Prolonged Lyme disease treatment: enough is enough

Lyme Disease Patient Trajectories Learned from Electronic Medical Data for Stratification of Disease Risk and Therapeutic Response

Lyme disease (LD) is the most common tick-borne illness in the United States. Although appropriate antibiotic treatment is effective for most cases, up to 20% of patients develop post-treatment Lyme disease syndrome (PTLDS). There is an urgent need to improve clinical management of LD using precise understanding of disease and patient stratification. We applied machine-learning to electronic medical records to better characterize the heterogeneity of LD and developed predictive models for identifying medications that are associated with risks of subsequent comorbidities. For broad disease categories, we identified 3, 16, and 17 comorbidities within 2, 5, and 10 years of diagnosis, respectively. At a higher resolution of ICD-9 codes, we identified known associations with LD including chronic pain and cognitive disorders, as well as particular comorbidities on a timescale that matched PTLDS symptomology. We identified 7, 30, and 35 medications associated with risks of these comorbidities within 2, 5, and 10 years, respectively. For instance, the first-line antibiotic doxycycline exhibited a consistently protective association for typical symptoms of LD, including backache. Our approach and findings may suggest new hypotheses for more personalized treatments regimens for LD patients.

Ceftriaxone-induced immune hemolytic anemia as a life-threatening complication of antibiotic treatment of 'chronic Lyme disease'

'Chronic Lyme disease' is a controversial condition. As any hard evidence is lacking that unresolved systemic symptoms, following an appropriately diagnosed and treated Lyme disease, are related to a chronic infection with the tick-borne spirochaetes of the Borrelia genus, the term 'chronic Lyme disease' should be avoided and replaced by the term 'post-treatment Lyme disease syndrome.' The improper prescription of prolonged antibiotic treatments for these patients can have an impact on the community antimicrobial resistance and on the consumption of health care resources. Moreover, these treatments can be accompanied by severe complications. In this case report, we describe a life-threatening ceftriaxone-induced immune hemolytic anemia with an acute kidney injury (RIFLE-stadium F) due to a pigment-induced nephropathy in a 76-year-old woman, who was diagnosed with a so-called 'chronic Lyme disease.'

Erythema migrans

Erythema migrans (EM) is the most common objective manifestation of Borrelia burgdorferi infection. Systemic symptoms are usually present. Most patients do not recall a preceding tick bite. Despite a characteristic appearance, EM is not pathognomonic for Lyme disease and must be distinguished from other similar appearing skin lesions. EM is a clinical diagnosis; serologic and PCR assays are unnecessary. Leukopenia and thrombocytopenia are indicative of either an alternative diagnosis, or coinfection with another tick-borne pathogen. When EM is promptly treated with appropriate antimicrobial agents, the prognosis is excellent. Persons in endemic areas should take measures to prevent tick bites.

Lyme disease

A 32-year-old pregnant woman from southeastern Connecticut presents to her physician in July at 26 weeks’ gestation because of a skin lesion. She reports she has had fatigue, arthralgia, and headache for 2 days and a rash in her left axilla for 1 day. She lives in a wooded area and works in her garden frequently. Six weeks earlier, she had removed a small tick that was attached behind her right knee. On physical examination, she is afebrile. She has an erythematous, oval macular lesion, 7 to 8 cm in diameter, in her left axilla, with enhanced central erythema; no other abnormalities are noted. How should her case be managed?

Clinical practice. Lyme disease

A 32-year-old pregnant woman from southeastern Connecticut presents to her physician in July at 26 weeks' gestation because of a skin lesion. She reports she has had fatigue, arthralgia, and headache for 2 days and a rash in her left axilla for 1 day. She lives in a wooded area and works in her garden frequently. Six weeks earlier, she had removed a small tick that was attached behind her right knee. On physical examination, she is afebrile. She has an erythematous, oval macular lesion, 7 to 8 cm in diameter, in her left axilla, with enhanced central erythema; no other abnormalities are noted. How should her case be managed?

Review of evidence for immune evasion and persistent infection in Lyme disease

Is chronic illness in patients with Lyme disease caused by persistent infection? Three decades of basic and clinical research have yet to produce a definitive answer to this question. This review describes known and suspected mechanisms by which spirochetes of the Borrelia genus evade host immune defenses and survive antibiotic challenge. Accumulating evidence indicates that Lyme disease spirochetes are adapted to persist in immune competent hosts, and that they are able to remain infective despite aggressive antibiotic challenge. Advancing understanding of the survival mechanisms of the Lyme disease spirochete carry noteworthy implications for ongoing research and clinical practice.

