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Scientists push for Lyme disease trials. Nature 2010. [DOI: 10.1038/news.2010.542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Friedman JH, Alves G, Hagell P, Marinus J, Marsh L, Martinez-Martin P, Goetz CG, Poewe W, Rascol O, Sampaio C, Stebbins G, Schrag A. Fatigue rating scales critique and recommendations by the Movement Disorders Society task force on rating scales for Parkinson's disease. Mov Disord 2010; 25:805-22. [PMID: 20461797 DOI: 10.1002/mds.22989] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Fatigue has been shown to be a consistent and common problem in Parkinson's disease (PD) in multiple countries and cultures. It is one of the most disabling of all symptoms, including motor dysfunction, and appears early, often predating the onset of motor symptoms. Several studies of the epidemiology of fatigue have been published, often using different scales, but few on treatment. The Movement Disorder Society (MDS) commissioned a task force to assess available clinical rating scales, critique their psychometric properties, summarize their clinical properties, and evaluate the evidence in support of their use in clinical studies in PD. Six clinical researchers reviewed all studies published in peer reviewed journals of fatigue in PD, evaluated the scales' previous use, performance parameters, and quality of validation data, if available. Scales were rated according to criteria provided by the MDS. A scale was "recommended" if it has been used in clinical studies beyond the group that developed it, has been used in PD and psychometric studies have established that it is a valid, reliable and sensitive to change in people with PD. Requiring a scale to have demonstrated sensitivity to change in PD specifically rather than in other areas in order to attain a rating of "recommended" differs from the use of this term in previous MDS task force scale reviews. "Suggested" scales failed to meet all the criteria of a "recommended" scale, usually the criterion of sensitivity to change in a study of PD. Scales were "listed" if they had been used in PD studies but had little or no psychometric data to assess. Some scales could be used both to screen for fatigue as well as to assess fatigue severity, but some were only used to assess severity. The Fatigue Severity Scale was "recommended" for both screening and severity rating. The Fatigue Assessment Inventory, an expanded version of the Fatigue severity Scale, is "suggested" for both screening and severity. The Functional Assessment of Chronic Illness Therapy-Fatigue was "recommended" for screening and "suggested" for severity. The Multidimensional Fatigue Inventory was "suggested" for screening and "recommended" for severity. The Parkinson Fatigue Scale was "recommended" for screening and "suggested" for severity rating. The Fatigue Severity Inventory was "listed" for both screening and severity. The Fatigue Impact Scale for Daily Use, an adaptation of the Fatigue Impact Scale was "listed" for screening and "suggested" for severity. Visual Analogue and Global Impression Scales are both "listed" for screening and severity. The committee concluded that current scales are adequate for fatigue studies in PD but that studies on sensitivity and specificity of the scales are still needed.
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Affiliation(s)
- Joseph H Friedman
- NeuroHealth, Parkinson's Disease and Movement Disorders Center, Warwick, Rhode Island 02886, USA.
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Chandra A, Wormser GP, Klempner MS, Trevino RP, Crow MK, Latov N, Alaedini A. Anti-neural antibody reactivity in patients with a history of Lyme borreliosis and persistent symptoms. Brain Behav Immun 2010; 24:1018-24. [PMID: 20227484 PMCID: PMC2897967 DOI: 10.1016/j.bbi.2010.03.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 02/20/2010] [Accepted: 03/02/2010] [Indexed: 01/09/2023] Open
Abstract
Some Lyme disease patients report debilitating chronic symptoms of pain, fatigue, and cognitive deficits despite recommended courses of antibiotic treatment. The mechanisms responsible for these symptoms, collectively referred to as post-Lyme disease syndrome (PLS) or chronic Lyme disease, remain unclear. We investigated the presence of immune system abnormalities in PLS by assessing the levels of antibodies to neural proteins in patients and controls. Serum samples from PLS patients, post-Lyme disease healthy individuals, patients with systemic lupus erythematosus, and normal healthy individuals were analyzed for anti-neural antibodies by immunoblotting and immunohistochemistry. Anti-neural antibody reactivity was found to be significantly higher in the PLS group than in the post-Lyme healthy (p<0.01) and normal healthy (p<0.01) groups. The observed heightened antibody reactivity in PLS patients could not be attributed solely to the presence of cross-reactive anti-borrelia antibodies, as the borrelial seronegative patients also exhibited elevated anti-neural antibody levels. Immunohistochemical analysis of PLS serum antibody activity demonstrated binding to cells in the central and peripheral nervous systems. The results provide evidence for the existence of a differential immune system response in PLS, offering new clues about the etiopathogenesis of the disease that may prove useful in devising more effective treatment strategies.
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Affiliation(s)
- Abhishek Chandra
- Department of Neurology and Neuroscience, Cornell University, New York, NY, USA
| | - Gary P. Wormser
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | | | | | - Mary K. Crow
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Norman Latov
- Department of Neurology and Neuroscience, Cornell University, New York, NY, USA
| | - Armin Alaedini
- Department of Neurology and Neuroscience, Cornell University, New York, NY, USA,Corresponding author: Armin Alaedini, Department of Neurology and Neuroscience, Weill Medical College of Cornell University, 1300 York Ave., LC-819, New York, NY 10065; Phone: 212-746-7841;
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Abstract
There is no better example of a relentless attack on evidence-based biomedical research and the integrity of outstanding scientists than that associated with the treatment of a poorly defined condition called "chronic Lyme disease." Here, a scientifically naive general population, the lay press, and legislators, who in most instances are unable to evaluate and judge scientific evidence properly, have been misled by patient advocate groups to believe that extended antibiotic therapy is the best and only solution to this condition. This has resulted in the unprecedented intrusion of government and the legal systems into the practice of medicine and scientific research. Because there is no clinical evidence that this condition is due to a persistent infection, advocating extended antibiotic therapy is not justified and has been shown to be harmful and of no benefit.
