Welcome to Johne’s (“yo-knees”), the most important disease that you probably never heard of. It
Cows with Johne's Disease (Photo courtesy of the Crohn's Disease Research Group, Sussex, UK)
is a serious, debilitating and sometimes fatal illness of cattle, goats, and sheep (among other animals), which the livestock and dairy industry is desperate to keep out of the public consciousness, despite the fact that it costs industrial agriculture many millions of dollars every year.
The reason for such industry reticence is that Johne’s disease in livestock is very similar – and possibly even identical – to Crohn’s disease in people, which currently afflicts an estimated 500,000 sufferers in North America alone, causing severe ulcerations of the gastrointestinal tract, immense pain, and loss of appetite and weight, often requiring surgical removal of the damaged bowel. And the big, dirty secret of today’s industrial dairy and meat producers is that animals suffering from flagrant Johne’s disease currently provide milk and meat directly to the American consumer.
In short, we eat lots of very, very sick cows, animals so ill that if you knew you were eating them, you wouldn’t.
As for the connection between Johne’s and Crohn’s, imagine that instead of trying their newly discovered antibiotic on bacteria, Alexander Fleming and his collaborators had injected it into people suffering from the flu. They would have concluded that penicillin wasn’t useful – a legitimate inference under these hypothetical circumstances, but tragically wrong. (Note to nonbiologists: antibiotics such as penicillin – for all their efficacy against certain bacteria – are useless against viruses.)
Now, fast-forward to the present. The received wisdom among physicians is that Crohn’s disease is caused by an “autoimmune” process, in which the body unaccountably turns against itself.
Asked about a possible bacterial cause of Crohn’s, the conventional medical response is a variant on our imagined attempt to cure a viral disease with penicillin: “Been there. Done that. Didn’t work.” Again, a seemingly legitimate inference, but in all likelihood, tragically wrong.
In fact, there is a bacterium strongly implicated in Crohn’s disease: Mycobacterium avium paratuberculosis (MAP). Closely related to the microbe that causes tuberculosis and leprosy, MAP is the critter that produces Johne’s disease – the livestock version of Crohn’s — in cattle and many other animals.
There is growing evidence that the connection between MAP and Crohn’s was ruled out prematurely and erroneously. Thus, early efforts to grow MAP in laboratories used the wrong culture medium (MAP, like the bugs that cause TB and leprosy, is notoriously slow-growing and fussy). Using the right materials, MAP has now been identified in Crohn’s patients and rarely in normal controls. Moreover, early attempts to cure Crohn’s with antibiotics likely failed for a very simple reason: they used the wrong antibiotics! Once again like TB and leprosy, MAP is very difficult to kill.
When it infects human beings, it has been claimed — but not confirmed — that MAP assumes a slightly different form than when it causes Johne’s in goats, sheep, or cattle. But there is no doubt whatever that MAP is the cause of Johne’s disease — and, moreover, MAP samples, taken from human beings with Crohn’s disease, induces Johne’s in goats. It nonetheless quickly became biomedical dogma that MAP did not cause Crohn’s in people, since human MAP could not be cultured in laboratories from Crohn’s sufferers.
In the last 15 years, however, things have changed dramatically.
As already noted, human MAP is a very slow-growing and finicky pathogen, as are most mycobacteria: another form, Mycobacterium leprae, which causes leprosy, even now cannot be grown in laboratory culture. But with suitable techniques, MAP can.
It is possible that Crohn’s is like “cancer,” “pneumonia,” or “heart disease,” which is to say, an amalgam of several different illnesses rather than a unitary phenomenon. Another possibility – much favored by medical and industry guardians of the conventional orthodoxy – is that MAP infection is a secondary, opportunistic consequence of Crohn’s rather than a cause. A similar claim, interestingly, was made 30 years ago by physicians rejecting any causative connection between gastric ulcers and Helicobacter pylori. No one has yet intentionally infected himself by eating a MAP-burger, analogous to Barry Marshall’s famous self-inoculation to demonstrate that H. pylori causes ulcers, but the parallels between MAP/Crohn’s and Helicobacter/gastric ulcers are numerous and instructive.
As to antibiotic treatment, it turns out that MAP is indeed very difficult to kill, just like its close relatives, the mycobacteria that cause leprosy and tuberculosis. But it can be done, when the right antibiotics are used; one successful combination, for example, includes clarithromycin, rifabutin, and clofazimine, and – as when treating leprosy and TB – must be continued for a long time.
Such treatments are long overdue, since Crohn’s disease shows all the hallmarks of a spreading zoonotic (animal-to-human) infection. Its incidence has sky-rocketed, closely paralleling the increase in factory farming and the frequency of Johne’s disease in domestic livestock. If Crohn’s were an “autoimmune” disease, as the old dogma has it, then such a rapid increase would be inexplicable, whereas the epidemiologic picture is consistent with that of a spreading pathogen. A large proportion of U.S. dairy herds appear to be infected with MAP, which is transmitted in milk and is not killed by pasteurization (ultra-pasteurization, on the other hand, with its higher temperature, might do the trick). Moreover, cattle suffering from Johne’s disease, and thus with fully disseminated MAP, are routinely slaughtered and their meat introduced into the food chain.
