrogenase deficiency [quinine) . As per quinine) , the patresponse . Babesiac anemia ,307, simc anemia  used to fections ,294. Tafmoglobin , similarmoglobin , and Babficiency ,311. Meaficiency , or if tficiency . In the Bartonella to further improve tolerability, as well as in other autoimmune dermatological diseases such as dermatitis herpetiformis, where dapsone is used in doses up to 400 mg per day [Laboratory values were closely monitored during the first month on DDDCT (week 3), then weekly (weeks 5–8) during the second month on DDDCT, and biweekly during the last week of an HDDCT pulse. Despite changes in a number of laboratory values during the course of treatment, all patient values returned to normal at the end of treatment . Laboratory values with a CBC, CMP , and methemoglobin levels were monitored before, during, and after DDDCT and HDDCT. There were temporary changes in white cell counts , platelets (3 patients had mild thrombocytopenia), transient elevation in myelocytes and metamyelocytes , regular decreases in hemoglobin (Hb) and hematocrit (Hct), and expected rises in the mean corpuscular volume (MCV) while on dapsone due to the drug’s effect as a folic acid inhibitor, affecting bone marrow production . There w per day ,314,315. per day ,317.Liver functions were closely monitored on rifampin and PZA due to the potential of both medications to cause transaminitis ,319. ASTBartonella, when the protocols were adhered to, including the laboratory testing schedule. Higher doses of methylene blue and anti-oxidants, as well as folic acid supplementation, used in this HDDCT protocol compared to prior published higher dose dapsone protocols [We regularly used liver support with NAC, ALA, glutathione, and sulforaphane , and addrotocols ,103, mayBartonella. We found that 8 weeks of DDDCT followed by a 4-day pulse of HDDCT was sufficient to put patients with CLD/PTLDS into long-term remission if they did not have evidence of active co-infections, i.e., Babesia and Bartonella. Patients who were co-infected with Bartonella were sicker, with more neuropsychiatric symptoms, immune deficiency, and increased autonomic and peripheral neuropathy. They required 8 weeks of DDDCT followed by a 6–7-day pulse of HDDDCT to improve and/or go into full remission. The 4-day HDDCT, although helpful in relieving symptoms in those with CLD and Bartonella, was insufficient to keep most co-infected patients with Bartonella in remission.This is, to our knowledge, the first effective, short-term oral, generic protocol for treating CLD/PTLDS and associated co-infections, including Bartonella had superior results using 8 weeks of DDDCT followed by a 6–7-day pulse of HDDCT. This confirms the culture results from Johns Hopkins researchers looking at Bartonella persisters in culture, where 6 days of combination antibiotic therapy  were required to completely eliminate Bartonella persisters in biofilms [Bartonella. Pyrazinamide may also have been helpful in inducing remission rates for Bartonella; however, larger controlled studies will be necessary to determine its beneficial effect [Babesia and/or Bartonella. Three patients (13%) also had a full resolution of their Lyme and tick-borne symptoms for 1 ½ months or longer, having recently completed the full protocol 6 weeks prior, and age, length of illness, or gender did not affect remission rates or clinical improvement. Sixteen patients (64%) were sick for 10–20 years or longer, and 8/16 (50%) were in remission, with 8/16 (50%) showing significant clinical improvement.Patients with evidence of chronic biofilms . We did biofilms ,104,105.l effect ,326. Of We recognize that the tick-borne protocol presented here is complex, has potential gastrointestinal issues (nausea and vomiting) and hematological side effects with HDDCT, and requires a highly motivated health provider and a highly engaged patient. It is, however, a protocol that we have demonstrated to be safe and effective when patients follow the guidelines outlined in Bartonella) [Borrelia, Babesia, and Bartonella), dysbiosis, leaky gut with food sensitivities or mast cell activation syndrome, environmental toxins , mineral deficiencies, and chronic insomnia. These six factors contributed to chronic inflammation, resulting in downstream effects including mitochondrial dysfunction, POTS/dysautonomia, liver dysfunction, autoimmunity, and hormonal dysregulation. Despite these overlapping variables, 100% of our patients had improvement in their tick-borne symptoms using this short-term, oral, generic antibiotic protocol, implying a major role for the biofilm/persister forms of the bacteria, i.e., Borrelia and Bartonella, in driving chronic symptomatology.Climate change and the rise in global temperatures are one of the greatest threats to mankind’s health and are increasing our risk of vector-borne illness, whether it be mosquito-borne  , flea-botonella)  or tick-tonella) . Lyme ditonella) , and clitonella) . Borrelitonella) , fibromytonella) , neuropstonella) ,66,67. Ttonella) ,332, sectonella) . OverlapBabesia