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Proof that chronic lyme disease exists. Interdiscip Perspect Infect Dis 2010; 2010:876450. [PMID: 20508824 PMCID: PMC2876246 DOI: 10.1155/2010/876450] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Accepted: 03/26/2010] [Indexed: 11/17/2022] Open
Abstract
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.
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Natural killer cells in chronic Lyme disease. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2010; 16:1704; author reply 1704-6. [PMID: 19880717 DOI: 10.1128/cvi.00260-09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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208
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Abstract
Neuroborreliosis is easily diagnosed by means of clinical symptoms and laboratory findings. Guiding symptoms are radicular pain and pareses of the extremities and the facial nerve. There is a great number of further less frequently occurring neurological symptoms, which can be attributed to a borrelial infection only by appropriate investigations of the CSF. Radiculitis is cured adequately by oral doxycycline while symptoms of the central nervous system are probably better treated intravenously by ceftriaxone, cefotaxime or penicillin G. Post-Lyme syndrome is a diffuse description of non-specific complaints, which are not the explicit result of a former infection with B. burgdorferi. As further antibiotics do not help and the CSF is unremarkable in most patients, a persistent infection with B. burgdorferi s.l. in all probability can be excluded.
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Affiliation(s)
- R Kaiser
- Neurologische Klinik, Klinikum Pforzheim, Kanzlerstrasse 2-6, 75175, Pforzheim, Deutschland.
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209
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210
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Subjective symptoms after treatment of early Lyme disease. Am J Med 2010; 123:79-86. [PMID: 20102996 DOI: 10.1016/j.amjmed.2009.05.011] [Citation(s) in RCA: 145] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 04/30/2009] [Accepted: 05/11/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Controversy exists over the significance and even the existence of post-Lyme disease symptoms because of the high rate of similar background symptoms in the general population. METHODS A European, prospective clinical trial in which doxycycline and cefuroxime axetil were compared in the treatment of adult patients with erythema migrans included a control group to address this question. Evaluations of patients were conducted at baseline, 14 days, and 2, 6, and 12 months after enrollment. Control subjects were evaluated at baseline and at 6 and 12 months. Subjective symptoms that newly developed or intensified since the onset of erythema migrans or the date of enrollment for controls were referred to as "new or increased symptoms." RESULTS Doxycycline and cefuroxime axetil had comparable efficacy. At both 6 and 12 months, the frequency of new or increased symptoms in patients with erythema migrans did not exceed the frequency of such symptoms in a control group of individuals of similar gender and age without a clinical history of Lyme disease. At 12 months after enrollment, only 5 (2.2%) of 230 evaluable patients reported new or increased symptoms, and in none of the patients were these symptoms of sufficient severity to be functionally disabling. CONCLUSION No significant differences were identified between doxycycline and cefuroxime axetil in the treatment of European patients with erythema migrans. The frequency of nonspecific symptoms in patients did not exceed that of a control group at > or =6 months after enrollment. We advocate inclusion of appropriate non-Lyme disease control groups in future studies in which nonspecific subjective symptoms are assessed after antibiotic therapy.
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211
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Mygland A, Ljøstad U, Fingerle V, Rupprecht T, Schmutzhard E, Steiner I. EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. Eur J Neurol 2009; 17:8-16, e1-4. [PMID: 19930447 DOI: 10.1111/j.1468-1331.2009.02862.x] [Citation(s) in RCA: 431] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- A Mygland
- Department of Neurology, Sorlandet Sykehus, Kristiansand, Norway.
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212
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Wormser GP, Shapiro ED. Authors' Reply. J Womens Health (Larchmt) 2009. [DOI: 10.1089/jwh.2009.1683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gary P. Wormser
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, New York
| | - Eugene D. Shapiro
- Departments of Pediatrics, Epidemiology and Public Health, and Investigative Medicine, Yale University School of Medicine and Graduate School of Arts and Sciences, New Haven, Connecticut
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213
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Ljøstad U, Mygland A. Remaining complaints 1 year after treatment for acute Lyme neuroborreliosis; frequency, pattern and risk factors. Eur J Neurol 2009; 17:118-23. [PMID: 19645771 DOI: 10.1111/j.1468-1331.2009.02756.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE To chart remaining complaints 1 year after treatment for neuroborreliosis, and to identify risk factors for a non-favorable outcome. METHODS We followed patients treated for neuroborreliosis prospectively, and assessed outcome by a composite clinical score. The impact on outcome of clinical, demographic and laboratory factors were analyzed by univariate analyses and logistic regression. RESULTS Out of 85 patients 41 (48%) had remaining complaints; 14 had objective findings and 27 subjective symptoms. Remaining complaints were associated with pre-treatment symptom duration >or=6 weeks (OR = 4.062, P = 0.044), high pre-treatment cerebrospinal fluid (CSF) cell count (OR = 1.005, P = 0.001), and female gender (OR = 3.218, P = 0.025). Presence of CSF oligoclonal bands (OCBs) was not analyzed in the logistic regression model due to many missing observations, but was found to be more frequent both pre-treatment (P = 0.004) and after 12 months (P = 0.015) among patients with remaining complaints as compared to patients with complete recovery. Further evaluation showed that objective remaining findings, and not subjective symptoms, were associated with pre-treatment symptom duration >or=6 weeks. No difference in outcome was observed between patients treated with IV ceftriaxone and patients treated with oral doxycycline. CONCLUSION Remaining complaints are common after neuroborreliosis. The majority of the complaints are subjective. Pre-treatment symptom duration >or=6 weeks, high pre-treatment CSF cell count, and female gender seem to be risk factors for remaining complaints. Presence of CSF OCBs may also predict a non-favorable outcome, but this should be further studied. Whether subjective and objective complaints are associated with different risk factors is also an issue for future studies.