This is itself an extraordinary fact, worth repeating and emphasizing: Cattle suffering from a severe bacterial infection related to tuberculosis and leprosy, characterized by pussy, intestinal ulcers and overall body wasting, and which may be literally identical to a pathogen that causes a devastating illness in genetically susceptible people, are – right now, as you read this – routinely being slaughtered, and their infected meat introduced into the food stream.
Those who thrilled, in their youth, to the exploits of “The Microbe Hunters,” as portrayed by the likes of Paul de Kruif, might want to prepare themselves for a repeat performance: the glory days of Pasteur and Koch may well persist into the 21st century, involving illnesses not hitherto identified as infectious, and focused especially on zoonotic transmission. If so, genuine concern with homeland – not to mention, kitchen — security will require scientific alertness as well as political courage on the part of microbiologists, veterinarians, public health authorities, the Food and Drug Administration, and the Department of Agriculture, because there’s more going on here than meets the eye. Powerful economic interests have largely succeeded, thus far, in stifling serious consideration of the MAP/Crohn’s connection, and for their own “good” economic reasons. Drug companies as well as gastroenterologists currently treat Crohn’s with infusions of extremely profitable immunosuppressant drugs (whose side-effects are equally extreme), and – most critically – the meat and dairy industry stands to lose literally billions of dollars if forced to eradicate Johne’s or even to segregate sick animals. This is why the livestock industry desperately wants Johne’s to remain below the public’s radar.
Stay tuned, however: If public health authorities ever act responsibly on behalf of their ostensible mandate – public health – the resulting impact will make the recent furor over “mad cow disease” look like a whisper.
23 Responses to The Most Important Disease You Probably Never Heard Of
cj_thorvaldson - January 1, 2011 at 8:31 pm
There are several problems with the theory that MAP causes human disease, particularly Crohn’s. Most notable among these is that even long-term use of anti-mycobacterial antibiotics (such as Myoconda, a triple antibiotic cocktail employed in the management of Crohn’s) fails to cure *anyone*. This is to say, while patients may feel better while on the drugs, once they go off- even after several months or years- the disease may come back.
Secondly, conventional modalities in management of CD such as TNF-alpha drugs (“biologics” such as Humira and Remicade) are EXPLICITLY not for use in individuals with Mycobacterium tuberculosis- a related organism. The reason being that infections + anti-TNF-alpha drugs is a bad, bad idea. However, despite what must surely be tens of thousands of patients, and perhaps millions of doses of anti-TNF drugs, there has yet to be one single report of a patient dying from fulminant MAP disease. I find this very odd, and highly inconsistent with the theory that Johnes = Crohn’s.
Lastly, while it is well-recognized that dietary management of IBD (using “canned” foods, or enteral diets, as well as total parenteral nutrition, in which the patient is fed a complete diet intravenously, sometimes for weeks or months) are effective in providing relief from the disease by inducing remission, it is not at all clear how dietary changes could affect the disease course caused by a facultative intracellular pathogen such as MAP. This is to say, if MAP can feed directly on the cells of the host, what does it matter what food is traveling through the lumen of the gut? There have been tens- perhaps hundreds- of studies demonstrating the efficacy of enteral and total parenteral diets; to deny that food- or some component of food- doesn’t play a role in CD would be to deny a substantial body of literature. This makes it very difficult to explain how MAP could be responsible for CD.
Between these three elements alone- the inexplicable failure of anti-mycobacterial antibiotics; the absence of ant-TNF-alpha-related mortality from fulminant MAP; the efficacy of enteral and total parenteral nutrition in the management of what is purportedly a facultative intracellular pathogen- it is difficult to argue that MAP must cause CD.
Very similar, yes. But there remains a great chasm in that leap from Johnes’ to Crohn’s.
Still, we should endeavor to control MAP in cattle. Nasty disease. Ugh.