spp. that played a major role in interfering with the success of DDDCT and HDDCT, and if questions 1 and 22 on the HMQ Lyme questionnaire are positive [Babesia FISH-positive remained in long-term remission. It is essential that we invest more research funding into finding effective treatments for chronic babesia. Patients who are immunosuppressed, splenectomized, and/or elderly with chronic health conditions, including cardiac and pulmonary problems, are at greater risk for lethal complications from Babesia [Babesia microti is now resistant to standard anti-malarial therapies, with new species on the horizon, we need new tools and arsenals to fight these chronic parasitic infections, which are making chronic LD patients sicker. Investing in regular surveillance of ticks is also essential to determine the constantly changing environment of bacteria, viruses, and parasites [Babesia odocoilei being reported in the United States, and we lack sufficient knowledge regarding its spread among ticks in the Northern Hemisphere, the parasite’s pathogenicity, and/or how new emerging Babesia species may interact with the same host, causing illness. Similarly, several of our patients had simultaneous active co-infections with Lyme disease, different Babesia species, and different Bartonella species. We lack sufficient knowledge about the complex interactions of these organisms, and we suggest more research funding should also be invested in these areas.It was ultimately chronic positive , it shou Babesia . Since Barasites . Our papBartonella exacerbating psychiatric symptoms. If the patient presents with classic Bartonella striae , Bartonella FISH, and a Bartonella Immunoblot (IgeneX Laboratories) and/or T Labs . VEGF is also a useful surrogate marker for active Bartonella and can be obtained through local laboratories.Based on our patient population, anyone suffering from severe neuropsychiatric symptoms who also has significant physical complaints seen in CLD/PTLDS, i.e., chronic fatigue, headaches, migratory muscle/joint/nerve pain, cognitive difficulties, and a sleep disorder, should alert the clinician to the possibility of riae see  with or riae see , pain onBorrelia and Bartonella conducted at major universities [Bartonella.If a patient with CLD/PTLDS has failed multiple antibiotic protocols and has not yet tried a biofilm/persister protocol such as dapsone combination therapy, it is the first therapy that we would recommend based on our clinical experience, as long as there are no clear contraindications, i.e., G6PD deficiency, iron deficiency anemia, severe sulfa allergy, etc. Although the role of biofilm and persister bacteria in Borreliosis and Bartonellosis has been debated in the scientific literature, multiple publications on dapsone combination therapy have shown significant efficacy rates with short-term antibiotic therapies in the treatment of CLD/PTLDS using combination therapies with a persister drug, dapsone, along with biofilm agents. The chronic Lyme community has been desperate to find a cure for this chronic illness . The “beersities ,336,337 Babesia and Bartonella, biofilm/persister medications, as well as MSIDS factors, were not regularly accounted for in prior randomized controlled trials for CLD/PTLDS evaluating the efficacy of chronic antibiotic therapy [Multiple infections, including  therapy ,341,342. therapy . A preci


The objective of this study was to compare quantitative electroencephalography (Q-EEG) characteristics of children with Attention-deficit/hyperactivity disorder (ADHD), taking into account the presence of a comorbidity for anxiety disorder. It also sought to investigate the impact of comorbid anxiety on the Q-EEG heterogeneity of children with ADHD.A total of 141 children with ADHD but without comorbid anxiety (ADHD-Only), 25 children with a comorbidity for anxiety disorder (ADHD-ANX) and 43 children in the control group were assessed. To compare Q-EEG characteristics between groups, we performed ANCOVA  on relative power and theta/beta ratio (TBR) controlling for covariates such as age, sex, and FSIQ. Relative power values from 19 electrodes were averaged for three regions . Furthermore, cluster analysis (Ward’s method) using the squared Euclidian distance was conducted on participants with ADHD to explore the impact of anxiety on the heterogeneity of Q-EEG characteristics in ADHD.post hoc analyses, It was found that the ADHD-ANX group has significantly higher beta power values than the ADHD-Only group in all regions. For the theta/beta ratio, the ADHD-Only group had significantly higher values than the ADHD-ANX group in frontal, central and posterior regions. However, the control group did not show significant differences compared to both the ADHD-Only and ADHD-ANX group. Through clustering analysis, the participants in the ADHD-Only and ADHD-ANX groups were classified into four clusters. The ratios of children with comorbidities for anxiety disorder within each cluster