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Affiliation(s)
- U Ljøstad
- Department of Neurology, Sørlandet Hospital HF, Kristiansand, Norway.
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214
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Abstract
BACKGROUND "Post-Lyme disease syndrome" refers to prolonged subjective symptoms after antibiotic treatment and resolution of an objective manifestation of Borrelia burgdorferi infection (Lyme disease). "Chronic Lyme disease" is a vaguely defined term that has been applied to patients with unexplained prolonged subjective symptoms, whether or not there was or is evidence of B. burgdorferi infection. OBJECTIVE To determine if the population of patients with chronic Lyme disease differs from the populations of patients with either Lyme disease or post-Lyme disease syndrome by examining the gender of patients with these diagnoses. METHODS Data on gender were compiled in this cross-sectional study based on a systematic review of published studies of antibiotic treatment in United States patients with post-Lyme disease syndrome (n = 184) or chronic Lyme disease (n = 490), and on cases of adults with Lyme disease reported to the Centers for Disease Control and Prevention from 2003 to 2005 (n = 43,282). RESULTS Patients with chronic Lyme disease were significantly more likely to be female than were patients diagnosed with either Lyme disease (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.98-2.94, p < 0.0001) or with post-Lyme disease syndrome (OR 2.32, 95% CI 1.62-3.34, p < 0.0001). CONCLUSIONS Patients with chronic Lyme disease differ with regard to gender from those with either B. burgdorferi infection or post-Lyme disease syndrome. This finding suggests that illnesses with a female preponderance, such as fibromyalgia, chronic fatigue syndrome, or depression, may be misdiagnosed as chronic Lyme disease.
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Affiliation(s)
- Gary P Wormser
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Munger Pavilion Room 245, Valhalla, NY 10595, USA.
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215
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Cameron DJ. Insufficient evidence to deny antibiotic treatment to chronic Lyme disease patients. Med Hypotheses 2009; 72:688-91. [PMID: 19268485 DOI: 10.1016/j.mehy.2009.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 01/05/2009] [Accepted: 01/07/2009] [Indexed: 01/24/2023]
Abstract
BACKGROUND The severity, length of illness, and cost of chronic Lyme disease (CLD) have been well described. A number of oral, intravenous, and intramuscular antibiotics have been prescribed for CLD. Surprisingly few antibiotic schedules prescribed for the treatment of CLD have been evaluated in randomized double-blind placebo-controlled clinical trials (RCTs). Physicians have increasingly turned to clinical treatment guideline (CPG) panels to judge the mixed results of the evidence. Two CPG panels have looked at the evidence only to reach opposite conclusions: (1) antibiotic therapy for CLD is not effective and (2) antibiotic therapy for CLD is effective. Physicians have been advised by guideline developers to use clinical discretion in diagnosing and treating CLD. Nevertheless, many health insurers - relying exclusively upon only one CPG - have a policy of automatically denying antibiotics to CLD patients regardless of the specifics of each case or the recommendations of the patient's physician. HYPOTHESES This paper examined the eight limitations of the evidence used to conclude that antibiotics therapy for CLD is not effective in forming the following hypothesis: insufficient evidence to deny antibiotic treatment to CLD patients. EVIDENCE FOR THE HYPOTHESIS There are eight limitations that support the hypothesis: (1) the power of the evidence is inadequate to draw definite conclusions, (2) the evidence is too heterogeneous to make strong recommendations, (3) the risk to an individual of facing a long-term debilitating illness has not been considered, (4) the risk to society of a growing chronically ill population has not been considered, (5) treatment delay has not been considered as a confounder, (6) co-infections have not been considered as a confounder, (7) the design of RCTs did not address the range of treatment options in an actual practice, and (8) the findings cannot be generalized to actual practice. IMPLICATIONS OF THE HYPOTHESES This hypothesis suggests that physicians should consider the limitations of the evidence before denying antibiotic treatment for CLD. Physicians who deny antibiotic treatment to CLD patients might inform their patients that there are some clinicians who disagree with that position, and then offer to refer them for a second opinion to a doctor who could potentially present a different point of view. The hypothesis also suggests that health care insurers should consider the limitations of the evidence before adopting policies that routinely deny antibiotic treatment for CLD patients and should expand coverage of CLD to include clinical discretion for specific clinical situations.
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Affiliation(s)
- Daniel J Cameron
- First Medical Associates, Medicine, 175 Main Street, Mount Kisco, NY 10549, USA.
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Affiliation(s)
- Chris D. Meletis
- Executive director of the Institute for Healthy Aging, a non-profit educational group, in Carson City, Nevada, and an associate professor of natural pharmacology at the National College of Natural Medicine, in Portland, Oregon
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217
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Georgiev VS. Tick-Borne Bacterial, Rickettsial, Spirochetal, and Protozoal Diseases. NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, NIH 2009. [PMCID: PMC7122040 DOI: 10.1007/978-1-60327-297-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Approximately 900 tick species exist worldwide, parasitizing a broad array of mammals, including humans, and thereby playing a significant role in the transmission of infectious diseases (1). In the United States, tick-borne diseases are generally seasonal and geographically distributed. They occur mostly during the spring and summer but can occur throughout the year.