dcruton - January 2, 2011 at 12:37 pm
Regarding eradication and “cure”. This argument was specifically addressed in the article. In short, causation is not proven by eradication and normalization of disease pathology. Koch’s postulates are the test for causation in infectious disease and Chiodini arguably fulfilled them, and Barash mentions this in the article: reference to baby goats. Nonetheless, improvement of disease symptoms with a correlating reduction in bacterial load would SUGGEST a causative role for MAP in CD (Relmans guidelines), and this has in fact been demonstrated in one patient (though preliminary given no validated assay). Regardless, and to re-iterate what Barash already said, “failure” to “cure” is simply not proof of MAP not causing CD. Tuberculosis is currently not “cured” in all patients — 80% will “cure” their TB infection in 12-15 months using standardized doses and appropriate drugs. No one knows which drugs, for how long or in what doses would be required to achieve an 80% cure rate for MAP. Moreover, this argument about cure is related to what was already mentioned in the article, which is that CD is a syndrome. Therefore there are different causes of CD because CD is in fact different diseases. So not all CD patients given anti-mycobacterial drugs should be cured because not all CD is caused by MAP. Also, it is possible that chemotherapy on its own is not sufficient to “cure” every intestinal mycobacteriosis every time – surgical intervention is often needed, like is required with hypertrophic intestinal TB. So until there is a validated assay for MAP’s detection, and until there are validated drugs and doses and durations for eradicating MAP in humans, the “no cure” argument is entirely misplaced. Therefore, it appears that the “failure” of anti-mycobacterial (NOT anti-MAP) antibiotics, is entirely explicable.
Regarding anti-TNF therapy. There is no evidence that MAP should be considered as likely as TB is to disseminate when anti-TNF therapy is administered. MAP and TB are qualitatively different mycobacteria. And in the case of Mycobacterium avium species, there is no published increase risk of M. avium disease when anti-TNF therapy is administered. Seeing as MAP is of the M. avium species, it would seem more prudent to use the M. avium data regarding what MAP might do when anti-TNF therapy is administered rather than the M TB data. MAP is the slowest growing organism of culturable mycobacteria. Nonetheless, and counter intuitively, infliximab has even been used to treat paradoxical reactions in complicated cases of TB infection.
Regarding enteral and total parenteral nutrition. I don’t see how their efficacy could disprove a causative role of MAP in SOME Crohn’s. No one knows exactly why those therapies can be transiently effective. Assuming, perhaps, it is because they reduce the antigenic stimulants making their way through a damaged bowel wall. The bowel wall, however, was damaged (under the MAP theory) by the initial immune response directed toward MAP. The two theories can co-exist. Under this co-existence, it would seem entirely consistent with the MAP theory that reducing the antigenic burden through nutritional interventions would result in a reduction of disease symptoms – this is likely related to the difficulty of treating intestinal mycobacterioses with just chemotherapy. The immune response directed toward MAP causes the remote lesion sites and then the fecal stream perpetuates the inflammatory process. TPN and EN may have a very important role in the medical management of the disease (especially for the increasing numbers of pediatrics who should be spared steroids), but they do not preclude a mycobacterial cause.
judith_lipton - January 2, 2011 at 4:01 pm
Regarding the first set of comments, by cj_thorvaldson, I would like to note that I happen personally to be a person who seems to have been “cured” of Crohn’s Disease, by all measurable parameters, on a protocol derived by Dr. Thomas Borody of Australia, using antibiotics specifically targeting MAP as the putative cause of Crohn’s.
I am a 59 year old physician. In 1986, I was diagnosed with what seemed to be ulcerative colitis, with a mild fluctuating course, that abruptly changed in March, 2004. I became septic from penetrating ulcers of my entire colon, and was clearly diagnosed with Crohn’s Disease, much to my surprise. Initial treatments with prednisone, azathioprine, and Remicade did help, and I was able to leave the hospital. However, I could not sustain every 8 week doses of Remicade. The Crohn’s relapsed in October, 2004, and I was again hospitalized with sepsis. While I was recovering from that episode, still in bed, still at home and not working, I happened to read Dr. Saleh Nasser’s seminal article in The Lancet about culturing MAP from the blood, biopsy specimens, and breast milk of people with Crohn’s Disease, and the possible connection to Johne’s. I immediately contacted Dr. Nasser, and also Dr. Robert Greenstein in New York, because I had raised fiber goats as a hobby, and one of them had become very sick and died of a wasting disease in the winter of 2003. I thought that perhaps I caught MAP from that goat.
Dr. Greenstein was kind enough to put me in touch with Dr. Borody, and Dr. Borody was kind enough to speak at length with my internist in Seattle. She agreed to put me on the mix of medicines that Borody suggested, including ethambutol, clofazimine, clarithromycin, rifabutin, and asacol. I began the antibiotics on December 10, 2004. In truth, I had a final Remicade shot early and January 2005, and then stopped Remicade and prednisone completely.
Stopping the prednisone lead to adrenal insufficiency, and I needed periodic physiological doses of hydrocortisone (note – not prednisone!) to maintain my blood pressure and homeostasis. However, I never again had any symptoms of Crohn’s Disease or colitis of any sort. Nothing. Nada.
In June 2008, I had repeat colonoscopy, showing complete healing of my bowel. Inflammatory parameters are low to normal. I have had no side effects. I have traveled extensively, from Prague to the Isle de Ometepe in Nicaragua, and had no GI problems, not even traveler’s diarrhea.
At this point, Dr. Borody suggested going off the antibiotics, and I have been off since May, 2010.
I now live part time in a remote area of Costa Rica and eat native foods, with no GI difficulty at all.