were significantly different .There were no significant group differences in cognitive and behavioral measures. However, significant differences between groups were observed in the theta values in the central region, and the beta values in the frontal, central and posterior regions. In Attention-deficit/hyperactivity disorder children with comorbid anxiety disorder showed lower theta power in the central region, higher beta power in all regions and lower TBR in all regions compared to those without comorbid anxiety disorder. The ratios of children with comorbidities for anxiety disorder within each cluster were significantly different. Attention-deficit/hyperactivity disorder (ADHD) is a neuropsychiatric disorder characterized by developmentally an inappropriate level of inattention, hyperactivity, and impulsivity. It is one of the most prevalent psychiatric disorders in childhood. Estimates of ADHD prevalence are highly variable, but it has been estimated that ADHD affects about 7.4% ∼ 9.5% of the childhood population –3.Attention-deficit/hyperactivity disorder often accompanies psychiatric comorbidities, which not only complicates its differential diagnosis but also contributes to the heterogeneity of clinical features in children with ADHD . AnxietyPrevious studies have primarily focused on examining the cognitive and behavioral characteristics of children diagnosed with both ADHD and anxiety disorder. These studies have reported deficits in working memory , slower Attention-deficit/hyperactivity disorder showed heterogeneity not just in its symptoms, but also in its brain activity, which can be examined by analyzing quantitative electroencephalography (Q-EEG) patterns. Q-EEG has been used to study neurophysiological basis of ADHD in the research field. It has also been used for assessing ADHD in the clinical field. Increased power in the theta band and decreased power in the beta band are the most consistently reported findings in ADHD children . Based oSome studies have proposed that the heterogeneity within ADHD populations can lead to the classification of Q-EEG results into different subtypes, which may explain the conflicting findings observed in previous studies . SpecifiTherefore, the goal of this study was comparing the QEEG characteristics of children with ADHD based on the presence and absence of comorbid anxiety. Additionally, we aimed to investigate whether the presence of comorbid anxiety disorder contributes to Q-EEG heterogeneity observed in children with ADHD.The ADHD only group (ADHD-Only) and the ADHD with a comorbidity for anxiety disorder group (ADHD + ANX) included children who made their first visit to the Department of Psychiatry at Samsung Medical Center  from 2017 to 2021.The inclusion criteria for children with ADHD were as follows: (1) aged 6–13 years, and (2) diagnosed with ADHD  according to the DSM-5  classification , based oThe exclusion criteria for all groups were as follow: (1) individuals with an IQ score lower than 70, as assessed by the Korean version of the Wechsler Intelligence Scale for Children 4th edition (K-WISC-IV); (2) individuals with current episodes of major depressive episode or manic episode based on clinical interview or the K-SADS-PL; (3) individuals with a history of psychiatric diagnoses including autism spectrum disorder, schizophrenia spectrum disorders, other psychotic disorders, or mood disorders with psychotic features, based on clinical interview or the K-SADS-PL; (4) individuals who had been prescribed any psychotropic medications, including psychostimulants, within the month prior to their first visit and Q-EEG measurement; (5) individuals with severe congenital diseases under ongoing treatment; (6) individuals with a history of convulsive disorders; (7) individuals with a history of hearing impairment or visual impairment.This study was based on retrospective chart review. It received ethical approval from the Samsung Medical Center Institutional Review Board (IRB No. SMC 2022-09-132). The study for healthy control group was performed independently. It also received ethical approval from the Samsung Medical Center Institutional Review Board (IRB No. SMC 2018-07-106).All participants were assessed with the Korean version of the ADHD Rating Scale (K-ARS), the Korean version of Wechsler Intelligence Scale for Children 4th edition (K-WISC-IV), the Korean Vineland Adaptive Behavior Scales-2nd edition (K-Vineland-II), Conner’s Continuous Performance Test (CCPT), and Korea-Child Behavior Checklist (K-CBCL).Furthermore, all participants underwent clinical psychiatric interviews conducted by psychiatrists to diagnose ADHD, assess ADHD symptoms, and determine the presence of psychiatric comorbidities, including anxiety disorders and other psychiatric disorders. The psychiatric diagnoses were subsequently confirmed by clinical psychologists using the K-SADS.The K-ARS, a scale composed of 18 items (9 items for assessing inattention and another 9 items for assessing hyperactivity) was