Chronic Lyme Disease is a condition without clear or consistent definition, and therefore is frequently a non-specific diagnosis. It is a term used by a few clinicians to describe a variety of symptoms that range from constitutional, musculoskeletal or neuropsychiatric.
Lyme Disease is a well-described and researched bacterial infection due to the spirochete, Borrelia burgdorferi, transmitted by the bite of a deer tick, Ixodes scapularis. Early in the disease (3 -30 days) symptoms include fever, headache, fatigue, and a rash (erythema migrans). Untreated, the infection can spread to joints, nervous system and heart manifesting as severe headaches and neck stiffness, joint pain and swelling particularly in the knees, facial palsy, palpitations, shooting pains and memory difficulty (especially short term)
Diagnosis is usually made based upon clinical history including exposure to tick bite, characteristic signs and symptoms, particularly the rash, and confirmed by serologic testing using a two step process. First, either an immunoassay or immunofluorescence test is performed, if positive or indeterminate, a Western blot test is performed. If the symptoms are acute (less than 30 days), both IgM and IgG Western blots are performed. If greater than 30 days, only the IgG is performed.
IDSA has developed treatment guidelines for confirmed Lyme Disease[1]. Preferred regimens include doxycycline, amoxicillin or cefuroxime for 14-21 days. Alternatively, ceftriaxone IM or selected macrolides may be used. If severe or neurologic symptoms, consider using parental therapy. Late disease can be treated with similar regimens extended up to 28 days. Of note, IDSA has recommended against the following:
- Combination antimicrobial therapy
- Multiple repeated courses of antibiotics
- Empiric treatment in the absence of confirmed diagnosis
- Use of immunoglobulin
Do long-term antibiotics help in chronic Lyme Disease? Overwhelmingly, the evidence is NO. And in fact, use of long-term antibiotics can be associated with its own set of complications including C.diff infection, paraspinal abscess, osteomyelitis and septic shock.
Your patients with chronic fatigue, generalized pain or fibromyalgia or neurologic symptoms (e.g. memory loss) may seek out ‘Lyme Disease specialists’ who diagnose based solely on clinical judgement and without confirmatory evidence. It should be noted that the likelihood of seronegative results being accurate increases the longer the patient has had symptoms so practitioners who advocate that seronegative patients with chronic, nonspecific symptoms may indeed have chronic Lyme Disease are doing so contrary to the evidence. These same practitioners may also prescribe prolonged courses of antibiotics, courses of immunotherapies, magnetic field therapies, garlic supplements, and stem cell transplants.
The bottom line is this: five randomized controlled trials have been conducted, and ALL conclusively have demonstrated that there is no substantial improvement in symptoms with prolonged courses of antibiotics, and can result in serious harm or death.[2],[3]
[1] https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/cid/43/9/10.1086_508667/1/43-9-1089.pdf?Expires=1497739881&Signature=LoH3cPJR6SbAO5BlPIJqcQ3LiUXE~DBNPFW5s5XpU81i~CfcyML4Sq1jRo~r4GWn12ZeVMJtonFjRcT1cYMgpT0an1QlDVg6J-xELBMnN1Rr49cVXB~gFMeJhX9H2B5WoMAhQ0b6rj6tGAn01N326hGByebmRs5Gf5zzYoPjMQ-~evxaMqW1dRQ79zugV5viySb8ZZVe9-8aT-dURIJl-p7UPHRcmmbnOlCiCJBlLw1zP48fOQCZtTayJMT2Bq8ZRx0IWiCNsrTfSSQZuVJPpA1OWQ0W6ElOw4TnpRivYsvIY3l6acAYM85gQCPknjUPy8SYoviDwzfQaqdehUpFIA__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q
[2] Ad Hoc Internatiohnal Lyme Disease Group. “A Critical Appraisal of “Chronic Lyme Disease”. NEJM, 2007, 357: 1422-30
[3] Berende A et al. “Randomized trial of longer-term therapy for symptoms attributed to Lyme Disease” NEJM, 2016, 374: 1209-20