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Nau R, Christen HJ, Eiffert H. Lyme disease--current state of knowledge. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:72-81; quiz 82, I. [PMID: 19562015 PMCID: PMC2695290 DOI: 10.3238/arztebl.2009.0072] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 09/01/2008] [Indexed: 01/01/2023]
Abstract
BACKGROUND Lyme disease is the most frequent tick-borne infectious disease in Europe. The discovery of the causative pathogen Borrelia burgdorferi in 1982 opened the way for the firm diagnosis of diseases in several clinical disciplines and for causal antibiotic therapy. At the same time, speculation regarding links between Borrelia infection and a variety of nonspecific symptoms and disorders resulted in overdiagnosis and overtreatment of suspected Lyme disease. METHOD The authors conducted a selective review of the literature, including various national and international guidelines. RESULTS The spirochete Borrelia burgdorferi sensu lato is present in approximately 5% to 35% of sheep ticks (Ixodes ricinus) in Germany, depending on the region. In contrast to North America, different genospecies are found in Europe. The most frequent clinical manifestation of Borrelia infection is erythema migrans, followed by neuroborreliosis, arthritis, acrodermatitis chronica atrophicans, and lymphocytosis benigna cutis. Diagnosis is made on the basis of the clinical symptoms, and in stages II and III by detection of Borrelia-specific antibodies. In adults erythema migrans is treated with doxycycline, in children with amoxicillin. The standard treatment of neuroborreliosis is third-generation cephalosporins. CONCLUSIONS After appropriate antibiotic therapy, the outcome is favorable. In approximately 95% of cases neuroborreliosis is cured without long-term sequelae. When chronic borreliosis is suspected, other potential causes of the clinical syndrome must be painstakingly excluded.
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Affiliation(s)
- Roland Nau
- Geriatrisches Zentrum, Evangelisches Krankenhaus Göttingen-Weende, Abteilung für Neurologie, Universitätsklinikum Göttingen, Göttingen, Germany.
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Cameron DJ. Clinical trials validate the severity of persistent Lyme disease symptoms. Med Hypotheses 2008; 72:153-6. [PMID: 19013025 DOI: 10.1016/j.mehy.2008.09.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 08/25/2008] [Accepted: 09/04/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Persistent Lyme Disease Symptoms (PLDS) have included fatigue, headaches, poor concentration and memory, lightheadedness, joint pain, and mood disturbances. Evidence-based guidelines committees disagree over the severity of PLDS. The 2004 International Lyme and Associated Diseases Society (ILADS) concluded that PLDS are severe. The 2006 Infectious Disease Society of America (IDSA) guidelines committee concluded that PLDS are nothing more than the "aches and pains of daily living" and an ad hoc International Lyme group concluded that PLDS are "symptoms common in persons who have never had Lyme disease." HYPOTHESIS Clinical trials validate the severity of persistent Lyme disease symptoms. EVALUATION OF THE HYPOTHESIS There are 22 standardized instruments used to measure the severity of PLDS among the four published National Institutes of Health (NIH) sponsored double-blind randomized placebo-controlled trials (RCTs). VALIDATING THE HYPOTHESIS: All four NIH sponsored RCTs validate the severity of PLDS. PLDS are as severe as symptoms seen in other serious chronic illnesses, and result in a quality of life lower than for the general population as determined by 22 standardized measures of QOL, including fatigue, pain, role function, psychopathology, and cognition. None of the four RCTs support the IDSA hypothesis that PLDS are nothing more than "the aches and pains of daily living" nor the ad hoc International Lyme group conclusion that PLDS are "symptoms common in persons who have never had Lyme disease." IMPLICATIONS OF THE HYPOTHESIS If the QOL of life for these patients is as poor as for patients with other serious chronic diseases, their symptoms need to be addressed by their doctors. Studies differ as to the precise cause of PLDS, the most effective treatments, and whether a cure is possible. But the fact that there is disagreement is not a license for physicians to ignore or turn away patients complaining of PLDS, or to dismiss their symptoms as purely psychosomatic. For physicians, the goal or purpose of treating PLDS should be the same as their purpose in treating other chronic illnesses that result in a poor QOL: vigorous pursuit of a cure, and where a cure proves impossible, amelioration of patients' symptoms and suffering. Even if this hypothesis fails to be apply to more than a fraction of the total Lyme disease population, this still represents a significant number of patients, and these findings could address a neglected aspect of caring for patients with Lyme disease.
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221
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Baker PJ. Beating Lyme. J Clin Invest 2008. [DOI: 10.1172/jci36641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
OBJECTIVES To survey present knowledge and controversies in European neuroborreliosis. MATERIAL AND METHODS The article is based on available literature, own experience, and a speech held by the authors. together on the Norwegian annual neurological meeting. RESULTS Diagnosis of neuroborreliosis is based on clinical neurological findings, laboratory support of borrelia infection, and indications of causality between neurological findings and borreliosis. In the absence of means to identify B. burgdorferi, antibody tests are used for laboratory diagnosis. Two to three weeks courses of IV penicillin or ceftriaxone are highly effective in neuroborreliosis. Oral doxycyclin is probably equally effective. Remaining symptoms five years after treatment for neuroborreliosis are reported in 25-50% of patients. CONCLUSIONS We suggest two levels of diagnostic accuracy; definite and possible neuroborreliosis. These case definitions are proposed to make the basis for treatment decisions. The prognosis of neuroborreliosis and pathophysiology of post-treatment conditions need further studies. Extensive treatments with antibiotics are not recommended.
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Affiliation(s)
- U Ljøstad
- Department of Neurology, Sørlandet Sykehus HF, Kristiansand, Norway.