It turns out that I probably did not catch MAP from my sick goat. Her daughter’s necropsy was negative, and the time frame was wrong. She died near Christmas, 2003, and I became very ill in March 2004, and that is much too short a time for MAP to infect someone and create severe disease. But if I had not known about Johne’s, I never would recognized the intellectual connection that Drs. Naser and Greenstein had pursued. For more information, I suggest that interested persons look at the web sites johnes.org, and thecrohnsdiseaseinitiative.com. You might also be interested in the report by the American Society of Microbiology, on MAP as a possible cause of Crohn’s Disease, 2008.
My story has unique elements, but it is not unique I personally know of at least a dozen other people who have been treated by Dr. Thomas Borody, Dr. William Chamberlin of El Paso, Texas, and by Dr. John Hermon-Taylor in the UK, with full and compete remissions of their inflammatory bowel disease.
So – point #1 – there are people who have been “cured” of Crohn’s with antibiotics for MAP.
Point #2 – Even if every single piece of evidence has not accrued to the effect that MAP causes Johne’s which causes Crohn’s in susceptible individuals, how can anyone justify eating cows who are sick with Johne’s Disease? I challenge such people to feed MAP burgers to their grandchildren for a few years, to test whether this food is safe. We should not be eating sick animals! This is self evident, and was evident 5000 years ago when the rules of kasruth were developed – people should not eat sick animals. Duh!
Point #3 – the payoff to the meat and dairy industry for minimizing this public health risk is huge, comparable only to the payoff to big pharmaceutical companies who make huge profits off of immune suppressing medications. If the house of cards falls down, and sick animals are taken off our dinner tables, and people with Crohn’s are treated with relatively inexpensive antibiotics, the losses to the meat and dairy industry and big pharma will be notable. However, gains in public and animal health will be even greater. The problems with Crohn’s and Johne’s Disease make mad cow look trivial, because the numbers of affected individuals, many of them children, are much larger than the victims of prion diseases, and are growing yearly.
This is a preventable epidemic, and requires the best minds in science and public health to stop it.
david_crichton - January 2, 2011 at 8:57 pm
Email, dated 2005, from Morris Potter of the FDA to Jeff Farber of Health Canada, regarding Health Canada’s yet to be released risk profile on MAP:
“I read through the risk profile and have drafted my reaction. Please look at the drafts to make sure that I’m covering the points you need and am not saying something that will lead you where you can’t go.”
Where can’t the government departments, which are supposed to look out for our health and safety, go?
liz_jaeger - January 3, 2011 at 12:58 am
I am the mother of an 18-year-old daughter who was diagnosed with Crohn’s in 2006. In 2009, a series of events threw her into a serious flare that we could not get turned around. Her GI doctor was at his wit’s end, and we knew we would be facing lifetime Remicade and/or surgery if something didn’t happen soon. As a last resort before turning to Remicade, he decided to contact Dr. Thomas Borody in Australia concerning his protocols for anti-MAP treatment. After their discussion of my daughter’s case, we decided to put her on the anti-MAP multi-antibiotic therapy that Dr. Borody prescribes for his patients and described by Dr. Lipton above. She began the therapy one year ago, Jan. 3, 2010, the same day she had surgery for a temporary ileostomy to allow her bowel to rest and heal.
The first two months of last year were progressive, but slow-going. However, by the first of March, her health just took off and has sky-rocketed ever since. That is the pattern observed by her GI doctor with his other patients he has since started on this therapy. The third month is when big improvements begin to show. We initially were told that she would probably have the ileostomy for 9-12 months. After just 5 months on the Anti-MAP therapy, we saw her GI and surgeon, and they were blown away by her progress. They decided to reverse the ileostomy immediately, which was the first of June. They simply could not believe the improvement. She went from having the worst peri-anal Crohn’s destruction any of the hospital staff and doctors had ever seen, to miraculous improvement (their description). Every medical staff person we saw was in sheer amazement at her complete turnaround. I didn’t know it back in January, but the surgeon had told the nurses that if something didn’t turn around, my daughter would not have an anus by Christmas 2010. He was very distraught at the idea of performing that surgery on a 17-year-old girl. Many of the nurses that had seen her 5 months prior didn’t even recognize her during the reversal hospitalization. She has now doubled her weight over what she weighed just over a year ago and has a SED rate of 1 and CRP of .10, which is virtually unheard of in Crohn’s patients. We are only one year into treatment, and my daughter has not a smidgen of Crohn’s manifestation anywhere. She has labs drawn every two weeks, which have only continued to improve as time goes on, and she continues to gain weight, most of it lately being muscle because she has the energy to exercise several days a week.
I personally will not wait for the government to get around to taking care of our health. Just watch the videos, “Food, Inc.”, “King Corn”, “Raw Milk, the Whole Truth”, and “The World According to Monsanto”. The first three are in libraries and the third is on the internet. After watching these, you will definitely think twice before purchasing meat at the grocery store. We have started buying all of our meat, poultry and dairy products from small family farmers whom we trust. Yes, it is more expensive, but I do not trust the United States commercial meat and dairy industry. The cost of responsibly-raised food will never compare to the fortune I have spent fighting my daughter’s disease for the last 5 years. As her GI doctor says, “This disease bankrupts people”.