Antiscience and ethical concerns associated with advocacy of Lyme disease

Advocacy for Lyme disease has become an increasingly important part of an antiscience movement that denies both the viral cause of AIDS and the benefits of vaccines and that supports unproven (sometimes dangerous) alternative medical treatments. Some activists portray Lyme disease, a geographically limited tick-borne infection, as a disease that is insidious, ubiquitous, difficult to diagnose, and almost incurable; they also propose that the disease causes mainly non-specific symptoms that can be treated only with long-term antibiotics and other unorthodox and unvalidated treatments. Similar to other antiscience groups, these advocates have created a pseudoscientific and alternative selection of practitioners, research, and publications and have coordinated public protests, accused opponents of both corruption and conspiracy, and spurred legislative efforts to subvert evidence-based medicine and peer-reviewed science. The relations and actions of some activists, medical practitioners, and commercial bodies involved in Lyme disease advocacy pose a threat to public health.

[Neuroborreliosis in patient with aplastic anaemia secondary to therapy with ticlopidine]

INTRODUCTION

Aplastic anaemia is a rare but potentially fatal complication of treatment with ticlopidine.

CASE OUTLINE

We present a 55-year-old male with aplastic anaemia which developed after 45 days of the therapy with 200 mg ticlopidine to prevent coronary thrombosis. The treatment with ticlopidine was withdrawn and broad spectrum antibiotics as well as transfusion of packed red cells, platelets and G-CSF were administered. Two weeks after the onset of the disease, the number of white blood cells dropped to 0.5 x 10(9)/l, along with drop of both haemoglobin concentration and the number of platelets. At that time, weakness of facial muscles due to bilateral facial nerve paralysis with Bell's phenomenon and after that weakness of muscles of both legs and signs of polyradiculoneuritis were developed. Western blot analysis of blood and liquor showed a high concentration of IgG and IgM antibodies against Borrelia burgdorferi. The treatment with cephtriaxone resulted in normalization of body temperature and gradual recovery of neurological findings. Blood picture became normal two months after the onset of the disease.

CONCLUSION

The treatment with ticlopidine may result in different haematological complications such as agranulocytosis/ granulocytopaenia, thrombotic trombocytopenic purpura and rarely aplastic anaemia. Due to these complications blood pictures in patients on this therapy should be closely followed up and in case of complications, the treatment with ticlopidine has to be stopped and introduce the therapeutic procedures depending on the sort of the complications and clinical presentation.

Proof that chronic lyme disease exists

The evidence continues to mount that Chronic Lyme Disease (CLD) exists and must be addressed by the medical community if solutions are to be found. Four National Institutes of Health (NIH) trials validated the existence and severity of CLD. Despite the evidence, there are physicians who continue to deny the existence and severity of CLD, which can hinder efforts to find a solution. Recognizing CLD could facilitate efforts to avoid diagnostic delays of two years and durations of illness of 4.7 to 9 years described in the NIH trials. The risk to society of emerging antibiotic-resistant organisms should be weighed against the societal risks associated with failing to treat an emerging population saddled with CLD. The mixed long-term outcome in children could also be examined. Once we accept the evidence that CLD exists, the medical community should be able to find solutions. Medical professionals should be encouraged to examine whether: (1) innovative treatments for early LD might prevent CLD, (2) early diagnosis of CLD might result in better treatment outcomes, and (3) more effective treatment regimens can be developed for CLD patients who have had prolonged illness and an associated poor quality of life.

Lyme neuroborreliosis in children: a prospective study of clinical features, prognosis, and outcome

BACKGROUND

Evaluation of children with clinically suspected neuroborreliosis (NB) is difficult. With a prospective study design we wanted to characterize children with signs and symptoms indicative for NB, investigate clinical outcome and, if possible, identify factors of importance for recovery.

MATERIAL/METHODS

Children being evaluated for NB (n = 177) in southeast Sweden were categorized into 3 groups: "confirmed neuroborreliosis" (41%) with Borrelia antibodies in the cerebrospinal fluid, "possible neuroborreliosis" (26%) with pleocytosis but no Borrelia antibodies in the cerebrospinal fluid, and "not determined" (33%) with no pleocytosis and no Borrelia antibodies in the cerebrospinal fluid. Antibiotic treatment was given to 69% of children. Patients were followed during 6 months and compared with a matched control group (n = 174).

RESULTS

Clinical recovery at the 6-month follow-up (n = 177) was generally good and no patient was found to have recurrent or progressive neurologic symptoms. However, persistent facial nerve palsy caused dysfunctional and cosmetic problems in 11% of patients. Persistent nonspecific symptoms, such as headache and fatigue, were not more frequently reported in patients than in controls. Influence on daily life was reported to the same extent in patients and controls. Consequently, persistent headache and fatigue at follow-up should not be considered as attributable to NB. No prognostic factors could be identified.

CONCLUSIONS

Clinical recovery was satisfactory in children being evaluated for NB although persistent symptoms from facial nerve palsy occurred. Persistent nonspecific symptoms, such as headache and fatigue, were not more frequently reported in patients than in controls.