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223
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Ljøstad U, Skogvoll E, Eikeland R, Midgard R, Skarpaas T, Berg Å, Mygland Å. Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trial. Lancet Neurol 2008; 7:690-5. [DOI: 10.1016/s1474-4422(08)70119-4] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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224
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Abstract
Studies have shown that most patients diagnosed with chronic Lyme disease either have no objective evidence of previous or current infection with Borrelia burgdorferi or are patients who should be classified as having post-Lyme disease syndrome, which is defined as continuing or relapsing nonspecific symptoms (such as fatigue, musculoskeletal pain, and cognitive complaints) in a patient previously treated for Lyme disease. Despite extensive study, there is currently no clear evidence that post-Lyme disease syndrome is caused by persistent infection with B burgdorferi. Four randomized placebo-controlled studies have shown that antibiotic therapy offers no sustained benefit to patients who have post-Lyme disease syndrome. These studies also showed a substantial placebo effect and a significant risk of treatment-related adverse events. Further research to elucidate the mechanisms underlying persistent symptoms after Lyme disease and controlled trials of new approaches to the treatment and management of these patients are needed.
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Affiliation(s)
- Adriana Marques
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892, USA.
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225
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Abstract
Erythema migrans (EM) is the most common objective manifestation of Lyme disease, accounting for about 90% of cases. Establishing the diagnosis of EM is important because appropriate treatment with oral antibiotics at an early stage of infection with Borrelia burgdorferi results in excellent outcomes. This article includes a discussion of the epidemiology of EM and its clinical, differential, and laboratory diagnosis. The treatment of EM and the prevention of Lyme disease are also discussed.
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Affiliation(s)
- Patricia Dandache
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
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226
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Baker PJ. Perspectives on "chronic Lyme disease". Am J Med 2008; 121:562-4. [PMID: 18589049 DOI: 10.1016/j.amjmed.2008.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 01/31/2008] [Accepted: 02/01/2008] [Indexed: 10/21/2022]
Abstract
There is much controversy about the treatment of Lyme disease with respect to 2 poorly defined entities: "chronic Lyme disease" and "posttreatment Lyme disease syndrome." In the absence of direct evidence that these conditions are the result of a persistent infection, some mistakenly advocate extended antibiotic therapy (>/=6 months), which can do great harm and has resulted in at least 1 death. The purpose of this brief report is to review what is known from clinical research about these conditions to assist both practicing physicians and lawmakers in making sound and safe decisions with respect to treatment.
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227
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Affiliation(s)
- William R Bowie
- Division of Infectious Diseases, University of British Columbia, Vancouver, British Columbia, Canada.
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Corapi KM, Gupta S, Liang MH. Management of Lyme disease. Expert Rev Anti Infect Ther 2008; 6:241-50. [DOI: 10.1586/14787210.6.2.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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229
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Halperin JJ. Diagnosis and treatment of the neuromuscular manifestations of Lyme disease. Curr Treat Options Neurol 2008; 9:93-100. [PMID: 17298770 DOI: 10.1007/s11940-007-0035-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Although estimates vary, the nervous system appears to be involved in 10% to 15% of patients infected with Borrelia burgdorferi. The resulting disorders, known collectively as neuroborreliosis or nervous system Lyme disease, generally respond well to antimicrobial therapy. Definitive treatment of nervous system infection typically consists of 2 to 4 weeks of parenteral ceftriaxone, cefotaxime, or high-dose penicillin (Class III). However, numerous European studies have shown that oral doxycycline is equally effective in patients with Lyme meningitis and cranial neuritis (Class II and III). This may be equally valid in patients infected with the strains prevalent in the United States, but this remains to be established.
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Affiliation(s)
- John J Halperin
- John J. Halperin, MD Atlantic Neuroscience Institute and New York University School of Medicine, Overlook Hospital, 99 Beauvoir Avenue, Summit, NJ 07902, USA.
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Cadavid D, Auwaerter P, Aucott J, Rumbaugh J. Treatment for the neurological complications of Lyme disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [DOI: 10.1002/14651858.cd006978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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232
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Nitrini R. Clinical and therapeutic aspects of dementia in syphilis and Lyme disease. HANDBOOK OF CLINICAL NEUROLOGY 2008; 89:819-823. [PMID: 18631797 DOI: 10.1016/s0072-9752(07)01271-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Ricardo Nitrini
- University of São Paulo School of Medicine, São Paulo, Brazil.
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234
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Seidel MF, Domene AB, Vetter H. Differential diagnoses of suspected Lyme borreliosis or post-Lyme-disease syndrome. Eur J Clin Microbiol Infect Dis 2007; 26:611-7. [PMID: 17605053 DOI: 10.1007/s10096-007-0342-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The symptoms of Lyme borreliosis are similar to those of a variety of autoimmune musculoskeletal diseases. Persistence of complaints is frequently interpreted as unsuccessful antibiotic treatment of Borrelia-associated infections. However, such refractory cases are rare, and re-evaluation of differential diagnoses helps to avoid the substantial risk of long-term antibiotic therapy. In this study, we analyzed patients who presented to our rheumatology unit with previous suspected or diagnosed Lyme borreliosis. Eighty-six patients from a 3.5-year period were evaluated. The mean age of patients was 49.2 +/- 17.2 years; 60% (n = 52) reported a tick bite and 33% (n = 28) an erythema. Forty-seven percent (n = 39) had positive enzyme-linked immunoassay results and Western blots (Mikrogen, Martinsried, Germany). All but 12 patients had already received antibiotic treatment previously. Nine percent (n = 8) had ongoing or recent Lyme borreliosis. Twenty-nine percent (n = 25) showed clinical symptoms and radiographic changes compatible with degenerative disorders of the cervical and/or lumbar spine. These patients were significantly older when compared to the other patients (59.3 +/- 13.7 years vs 46.1 +/- 17.2 years, p = 0.001). Seventeen percent (n = 16) had arthropathies related to psoriasis or rheumatoid arthritis. Twelve percent (n = 10) were positive for the HLA B27 antigen. Other diseases were less frequent. Six patients (7%) could not be diagnosed conclusively, and four of these patients had negative Borrelia immunoassay results. In conclusion, Borrelia-associated diseases were rare in this study. Differential diagnoses helped to initiate a successful disease-specific therapeutic strategy.