conducted to assess the severity of ADHD symptoms. Participants rated the presence of symptoms over the past week on a scale ranging from 0  to 3 (very much) for each item. For this study, the parent-report version of the K-ARS completed on the first visit was employed.The K-WISC-IV was conducted to evaluate the intelligence of the children in the study. The K-WISC-IV is the Korean version of the WISC-IV , which iIn addition to assessing overall intelligence, the CCPT was administered to evaluate the sustained and selective attention of the participants. The CCPT is a computerized continuous performance task  that invThe CCPT provided T-scores for omission and commission errors, signal detection parameters, and reaction time. The average speed of all target responses for the entire test (Hit Reaction Time) served as an overall response time measure. Variability dependent measures included the standard error of Hit Reaction Time (Hit Reaction Time SE); a measures of “within-respondent” variability that could compare the variability of 18 time blocks to the overall variability, Hit reaction time SE (Variability); change in reaction time across the duration of the test (Hit Reaction Time Block Change) and its associated standard error (Hit SE Block Change); the change in mean reaction time for different ISIs  of 1, 2, and 4 s (Hit Reaction Time ISI change) and its associated standard error (Hit SE ISI Change).The CCPT also provided an indicator of unusual patterns of responding, such as unusually slow, random, or anticipatory responses, or repeated responses without consideration of the stimuli or task requirements (Perseveerations). Accuracy-dependent measures included the Omission error (failure to respond to target letters), Commission error (response to non-target letters), and detectability (d’), which measured the overall discriminative power to differentiate between signal and noise distributions. High T-scores indicated poor performance for all items except detectability (d’).The K-Vineland-II was administered to evaluate the overall adaptation level of participants. The Vineland-II is designed to assess the daily functioning of an individuals, including both those who are typically developing and those with disabilities, within the age range from preschool to early adulthood. Three domains of measurement–Communication, Daily Living Skills, and Socialization Skills- represent various dimensions of adaptive behavior. For each domain, age-matched T-scores were calculated and an overall adaptive behavior composite score was generated by combining the scores across the domains. In each domain, a high T-score indicates better adaptive functioning.The CBCL was administered to assess a wide range of childhood behaviors. The CBCL was completed by the main caregiver of each participant to assess behavior of participants in the past 6 months. The items on the CBCL measured specific emotional and behavioral problems on a 3-point Likert scale (0 = “Not True” to 2 = “Very True or Often True”). The CBCL consisted of two empirically derived broadband scales and eight syndrome scales . The broFor all participants, diagnostic, behavioral, cognitive, and EEG data were collected prior to the initiation of medication. The results of the aforementioned assessments were presented and utilized for further analyses as age-matched T scores.Electroencephalography recording was conducted using a 62-channel digital electroencephalography device . Nineteen surface electrodes were positioned according to the international 10/20 location system . All electrodes were referenced to linked ears, and each electrode was silver-plated. Impedance was below 5 Ohms. Each participant was asked to keep awake with eyes closed in a quiet room with sound insulation. EEG data were recorded for approximately 5 min, and experienced technicians examined the data to exclude any artifacts. The recorded EEG data were analyzed using a Q-EEG analysis software . The Continuous EEG data were Fourier transformed and divided into four frequency bands for further analysis: delta (1–4 Hz), theta (4–8 Hz), alpha (8–12 Hz), and beta (12–25 Hz). The power spectrum for each frequency band was calculated. The relative power  and theta/beta power ratio were calculated based on the absolute power values. Additionally, further analysis of the beta frequency band involved dividing it into sub-band by dividing bands into beta 1 (12.0–15.0 Hz), beta 2 (15.0–18.0 Hz), beta 3 (18.0–25.0 Hz), and high beta (25.0–30.0 Hz).Group differences on demographic, cognitive, and behavioral characteristics among ADHD-Only, ADHD-ANX, and HC groups were assessed by ANOVA  for continuous dependent variables and chi-squared analysis for dichotomous variables (sex and comorbidity pattern).In order to compare Q-EEG characteristics of participants according to presence or absence of ADHD and comorbid anxiety, intergroup comparisons for each location and frequency bands were performed through ANCOVA  using age, sex, and FSIQ as covariates