The thing that gets me the most is how it is virtually impossible to find doctors who are willing to recognize the validity of the anti-MAP therapy, and as my daughter’s GI doctor says, even recognize MAP as a valid Crohn’s diagnosis. I have to travel nearly 12 hours one way, crossing 5 states to take her to this doctor that is willing to prescribe the drugs. We were finally able to get a local GI to go along with the treatment, but that was in March, after she was starting to turn around and the antibiotics obviously were working. He is now on board with us, but I’m not sure he is even suggesting it to any of his other patients yet. There is not a single doctor at the local children’s hospital in our large metropolitan city that will consent to this therapy. I have attended Crohn’s symposiums and lectures when someone has brought up questions about MAP, and every single forum doctor has discredited not only any anti-MAP therapy, but even the possibility of Crohn’s having a bacterial origin. They always have the same answer, “We don’t know what causes Crohn’s, but we know it isn’t bacterial.” When I posed that question to Dr. Borody myself, he told me, “We KNOW that Crohn’s is a bacterial disease in most patients.” If this is known, then why aren’t we treating patients for it in the United States?
There are answers available. If you will take the time to watch the aforementioned videos, you will know that the answer lies within the political beauracracy of the FDA which is protecting tainted food and money-making drug empires. There is a huge conflict of interest between FDA officials and the meat, dairy, and drug industries which is preventing this problem from being addressed. That, Mr. Crichton, is where the government cannot go, at least in the United States.
katisumas - January 3, 2011 at 11:23 am
Thanks David Barash and the commentators for sharing invaluable information…
cwinton - January 3, 2011 at 12:27 pm
One can only wonder what other dirty little secrets are hiding out there in greed-land. It is unconscionable that the FDA, who is supposed to protect the integrity of our increasingly mass-produced food supply, has yet to take action to ensure that such obviously sick animals are removed from the food chain, putting who knows how many at risk.
mycomike - January 3, 2011 at 2:04 pm
I commend Dr. Barash’s article for bringing this crucial issue to light. It’s a fairly simple concept: “Healthy food comes from healthy animals”. And, it is a simple truth that animals with paratuberculosis are not healthy. However, producers have no mandate from regulatory agencies such as the FDA or USDA to handle MAP-infected animalsor their products differently. To do what many suggestion is “the right thing” today and keep MAP-infected animals and products out of the food chain, would come totally at the owner’s expense; an unfair expectation for producers already on the ropes financially.
Veterinarians have the tools and the knowledge to assure that foods of animal-origin come from healthy animals, whether they live on large or small farms. Note: the “organic” label or “locally produced” label verify nothing about animal health.
Better animal health programs come at a cost and those costs should be shared by producers, processors, and consumers. For paratuberculosis today, a decision by food safety regulators to exercise the “precautionary principle”, label MAP as a potential zoonotic agent, and adopt measures to limit as much as possible the levels of MAP contamination of raw milk and meat would go far to protect the coming generations of children from MAP exposure, possible infection, and potentially Crohn’s disease. See the white paper by TAFS for more: http://www.tseandfoodsafety.org/paratuberculosis.html
Lastly, before subscribing to theories of big agribusiness conspiracy or influence peddling with government regulators, look to NIH who does not count MAP as a human health concern worthy of research funding and medical gastroenterologists who by and large tell patients to ignore the crazies who believe MAP is a human health concern.
moihassan - January 3, 2011 at 3:57 pm
You should be a guest at Bill Mahar’s show.
recmlc - January 3, 2011 at 4:18 pm
Terrific article
david_crichton - January 4, 2011 at 10:32 am
Make what you will of the following quote from results of an Access to Information Request made to Health Canada regarding the preparation of its draft risk profile on MAP and related research priorities. I, for one, believe it demonstrates how economic discourses predominate govern-mentality decision-making processes.
“On Wed, Jun 11, 2008 at 1:18 PM, Jeff Farber [Director of the Bureau of Microbial Hazards] wrote:
Hi Mark,
I know you were worried about the wording/context in terms of us putting the MAP research priorities up on the HC Web site. Would you possibly be willing to provide us some preamble/wording that you would be comfortable with us using, when we post the research priorities?
Thanks.
Jeff
On Thurs, Jun 12, 2008 at 8:18 AM MST, Mark D. Klassen Director of Technical Services of the Canadian Cattlemen’s Association & Beef Information Centre replied:
Hello Jeff,
I think the primary concern is around the perception that anything that is being researched is likely risky. This is of course the challenge of being proactive. If you could send me a copy of the research priorities text to be posted I will do my best.