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Affiliation(s)
- M F Seidel
- Medical University Policlinic, Rheumatology Unit Wilhelmstr, Bonn, Germany.
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235
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Feder HM, Johnson BJB, O'Connell S, Shapiro ED, Steere AC, Wormser GP, Agger WA, Artsob H, Auwaerter P, Dumler JS, Bakken JS, Bockenstedt LK, Green J, Dattwyler RJ, Munoz J, Nadelman RB, Schwartz I, Draper T, McSweegan E, Halperin JJ, Klempner MS, Krause PJ, Mead P, Morshed M, Porwancher R, Radolf JD, Smith RP, Sood S, Weinstein A, Wong SJ, Zemel L. A critical appraisal of "chronic Lyme disease". N Engl J Med 2007; 357:1422-30. [PMID: 17914043 DOI: 10.1056/nejmra072023] [Citation(s) in RCA: 300] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Henry M Feder
- Department of Family Medicine and Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA.
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236
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Martinot M. [Microbiological and pharmacological data useful for the treatment of Lyme disease. Treatment and follow up of early Lyme disease (erythema migrans)]. Med Mal Infect 2007; 37:394-409. [PMID: 17714902 DOI: 10.1016/j.medmal.2006.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 11/20/2022]
Abstract
The aim of this review was first to analyze the microbiological and pharmacological criteria used to choose a treatment for Lyme disease. The determination of Borrelia burgdorferi sensu lato susceptibility to antibiotics is difficult, especially because of the lack of standardization in the methods used. In vitro data is helpful to determine Lyme treatment but discrepancies between in vitro and in vivo results highlight the need to confirm this data by clinical trials. The second part is an analysis of the literature made to evaluate the current strategies of treatment and follow up of early Lyme disease characterized by erythema migrans (EM). beta-lactams (penicillin G and V, amoxicillin, cefuroxime axetil, ceftriaxone), tetracyclines (doxycycline), and macrolides (mainly azithromycin) are the drugs most frequently used during clinical trials. The comparison between treatments is difficult because of the lack of reliable clinical and biological criteria to identify complete recovery. However the prognosis of treated EM is good in most trials. If a clinical follow-up remains necessary after the treatment of an EM, prolonged antibody production among asymptomatic patients reduces the interest of a serological follow-up.
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Affiliation(s)
- M Martinot
- Service de médecine interne et rhumatologie, centre hospitalier Louis-Pasteur, 39, avenue de la Liberté, 68000 Colmar, France.
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237
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Begon E. [Lyme arthritis, Lyme carditis and other presentations potentially associated to Lyme disease]. Med Mal Infect 2007; 37:422-34. [PMID: 17698309 DOI: 10.1016/j.medmal.2006.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 10/23/2022]
Abstract
Lyme disease or Lyme borreliosis is the most common tick-transmitted disease in the Northern hemisphere and is caused by Borrelia burgdorferi spirochetes. Lyme disease commonly begins with a characteristic skin lesion, erythema migrans. Weeks or months later, the patients may have neurologic, joint, or cardiac abnormalities. Some patients may still present persistent deep fatigue and various unspecific symptoms after standard courses of antibiotic treatment for Lyme disease. This constellation of symptoms has been variously referred to as "chronic Lyme disease", or "post-Lyme disease syndrome". The first French National Consensus Conference on Lyme Disease was the reason to review all aspects of articular and cardiac manifestations of Lyme disease after a synthesis of recent literature. The involvement of Borrelia species in chronic Lyme disease and other pathologies is discussed.
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Affiliation(s)
- E Begon
- Service de dermatologie, centre hospitalier général René-Dubos, 6, avenue de l'Ile-de-France, BP 79, 95303 Cergy-Pontoise cedex, France.
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238
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Hansmann Y. Le traitement des phases secondaires et tertiaires de la borréliose de Lyme. Med Mal Infect 2007; 37:479-86. [PMID: 17367972 DOI: 10.1016/j.medmal.2006.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 12/21/2022]
Abstract
The treatment of secondary and tertiary Lyme borreliosis is difficult because of antibiotic lack of efficacy. This fact may be explained by several factors: the specific pathophysiology, involving not only the presence of bacteria, but also immunological reactions. There is no specific method of diagnosis resulting in difficulties for good indication of treatment and to evaluate treatment efficacy. The literature review shows that ceftriaxone and doxycycline are the two most efficient antibiotics in this indication. Even if the methodology of the published studies is not always convincing, these two antibiotics proved their efficacy in articular as well as in neurological forms of the disease. In the late stage of borreliosis, antibiotics are less efficient. Various treatment modalities with different dosage or duration of treatment cannot let us conclude on a convincing regimen.
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Affiliation(s)
- Y Hansmann
- Service des maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
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Papo T. Certains symptômes cliniques aspécifiques ont-ils une origine borrélienne? Med Mal Infect 2007; 37:507-10. [PMID: 17360137 DOI: 10.1016/j.medmal.2007.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Accepted: 01/15/2007] [Indexed: 10/23/2022]
Abstract
Chronic manifestations (knee arthritis, encephalomyelitis, axonal polyneuropathy) may occur in the late phase of Lyme disease. Contrasting with such well-defined manifestations, the "post-Lyme syndrome" includes symptoms such as fatigue, algia, malaise, cognitive disorders, after treatment of a documented Lyme disease. The analysis of clinical, neuropsychological, bacteriological, immunological, epidemiological, quality of life, and treatment data does not support the reality of such a syndrome. Moreover, no physiopathological data can relate Borrelia infection to such symptoms in patients without previously documented Lyme disease symptoms but who are seropositive (or even sometimes without serodiagnosis as for instance in the Munchausen by proxy, or Gulf war syndromes).