considering their widely known impact on EEGs , 21. Relp < 0.05) was used for statistical significance in this study. If there were significant differences between groups, post hoc analyses with Bonferroni correction were conducted. Bonferroni correction were also conducted for multiple comparisons of behavioral and cognitive measures. In these cases, p-values are indicated as adjusted values.Cluster analysis was conducted on participants with ADHD (ADHD-Only groups and ADHD-ANX groups) to explore the contribution of comorbid anxiety disorder to the heterogeneity of ADHD Q-EEG characteristics. Participants in these two groups were hierarchically clustered by Ward’s method, using the squared Euclidean distance to measure differences between subjects. The variables used in the cluster analysis were population-based age-matched z-score provided by the Neuroguide software of relative power estimates for 19 electrode locations of each frequency band. The z-scores standardized the contribution of each variable while accounting for the impact of age. Following the clustering process, chi-squared analysis was performed to examine difference in the ratios of subjects diagnosed with anxiety disorder within subgroups obtained as a result of cluster analysis. Statistical analyses (ANOVA) were conducted to compare clinical measures across subgroups. Additionally, intergroup comparisons (ANCOVA) were performed, considering age and FSIQ as covariates, to assess the differences between each subgroup and the control or overall ADHD group. A significance level of 0.05  were included in the analysis. Out of the initial 185 children who met the inclusion criteria, 19 children were excluded based on the exclusion criteria, As a result, the analysis included 166 children with ADHD. The ADHD-Only group consisted of 141 children . The ADHD-ANX group consisted of 25 children . The specific diagnoses were as follows: 4 children with social anxiety disorder, 2 with generalized anxiety disorder, 3 with separation anxiety disorder, 1 with specific phobia, and 16 with other specified anxiety disorder. The HC group consisted of 43 children . There were no significant differences in age or sex between ADHD-Only, ADHD-ANX, and HC groups. Detailed demographic characteristics of each group are presented in The mean K-ARS score was statistically significantly higher in the ADHD-Only group  and the ADHD-ANX group (22.12 ± 8.90) compared to the HC group (4.81 ± 3.55). However, It was not significantly different between the ADHD-Only group and the ADHD-ANX group.Regarding the K-WISC-IV, group differences were observed in FSIQ and all subscales including VCI, PRI, WMI, and PSI . HoweverIn terms of the CPT, the HC group demonstrated significantly lower scores (indicating better attention performance) than the other two groups in d,’ omission errors, commission errors, HRT SE and Variability. No significant differences in any CPT items were observed between the ADHD-Only group and the ADHD-ANX group.Regarding the K-Vineland-II, the HC group exhibited significantly higher scores (indicating better adaptive functioning) than the other two groups at all times. No significant group differences were observed in any item of K-Vineland-II between the ADHD-Only group and the ADHD-ANX group.p < 0.01), and thought problem domain   than the other two ADHD groups at all time. The ADHD-ANX group had significantly higher scores in Anxious/Depressed domain  .post hoc analyses, the ADHD-ANX group showed significantly higher beta power values than the ADHD-Only group in all regions. However, There were no significant group differences in beta bands between the HC group and the other two groups in any of the regions , with a considerable number of them also exhibiting comorbid anxiety disorder (5 of 11 participants).The results of this study revealed that participants with ADHD did not show a significant increase in theta, decrease in beta, or increase in TBR compared to the control group. Only a subgroup, cluster 1, had a high TBR compared to the control group. These results were different from a previous study reporting that increased theta, decreased beta, and increased TBR were commonly observed in ADHD relative to normal controls .On the other hand, a meta-analysis suggested that the diagnostic and prognostic value of TBR is limited to a subgroup of ADHD because of the heterogeneity of Q-EEG in ADHD , which aPrevious studies have suggested that ADHD children with a comorbidity for anxiety disorder exhibit different cognitive or behavioral characteristics compared to those without a comorbidity for anxiety disorder, such as lower impulsivity and worse working memory . HoweverHow can beta activity be increased in ADHD children with a comorbidity for anxiety disorder? The association between beta excess and anxiety has been reported repeatedly , 15, 22.Some research studies have proposed that comorbid anxiety can moderate certain ADHD symptoms, particularly externalizing behaviors such as aggression. A 