Mark”
Too bad the human discourses don’t seem to have quite the same direct influence, weight or urgency with HEALTH Canada; surely patients are “stakeholders” too? But their costs are so abstract and difficult to quantify and put in a cost-benefit analysis. Nevertheless, I wonder how Gloria http://www.youtube.com/watch?v=7a2CzDZ_te4&feature=fvw and Caden http://www.youtube.com/watch?v=B3L1oObY_Nk&feature=related would word the research priorities? Maybe between emails with the Canadian Cattlemen’s Association or Les Producteurs Laitiers du Canada, Leona Aglukkaq and Jeff Farber and the gang could drive ten minutes from their offices to visit the epidemic of pediatric Crohn’s disease at the Children’s Hospital of Eastern Ontario? Consider it a PD Day.
azgrrl - January 4, 2011 at 11:31 am
Agribusiness is destroying farmers and the health of many. Completely agree that healthy foods come from healthy animals and as a nation, we should insist on ethical treatment and standards and stop factory production that devalues the land surrounding it as well as the decrease in small family farms. The Untold Story of Raw Milk by Ron Schmidt is a wonderful read with factual evidence regarding the benefits of raw milk and reasons to know your local farmer and buy locally from farmers who truly follow tested and true methods of animal husbandry.
adamreed - January 4, 2011 at 4:52 pm
There is a fairly easy test of the hypothesis that MAP from milk or meat causes Crohn’s in humans: what is the incidence of Crohn’s in “vegans?” If the hypothesis is true, then the incidence of Crohn’s in people who abstain from milk and meat should be, with other factors controlled, significantly lower than in the general (milk-drinking, meat-eating) population. If such a result were in evidence, we would have reason to be worried. Without evidence, all one has is arbitrary speculation…
cdresearcher - January 4, 2011 at 8:13 pm
For more information on this subject see:
http://www.thecrohnsdiseaseinitiative.com
To help support research in this area go to and vote (EVERY DAY):
http://www.refresheverything.com/crohnsd
and
http://www.refresheverything.com/crohnsd2
david_crichton - January 4, 2011 at 9:10 pm
hey adam, that’s a possibility. unfortunately however, and though milk and meat are often the most suspected sources of transmission, there are other theoretically possible sources as well from environmental cycling: frozen vegetables, vegetables, municipal water supplies, one’s own well contaminated by water tables, aerosols, canned foods, household pets to humans… think of e-coli outbreaks transmitted through tomatoes and not just hamburgers. there is data confirming clusters of Crohn’s within spatial areas: is this because of people all buying the same contaminated meat from one farm or because a nearby water supply was contaminated? though no one knows for sure if these other sources would transmit sufficient doses of MAP, or if these other sources actually do contain MAP or if it is sampling errors based on the use of tools which might be too sensitive/not specific for MAP. what is a minimum infective dose for humans anyways? however, what is thought, is that MAP is not an environmental organism. meaning, it needs to replicate inside a host’s cells. and because the main reservoir for MAP is thought to be coming from cattle, that is where the biggest prevention efforts should be directed; limit MAP on farms, and hopefully limit it in those other potential sources as well. the vegan hypothesis could be explored but it seems like it would be quite complicated.
adamreed - January 4, 2011 at 9:22 pm
David: Regardless of complicating factors, a significant difference in the incidence of Crohn’s between Vegan and conventional (milk-drinking, meat-eating) would be predicted by the hypothesis. Surely, for all the time and effort spent spinning evidence-free bullshit on either side of the question, why doesn’t someone cut the hot air and get the numbers?
david_crichton - January 4, 2011 at 9:47 pm
is that bullshit MAP positive or negative by IS900 or culture?
paradime - January 5, 2011 at 7:24 am
Having read the first response to the Barash piece as a gastroenterologist with a large Crohn’s practice and 15 year experience with Anti-MAP therapy it makes me sad there are still people out there who, without apparent scientific background, are willing to destroy a future therapy for which so many children and young people are waiting, with internal, peri-anal and recto-vaginal fistulae discharging, undergoing surgery etc …targeting an infection which has not previously been seriously targeted. All reminiscent of another chronic infection of the completely other end of the small bowel, the duodenum, which results in similar ulceration, stricture, perforation and obstruction…Helicobacter pylori , whose role in ulcer disease suffered from similar inane comments…often by qualified physicians…It took more than 20y for our “Triple Therapy” for H pylori to be accepted as standard of care for ulcer disease, yet causality of DU by H pylori has never been proven by Koch’s postulates [only gastritis is proven].The arguments below seem to have superficial substance, and will unfortunately deceive the majority of readers, who do not have the scientific knowledge to see the blunders in this response. Smacks of the Dunning-Kruger Effect [yes, please Google...may be instructive].