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Affiliation(s)
- T Papo
- Service de médecine interne, hôpital Bichat, 46, rue Henri-Huchard 75877 Paris cedex 18, France.
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240
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Mohseni Zadeh M. Traitement et suivi des phases secondaire et tertiaire de la borréliose de Lyme. Med Mal Infect 2007; 37:368-80. [PMID: 17707605 DOI: 10.1016/j.medmal.2006.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 10/22/2022]
Abstract
The aim of this review was to analyze the current strategies of treatment and follow-up of disseminated and late Lyme borreliosis. A comprehensive search was performed using the Medline database. Only relevant reviews, expert guidelines and randomized controlled clinical trials were selected and, if necessary, open trials. Major drugs used in these studies were amoxicillin, doxycycline, penicillin G, and ceftriaxone. Oral administration of antibiotics was preferred in Lyme arthritis whereas parenteral drugs were mostly used in neuroborreliosis. The treatment duration usually ranged from 14 to 30 days. Prolonged antibiotic courses recommended by some authors in post-Lyme syndromes were not validated by several randomized placebo controlled studies. Follow up patterns were analyzed in order to determine possible prognosis parameters allowing to distinguih active Borrelia burgdorferi infection from a sequel of infection.
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Affiliation(s)
- M Mohseni Zadeh
- Service de médecine interne et de maladies infectieuses et tropicales, hôpital civil, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
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241
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Oksi J, Nikoskelainen J, Hiekkanen H, Lauhio A, Peltomaa M, Pitkäranta A, Nyman D, Granlund H, Carlsson SA, Seppälä I, Valtonen V, Viljanen M. Duration of antibiotic treatment in disseminated Lyme borreliosis: a double-blind, randomized, placebo-controlled, multicenter clinical study. Eur J Clin Microbiol Infect Dis 2007; 26:571-81. [PMID: 17587070 DOI: 10.1007/s10096-007-0340-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Despite rather strict recommendations for antibiotic treatment of disseminated Lyme borreliosis (LB), evidence-based studies on the duration of antibiotic treatment are scarce. The aim of this multicenter study was to determine whether initial treatment with intravenous ceftriaxone (CRO) for 3 weeks should be extended with a period of adjunct oral antibiotic therapy. A total of 152 consecutive patients with LB were randomized in a double-blind fashion to receive either amoxicillin (AMOX) 1 g or placebo (PBO) twice daily for 100 days. Both groups received an initial treatment of intravenous CRO 2 g daily for 3 weeks, followed by the randomized drug or PBO. The outcome was evaluated using the visual analogue scale at the follow-up visits. The final analysis included 145 patients, of whom 73 received AMOX and 72 PBO. Diagnoses of LB were categorized as either definite or possible, on the basis of symptoms, signs, and laboratory results. The diagnosis was definite in 52 of the 73 (71.2%) AMOX-treated patients and in 54 of the 72 (75%) PBO patients. Of the patients with definite diagnoses, 62 had neuroborreliosis, 45 arthritis or other musculoskeletal manifestations, and 4 other manifestations of LB. As judged by the visual analogue scale and patient records, the outcome after a 1-year follow-up period was excellent or good in 114 (78.6%) patients, controversial in 14 (9.7%) patients, and poor in 17 (11.7%) patients. In patients with definite LB, the outcome was excellent or good in 49 (92.5%) AMOX-treated patients and 47 (87.0%) PBO patients and poor in 3 (5.7%) AMOX-treated patients and 6 (11.1%) PBO patients (difference nonsignificant, p = 0.49). Twelve months after the end of intravenous antibiotic therapy, the levels of antibodies against Borrelia burgdorferi were markedly decreased in 50% of the patients with definite LB in both groups. The results indicate that oral adjunct antibiotics are not justified in the treatment of patients with disseminated LB who initially receive intravenous CRO for 3 weeks. The clinical outcome cannot be evaluated at the completion of intravenous antibiotic treatment but rather 6-12 months afterwards. In patients with chronic post-treatment symptoms, persistent positive levels of antibodies do not seem to provide any useful information for further care of the patient.
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Affiliation(s)
- J Oksi
- Department of Medicine, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
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242
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Auwaerter PG. Point: antibiotic therapy is not the answer for patients with persisting symptoms attributable to lyme disease. Clin Infect Dis 2007; 45:143-8. [PMID: 17578771 DOI: 10.1086/518854] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 04/11/2007] [Indexed: 01/01/2023] Open
Abstract
It is not well understood why some patients develop a subjective syndrome that includes considerable fatigue, musculoskeletal aches, and neurocognitive dysfunction after receiving standard antibiotic courses for the treatment of Lyme disease. Some practitioners use the term "chronic Lyme disease" and order prolonged courses of oral and parenteral antibiotics, believing that persistent infection with Borrelia burgdorferi is responsible. However, well-performed prospective studies have found neither evidence of chronic infection nor a benefit worthy of long-term antibiotic therapy for these patients. Such extended antibiotic therapy poses hazards and cannot be viewed as acceptable. The term "chronic Lyme disease" should be discarded as misleading; rather, the term "post-Lyme disease syndrome" better reflects the postinfectious nature of this condition. Further research is necessary to understand possible mechanisms of these chronic symptoms following Lyme disease as well as to find effective therapies.