10-year longitudinal study reported that anxiety has a protective effect against proactive and reactive aggression of ADHD patients . If the Excessive beta activity in ADHD with a comorbidity for anxiety disorder might also have implications for the selection and use of medication for ADHD. It has been reported that the use of methylphenidate can increase frontal beta activity, and there is a correlation between beta increase and clinical response to medication . On the In this study, the majority of psychiatric comorbidities  were included except for autism spectrum disorder and intellectual disability, which might have limitations to perform tests. Considering the high psychiatric comorbidity of ADHD, this research setting reflected clinical reality better. In addition, the effect of psychotropic medication on Q-EEG was excluded by including only drug-naïve subjects.This study should be understood in the context of the following limitations. Firstly, because subjects in the control group were recruited independently, their baseline characteristics were slightly different from those in the patient group. However, by correcting FSIQ, age, and sex, the impact of differences was minimized. Secondly, due to the limited number of participants, anxiety disorders were analyzed as a single category without further subdivision. Consequently, the differences between individual anxiety disorders could not be revealed. Thirdly, this study did not compare children with anxiety disorder but without ADHD. Typically, children who primarily present with anxiety symptoms do not undergo Q-EEG examinations during hospital visits. Since this study was conducted retrospectively, it was challenging to investigate this specific group of children.This study classified children with ADHD based on the presence or absence of a comorbidity for anxiety disorder and compared their Q-EEG values. Children with both ADHD and comorbid anxiety disorder exhibited lower theta power in the central region, higher beta power across all regions and lower TBR across all regions compared to those without comorbid anxiety disorder. In the additional cluster analysis, children with ADHD were classified into four clusters with distinct Q-EEG characteristics, and it was observed that these clusters exhibited differences in the rates of psychiatric comorbidities among the children within them. Specifically, The ratios of children with comorbidities for anxiety disorder within each cluster were significantly different. If studies with prospective design are conducted on these children with both ADHD and anxiety disorder, the relationship between anxiety and ADHD may be further revealed.The original contributions presented in this study are included in this article/The studies involving human participants were reviewed and approved by the Institutional Review Board, Samsung Medical Center. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.CJ and Y-SJ conceived the study. CJ and SO designed the research methodology. CJ organized the patient group data and wrote the initial draft of the manuscript in discussion with IS, YP, and EL. SO organized the control group data. HL and JL provided advice on the analysis method. Y-SJ supervised the entire process. All authors contributed to the manuscript and approved the submitted version.


Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are childhood-onset disorders associated with functional and psychosocial impairments that may persist into adulthood, leading to serious personal and societal costs.This study aimed to examine the socio-economic difficulties, physical and mental comorbidities, and psycho-social vulnerabilities associated with ADHD, ASD, and their co-occurrence among young adults.N=182 individuals received a single diagnosis of ADHD, n=78 of ASD, and n=51 received both diagnoses and were considered the co-occurrence group. Multiple multinomial logistic regression analyses were performed.16 365 families with children born 1997–1999, were involved in the prospective population-based ABIS study (All Babies in Southeast Sweden). A total of 6 233 ABIS young adults answered the questionnaire at the 17–19-year follow-up and were included in this case–control study. Diagnoses of ADHD and ASD from birth up to 17 years of age were obtained from the Swedish National Diagnosis Register. p < .001), experienced worse sleep quality  and concentration difficulties . ASD group were two-fold more likely to experience concentration difficulties  and tended not to have faith in the future , however, showed lesser risk-taking bahaviours . Finally, the co-occurrence was significantly associated with unemployment  and tended to have a higher risk of autoimmune disorders , however, showed a 51% lower risk of stomach pain .In the univariate analyses all three conditions were significantly associated with concentration difficulties, worse health quality, lower socio-economic status, lower faith in the future, less control over life, and lower social support. In the adjusted analyses, individuals with ADHD were almost three-times more likely to have less money compared with their friends (aOR 2.86; All these conditions significantly deteriorated several areas of life. ADHD/ASD co-occurrence is a heavy burden for health associated with several psychosocial vulnerabilities, that shared a similar morbidity pattern with ADHD although showed less risk cognitive and behavioral profile, similar to the ASD group. Long-term follow-up and support for individuals with these conditions over the life course are crucial.The online version contains supplementary material available at 10.1186/s12888-023-05298-3. Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are common childhood-onset neurodevelopmental disorders , 2 generThe phenotypes of neurodevelopmental disorders (NDDs) are heterogeneous, and their complexity is compounded by high comorbidity rates with several conditions  . In prevIt has also been shown that psychological, physical, and sexual forms of abuse and household dysfunction such as substance abuse, mental illness, and violence were associated with risk behaviours like binge drinking and smoking, poor health in general, and a higher risk of obesity, myocardial infarction, and stroke . Risk-taDespite the growing body of research pointing at the impact of ADHD and ASD on health and quality of life, little is known regarding their co-occurrence, which could be associated with greater impairment than a single condition and could be less responsive to standard treatments for either disorder. The current study aimed to examine the socio-economic difficulties, physical and mental comorbidities, and psycho-social vulnerabilities associated with ADHD, ASD, and especially their co-occurrence in early adulthood.This study includes data from the ABIS-Study (All Babies in Southeast Sweden), a longitudinal, population-based cohort study based on data collected from 16 365 families with children born between October 1997 and October 1999 in Southeast Sweden. ABIS-Study aims to investigate how environmental and genetic factors influence the development of immune-mediated diseases, which include ADHD and ASD, where immune mechanisms may play a role . The chin = 6 233), by cross-linking with the Swedish National Patient Register (NPR), containing all hospital inpatients (since 1973) and outpatients (since 2001) International Classification of Diseases (ICD-8 to ICD-10) based on doctor-set diagnoses [n = 182), those who received a unique ASD diagnosis (n = 78), and those who got both diagnoses (ADHD and ASD co-occurrence) (n = 51), according to the NPR, are the three-case groups. The rest of the study population constitutes the control group (N = 5 860)  and Lund University (LU 83–97) in Sweden, and connection of the ABIS registers to National registers was approved by the Research Ethics Committee in Linköping (Dnr 2013/253–32). All methods were carried out following relevant guidelines and regulations.The items from the web survey answered at 17–19 years of age .Comprised questions regarding health quality (ranged from 1 very poor to 5 excellent), exercise until get sweaty (dichotomic), weekdays and weekends screen time exposure  , sleep q, and social support  were included as well. It also involved if the participants had been exposed to serious life events in the last two years, including death or severe illness in the family , unstable family situation , contact with social authorities for support, if they were sexually or physically abused (by an adult or peer), and robbery victim. An index of stressful life events was developed based on the cumulative frequency of the described stressful events .Involved questions about faith in the future, control over life, perceived stress during the last month , and being bullied . If they feel down or depressed, worried or anxious, and concentration difficulties  were also added. Questions regarding job or academic feelings/performanceThe questionnaire included 5 dichotomic items regarding tobacco smoking, e-cigarette use, hashish/marijuana smoking, snuff use, and alcohol consumption. An index with a max. score of 5 points was made and a higher score corresponded to many unhealthier/risk-taking behaviours. The questionnaire also included other 5 items that assessed particpants´perceptions of the above-mentioned risk-taking behaviours . All items ranged from 1  to 5 (extremely harmful), the index had a max. score of 25. Scores from 5 to 15 were considered slightly/moderately harmful, while scores between 16 and 25 were considered extremely/quite harmful.p-value ≤ 0.05 was considered statistically significant, and multiple comparisons between the three case-groups were adjusted using Bonferroni correction . Dichotomous variables were presented as frequencies and percentages, and differences between groups were assessed using the Chi-squared test. A n Tables  and 4. AAll case-groups showed lower participation in the 17–19 years follow-up compared to the controls. Females