Dr. Franco and Antibiotic Treatment

Dr. Franco and Antibiotic Treatment

     The idea that rheumatic diseases might be triggered by infectious microorganisms first occurred to Dr. Franco when he was still in medical school. While learning about tropical medicine, he studied patients with tropical infectious diseases such as typhoid fever, brucellosis, and shigellosis. Along with fever and gastrointestinal distress, these patients also exhibited symptoms of joint involvement. This piqued Dr. Franco's curiosity because the joint involvement was to a degree that it resembled other arthritic ailments.
      For instance, patients with typhoid had many joints involved and reminded Dr. Franco of early rheumatoid arthritis or systemic lupus erythematosus while patients with brucellosis had spine and other joint involvement similar to that of ankylosing spondylitis. Patients with shigellosis had inflammation of the sacroiliac joints in keeping with reactive arthritis. Since there were those similarities and since no bacterial culprit could be isolated from patients with rheumatoid arthritis, Dr. Franco reasoned that perhaps R. A. was caused by a viral infection. It wasn't until years later that he would find out how close he was to the truth.
      Throughout his rheumatology fellowship in New York during the late '70s, Dr. Franco continued asking questions and searching for answers. He scoured the medical literature for all that was written about the interrelationship between infections and rheumatic diseases. He learned everything he could about the microorganisms that cause bone and joint disease, namely bacteria, viruses, fungi, parasites, and Mycoplasmas.
Bacterial infections were known to cause septic and reactive arthritis. Multiple viruses were implicated in arthritis while some frequently caused it. Species of fungi were known to be pathogens that could lead to arthritis and parasites had been associated with joint and bone lesions. The role Mycoplasma played in arthritis, however, had been debated for years.
      Mycoplasma species differ from bacteria in that they are very small and lack a cell wall. They are the smallest organism able to survive outside of cells. They enter the tissue of different organs frequently penetrating mucosal cells and cause injury to the cell membranes. Once damage to the body occurs, the body frequently is unable to clear the Mycoplasma from the site of infection without antimicrobial treatment.
      With all that was known about the causes of rheumatic diseases, Dr. Franco was frustrated and baffled that the treatments for these ailments were not more effective. While practicing rheumatology in the '80s, he had seen some success with the disease-modifying antirheumatic drugs (DMARDs). Ever curious, he wanted to know why. What did they have in common? He soon discovered that the common thread in DMARDs, at that time, was the fact that some of them possessed antimicrobial properties including gold salts, sulfasalazine, penicillamine, and hydroxychloroquine. That observation led him to presume there must be something to the connection between certain DMARDs antimicrobial properties and their success against rheumatoid arthritis and the effectiveness of antimicrobial treatment on ridding the body of Mycoplasma.
      Then, in 1988, he read, "The Road Back" by Dr. Thomas M. Brown and Henry Scammell. In their book they theorized that Mycoplasma was a bacteria that behaved as a virus. When Dr. Franco read that, it took him all the way back to his med school days. That would explain why no bacterial culprit could be detected in patients with rheumatoid arthritis. The bacteria were camouflaged, hiding if you will. They couldn't be isolated because they were residing intracellularly, like a virus.
      Dr. Franco realized the implications of this. He knew they were very close to a breakthrough in understanding how Mycoplasma may cause rheumatoid arthritis. If the theory proved correct, then perhaps a better, more effective way to treat R. A., maybe even reverse it, was just around the corner. He was very anxious to meet with Dr. Brown and discuss the possibilities so he called the Arthritis Institute.
Unfortunately, he was too late. Dr. Brown had recently passed away.
      Dr. Franco was stunned. He fully recognized the enormous contribution of Dr. Brown and his research in the field of rheumatology. The impact of that work could affect millions. Dr. Franco thought it was only right that that vital work continue. It was then that he decided to put Dr. Brown's theory into practice.
Starting in 1988, Dr. Franco enrolled approximately 150 patients with rheumatoid arthritis on the antibiotic treatment. He began by prescribing low dose tetracycline. Later he added other antibiotics, including doxycycline, erythromycin, and minocycline.
      With this treatment, he noticed that most patients would initially worsen, due to the development of the Herxheimer's Reaction. However, this would pass after a few weeks or months and thereafter improvement would ensue. Progress was usually slow, except with patients who had rheumatoid arthritis for a short period of time and an even faster recovery in younger individuals.
      After seven years of using this treatment modality, the overall results were very encouraging. In order to confirm this, Dr. Franco reviewed, retrospectively, the cases of 255 patients with R. A. who had been treated over a period of between six months and seven years. The data confirmed that patients with R. A. improved on various antibiotics.

     The results show that 78% of patients had a better than 20% improvement, and 53% had a better than 50% improvement. 22 % of the patients did not improve. Other findings were as follows:

  1. The earlier the treatment is started in the course of the illness, the better the results.
  2. The milder the disease, the better the response to the antibiotics.
  3. The longer the duration of treatment, the greater the improvement.
  4. The best responders were, on average, younger patients.
  5. Frequently patients worsen initially for a few weeks before noticing improvement due to Herxheimer reaction.
  6. The most effective antibiotics were the combination of oral Minocycline and intravenous Clindamycin.
  7. Tetracycline, especially at low doses, was not as effective.
  8. The incidence of side effects was minimal and usually mild, even in patients followed for several years.

     Dr. Franco concluded that the antibiotics tested were effective and safe for rheumatoid arthritis patients. These antibiotics should be a valuable addition to the armamentarium for the treatment of rheumatoid arthritis, especially in view of the fact that disease-modifying antirheumatic drugs were often not effective or tolerated for long periods of time.

      The treatment that Dr. Brown advocated for years, and that Dr. Franco continues to advocate now, is promising. It is based on a different perspective that the disease is potentially curable. So, there is hope for patients with rheumatoid arthritis and other rheumatic diseases. Most rheumatologists agree that the treatment of patients should be individualized, preferably using less toxic drugs. Because of our experience at the Arthritis Center of Riverside, we are refining treatment modalities based on a better understanding of how infections, especially chronic and hidden infections, trigger the immune system to partake in the ensuing damage of joints and other target organs. We find it is equally important to strengthen the immune system, to neutralize the inflammatory response, and to repair damaged tissue, preferably with non-toxic agents such as nutritional supplements.



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Arthritis Center of Riverside
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     *The information in this website is not intended to replace a rheumatology textbook nor be a complete update of the rheumatology scientific literature.  It should not be misconstrued as personal medical advice.  Rather, it portrays Dr. Al Robert Franco's interests in the field of rheumatology, namely, the interrelationship between infections and rheumatic diseases and how this applies to the treatment of arthritis.