I will address the three points made by the writer of this first response…his/her criticisms repeated labelled with capital A,B, C,D…followed by my response
A.There are several problems with the theory that MAP causes human disease, particularly Crohn’s. Most notable among these is that even long-term use of anti-mycobacterial antibiotics (such as Myoconda, a triple antibiotic cocktail employed in the management of Crohn’s) fails to cure *anyone*. This is to say, while patients may feel better while on the drugs, once they go off- even after several months or years- the disease may come back.
This aged argument holds no water in that failure to CURE or relapse of the disease is never an argument the infection is not causal. That is like saying “Triple Therapy” for HIV does not cure *anyone* hence the HIV virus does not cause AIDS {efavirenz, tenofovir, and FTC}! When patients come off this triple therapy HIV recurs. I guess this writer will now tell all these HIV patients to stop their anti-HIV Triple Therapy [Is it called HIVconda?] and perhaps ultimately allow them to die ? Dunning-Kruger may have had insight. Secondly, this argument has no scientific basis as the Author probably relies on the only publication on the anti-MAP triple combination by Selby et al [Note Myoconda was not used by Selby] who never tested for MAP, employed low drug doses, used 1/2 dose, double-encapsulated Clofazimine which did not dissolve in the majority of patients so being unavailable to treat the presumed MAP, and he did not carry out the trial to GCP standards as he failed to replace this large cohort of maltreated patients with fresh recruits. Myoconda has a much better profile and is there is now a small group of patients off all therapy without relapse for 2-6 years..It may be worth noting Barash did not suggest any therapy holds the answer, but his was a call to do something to cull this epidemic. We do need better therapies both anti-mycobacterial, immunostimulants [as Crohns is most likely to be an immune dysregulation where our cells, perhaps due to a genetic predisposition (eg CARD15) are unable to clear intracellular maycobacteria, though most of us understand the word 'autoimmune' and I guess this why the Author used this term ), and perhaps special probiotics, to fight the disease and help the suffering kids].
B.Secondly, conventional modalities in management of CD such as TNF-alpha drugs (“biologics” such as Humira and Remicade) are EXPLICITLY not for use in individuals with Mycobacterium tuberculosis- a related organism. The reason being that infections + anti-TNF-alpha drugs is a bad, bad idea. However, despite what must surely be tens of thousands of patients, and perhaps millions of doses of anti-TNF drugs, there has yet to be one single report of a patient dying from fulminant MAP disease. I find this very odd, and highly inconsistent with the theory that Johnes = Crohn’s.
I clearly understand why the author finds this ‘odd’. The simple answer is that we poorly understand the nature of MAP and treatment of infection-associated inflammatory response. In TB [Mycobacterium tuberculosis], we treat the infection without the use of steroids otherwise TB may disseminate (it has cell walls ) with death due to miliary TB. HOWEVER, in CNS TB we do use steroids to limit nerve damage. In Leprosy [Mycobacterium leprae], the nerve inflammatory response to the M leprae is so intense at times that we routinely use steroids, azathioprine, and anti-TNF-alpha biologics have been used. In other words, in some Mycobacterial infections the inflammation is particularly important and both anti-Mycobacterial and immune-suppressants are used. Interestingly no miliary Leprosy occurs with steroids and even azathioprine and anti-TNF’s! Looks like classic TB is the ONLY one where we cannot use anti-TNF’s…surprise surprise…! Well, MAP is again different. It resides almost exclusively intra-cellularly without a cell wall. It has no capacity for miliary dissemination in man, as it cannot survive outside the cell. So anti-TNF use is unable to cause miliary dissemination of MAP in Crohn’s. You are picking on the wrong bug! Wrong analogy. Unscientific argument. You might have asked it’s ‘very odd’ H pylori and so many other bugs which infect a Crohn’s patient don’t disseminate…Because they are unable to.. Incidentally, from FDA published figures you might be interested to know our wonderful anti-TNF ‘biologics’ rate as one of the most deadly prescribed drugs, killing well over 5,000 American’s to date. And, no cure in *anyone*!
C.Lastly, while it is well-recognized that dietary management of IBD (using “canned” foods, or enteral diets, as well as total parenteral nutrition, in which the patient is fed a complete diet intravenously, sometimes for weeks or months) are effective in providing relief from the disease by inducing remission, it is not at all clear how dietary changes could affect the disease course caused by a facultative intracellular pathogen such as MAP. This is to say, if MAP can feed directly on the cells of the host, what does it matter what food is traveling through the lumen of the gut? There have been tens- perhaps hundreds- of studies demonstrating the efficacy of enteral and total parenteral diets; to deny that food- or some component of food- doesn’t play a role in CD would be to deny a substantial body of literature. This makes it very difficult to explain how MAP could be responsible for CD.