constitute 36.5% of NDDs cases, 48.4% of ADHD, 37.2% of ASD, and 37.3% of the co-occurrence group, were women. All three conditions reported having less money than friends, while ASD and the co-occurrence groups were more likely to be unemployed  more regularly, lower physical activity, and worse sleep quality than the control group did. ASD group reported having severe illness in the last two years, lower physical activity, and were more likely to be overweight/obese. The ASD group also reported longer screen exposure (> 4 h/day) than the control group. The co-occurrence group was more likely to have a severe illness and autoimmune diseases, tended to be underweight or overweight/obese, and reported worse sleep quality than the control group did. The co-occurrence group also reported longer screen exposure (> 4 h/day) during weekends but was not significant Table .Table 2HAll three case-groups reported having contacted social authorities for support, regular concentration difficulties, lower faith in the future, and a lack of social support, compared with the control group. The ADHD and the co-occurrence groups were more likely to experienced 3 or more serious life events in the last two years, however, those events were more violence-related  in the ADHD group, while death/illness in the family and unstable family situation where predominantly associated with the co-occurrence group. Both groups also indicated worse job or academic feelings/performance, frequent anxious and depressed feelings, and being bullied (did not rich the significance in the ADHD group). The ADHD group also reported greater perceived stress, and less control over life than the control group did. The ASD group, like the ADHD group, reported less control over life  than the ADHD group, and better sleep quality than the ADHD and the co-occurrence group. In terms of vulnerability, the co-occurrence group reported having contact with social authorities to a greater extent than the ADHD group and being bullied more often compared to the ASD group. The ADHD group perceived higher stress levels than the ASD group did. What concerns about risk-taking behaviours, the ADHD group was more likely to smoke e-cigarettes and consume alcohol than ASD and the co-occurrence group, but also used snuff to a  greater extent than the ASD group. Oppositely, the ASD group reported tobacco and hashish/marijuana smoking to a lesser extent than the ADHD and the co-occurrence group. Regarding perceptions of risk-taking behaviours, the co-occurrence group considered smoking hashish/marijuana every week as more harmful than the ADHD group, and alcohol consumption every week than the ASD group . In this line, a study found that adults with ADHD visited physicians 10 times more often and had rates of emergency room visits and hospitalization three times greater than controls . This grOur study has important strengths as our results are based on a large prospective birth cohort from the general population with a follow-up for more than 20 years and the strength of merging doctor-set diagnoses of ADHD, ASD, and autoimmune disorders via the National Diagnosis Register. However, our study also has some limitations. Besides diagnosis and household income, all other data are based on self-reported questionnaires, and therefore they could potentially be subject to recall bias, even though it is unlikely that this can explain our results. The attrition analyses showed that the families of young adults that responded to the 17–19 year questionnaire, have higher household income, higher parental education level, both parents were born in Sweden, and live together. If anything, this makes our observed associations even more obvious, suggesting that socio-economic status, health quality, faith in the future, control over life and social support are significantly compromised in individuals with any of these conditions. In addition, more young females than males participated, but we saw the same trends in both sexes. Future studies should gather information from sources beyond self-reports of individuals with ADHD and ASD, especially if they have psychiatric comorbidities. It might also be warranted to consider pharmacological treatment in subjects with ADHD in relation to different comorbidities.ADHD, ASD, and their co-occurrence significantly deteriorated socio-economic status, health quality, faith in the future, control over life, and social support. The co-occurrence of both disorders is a heavy burden for health, it is associated with several psychosocial vulnerabilities, and shares a similar morbidity pattern with ADHD while a less risk-taking behaviours and perceptions, according to the ASD group. Subjects with ADHD are exposed to different challenges than those with ASD. Understanding the impact of ADHD, ASD, and their co-occurrence allows improving the chance of prevention and development of early treatments with the potential to change the specific trajectory of morbidity later in life.Additional file 1.