This is a well known clinical observation which casts absolutely no concerns about etiology as suggested above. If ,as most experts agree, Crohn’s is caused by an ‘immune dysregulation’ then the above argument would be equally critical of such an etiology and in fact would be suggesting that a dietary component causes Crohn’s. In fact, the dietary improvement is in symptoms is thought to be due to the control of the associated ‘IBS’ or flora superinfection which frequently co-exists in patients given so many antibiotics. Remove some food components [patient on diet] and absence of such growth nutrients or ‘food’ for small[SIBO] and large bowel bacterial overgrowth improves symptoms in IBS, Colitis and Crohn’s. In fact, most Crohn’s patients who place themselves on a gluten-free diet also improve! This in no way proves they have Celiac Disease but rather states they have bacteria in their lumen which ‘starve’ on the diet, bacterial numbers fall, reduced ‘toxins’ no longer cause eg diarrhea and such improvement leads uninformed people to conclude Crohn’s has a dietary cause! Our writer of this response will similarly have us believe that duodenal ulcer was not caused by H pylori infection because such patients admitted to hospital on a milk/cream diet used to heal their ulcers…..!!!!!!!!!!
D.Between these three elements alone- the inexplicable failure of anti-mycobacterial antibiotics; the absence of ant-TNF-alpha-related mortality from fulminant MAP; the efficacy of enteral and total parenteral nutrition in the management of what is purportedly a facultative intracellular pathogen- it is difficult to argue that MAP must cause CD.
The explanations for these ‘three elements alone’ suffice to show how ‘great a chasm’ there exists between the informed and uninformed, who will nevertheless use outdated arguments without addressing the remaining problems. For example, given our knowledge of the struggle for development of drugs for TB, how do we better develop drugs to kill intracellular MAP? How do we immuno-stimulate Crohn’s patients intracellular environment to reverse their immune deficiency? Given the published data that all MAP is pathogenic and Koch’s postulates having been fulfilled for its causality in Crohn’s, what efforts should we undertake to obtain grant support to better research this area especially as the available biologics are but of transient help.
mycomike - January 5, 2011 at 2:44 pm
Adam: The vegan test is an interesting approach to the MAP-IBD hypothesis. However, there are three problems. First, as pointed out by Mr. Crichton, there are other plausible modes of MAP exposure than just meat and milk (EPA found PCR evidence of MAP in >90% tap water in Ohio; Beumer, Appl.Env.Microbiol 21:7367, 2010). Second, the USA has no database reflecting an accurate count of IBD patients, much less their diet. Third, since epidemiological evidence indicates that the environmental “trigger” for IBD happens in early childhood, the vegan population studied must be vegan from birth.
Related to other dietary discussions, anything that “makes life easier” on a damaged bowel will likely make a patient feel better. It will not likely alter the course of a MAP infection deep in the bowel wall and regional lymph nodes. Cows with Johne’s disease will often stop having diarrhea by changing their diet, however, their MAP infection remains uncured.
recmlc - January 7, 2011 at 12:35 pm
When bashing anti-mycobacterial antibiotics please check out the following studies done in animmals in which MAP is the known cause of disease and the drugs are pallative only
Slocombe, R. F. 1982. Combined streptomycin-isoniazid-rifampin therapy in the treatment of
Johne’s disease in a goat. Can. Vet. J. 23:160-163.
St.-Jean, G. 1996. Treatment of clinical paratuberculosis in cattle. Vet. Clin. North Am. Food
Anim. Pract. 12: 417-430.
St.-Jean, G. and A. D. Jernigan. 1991. Treatment of infection in ruminates. Vet.
Clin. North Am. Food Anim. Pract. 7:793-804.
recmlc - January 7, 2011 at 12:42 pm
FOr cures of cattle with early-staged disease see
Virulence 1:3, 145-155; May/June 2010;
paradime - January 9, 2011 at 12:41 am
Hi recmlc :
You made a very important point. If we can barely treat and,? rarely cure Johne’s in animals where there is no question of causality and MAP is so readily detectable, suppressive/palliative therapy in humans with available anti-MAP is impressive, and approaches a ‘miracle’ in those few we think might have achieved a cure….though much more time needs to pass.
One could look at the ‘flipside’ as one microbiologist commented,… since there are no non-pathogenic MAP we should ask that until scientific studies can demonstrate MAP not to be pathogenic in man, it should always be treated…as we do with syphilis and H pylori etc etc
olyoly - February 4, 2011 at 2:02 am
My son was diagnosed for Crohn’s in Nov. 2001, he was 13 years old. He needs to be admitted in the hospital every 5 or 6 months, he been treated on prednisone, azathioprine, and pentaza. My son also needs to go every 3 months to the Emergency Room for blood transfusion because his hemoglobin go down to 4.1, and at this point, his GI wants to treat him with Remicade, but my son refused that treatment, he wants to try anti-MAP, and we agree with Dr. Lipton about anti-MAP. I been trying very hard in order for my son to receive a treatment of anti-MAP and I have not received any answer. I need help on this, I BELIEVE that Micobacterium Avium Paratuberculosis-MAP is the cause of CROHN’s disease. I would like to find a solution to EXTERMINATE with that BUG!!!! my son is a young men suffering and getting depressed day by day. If some one has any information for me, my e-mail is olindabello@msn.com