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Affiliation(s)
- Paul G Auwaerter
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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243
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Stricker RB. Counterpoint: long-term antibiotic therapy improves persistent symptoms associated with lyme disease. Clin Infect Dis 2007; 45:149-57. [PMID: 17578772 DOI: 10.1086/518853] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Accepted: 02/21/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Controversy exists regarding the diagnosis and treatment of Lyme disease. Patients with persistent symptoms after standard (2-4-week) antibiotic therapy for this tickborne illness have been denied further antibiotic treatment as a result of the perception that long-term infection with the Lyme spirochete, Borrelia burgdorferi, and associated tickborne pathogens is rare or nonexistent. METHODS I review the pathophysiology of B. burgdorferi infection and the peer-reviewed literature on diagnostic Lyme disease testing, standard treatment results, and coinfection with tickborne agents, such as Babesia, Anaplasma, Ehrlichia, and Bartonella species. I also examine uncontrolled and controlled trials of prolonged antibiotic therapy in patients with persistent symptoms of Lyme disease. RESULTS The complex "stealth" pathology of B. burgdorferi allows the spirochete to invade diverse tissues, elude the immune response, and establish long-term infection. Commercial testing for Lyme disease is highly specific but relatively insensitive, especially during the later stages of disease. Numerous studies have documented the failure of standard antibiotic therapy in patients with Lyme disease. Previous uncontrolled trials and recent placebo-controlled trials suggest that prolonged antibiotic therapy (duration, >4 weeks) may be beneficial for patients with persistent Lyme disease symptoms. Tickborne coinfections may increase the severity and duration of infection with B. burgdorferi. CONCLUSIONS Prolonged antibiotic therapy may be useful and justifiable in patients with persistent symptoms of Lyme disease and coinfection with tickborne agents.
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244
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Nau R, Schmidt H. Long-term neuropsychological deficits after central nervous system infections despite adequate therapy. J Neurol 2007; 254 Suppl 2:II80-3. [PMID: 17503137 DOI: 10.1007/s00415-007-2019-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neuropsychological deficits are common consequences of central nervous system infections despite adequate treatment. The frequency and severity depends on the causative pathogen and the site(s) of injured brain parenchyma. The severity ranges from mild cognitive abnormalities not interfering with everyday life performance to fully developed Wernicke-Korsakow syndrome with complete inability to incorporate new information into long-term memory and to persistent vegetative state. In several conditions, rapid initiation of adequate therapy is crucial to minimise neuropsychological impairment.
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Affiliation(s)
- Roland Nau
- Dept. of Neurology, Georg-August-University, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
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245
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Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt LK, Fish D, Dumler JS, Nadelman RB. Reply to Pollock, Donta, Wilson, and Arne. Clin Infect Dis 2007. [DOI: 10.1086/513029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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246
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Jarefors S, Janefjord CK, Forsberg P, Jenmalm MC, Ekerfelt C. Decreased up-regulation of the interleukin-12Rbeta2-chain and interferon-gamma secretion and increased number of forkhead box P3-expressing cells in patients with a history of chronic Lyme borreliosis compared with asymptomatic Borrelia-exposed individuals. Clin Exp Immunol 2007; 147:18-27. [PMID: 17177959 PMCID: PMC1810439 DOI: 10.1111/j.1365-2249.2006.03245.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Lyme borreliosis (LB) can, despite adequate antibiotic treatment, develop into a chronic condition with persisting symptoms such as musculoskeletal pain, subjective alteration of cognition and fatigue. The mechanism behind this is unclear, but it has been postulated that an aberrant immunological response might be the cause. In this study we investigated the expression of the T helper 1 (Th1) marker interleukin (IL)-12Rbeta2, the marker for T regulatory cells, forkhead box P3 (FoxP3) and the cytokine profile in patients with a history of chronic LB, subacute LB, previously Borrelia-exposed asymptomatic individuals and healthy controls. Fifty-four individuals (12 chronic LB, 14 subacute LB, 14 asymptomatic individuals and 14 healthy controls) were included in the study and provided a blood sample. Mononuclear cells were separated from the blood and stimulated with antigens. The IL-12Rbeta2 and FoxP3 mRNA expression was analysed with real-time reverse transcription-polymerase chain reaction (RT-PCR). The protein expression of IL-12Rbeta2 on CD3(+), CD4(+), CD8(+) and CD56(+) cells was assessed by flow cytometry. Furthermore, the secretion of interferon (IFN)-gamma, IL-4, IL-5, IL-10, IL-12p70 and IL-13 was analysed by enzyme-linked immunospot (ELISPOT) and/or enzyme-linked immunosorbent assay (ELISA). Chronic LB patients displayed a lower expression of Borrelia-specific IL-12Rbeta2 on CD8(+) cells and also a lower number of Borrelia-specific IFN-gamma-secreting cells compared to asymptomatic individuals. Furthermore, chronic LB patients had higher amounts of Borrelia-specific FoxP3 mRNA than healthy controls. We speculate that this may indicate that a strong Th1 response is of importance for a positive outcome of a Borrelia infection. In addition, regulatory T cells might also play a role, by immunosuppression, in the development of chronic LB.
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Affiliation(s)
- S Jarefors
- Division of Clinical Immunology, Faculty of Health Sciences, University of Linköping, Sweden.
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247
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Feder HM, Abeles M, Bernstein M, Whitaker-Worth D, Grant-Kels JM. Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis. Clin Dermatol 2007; 24:509-20. [PMID: 17113969 DOI: 10.1016/j.clindermatol.2006.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most patients with erythema migrans, the pathognomonic rash of Lyme disease, do not recall a deer tick bite. The rash is classically 5 to 68 cm of annular homogenous erythema (59%), central erythema (30%), central clearing (9%), or central purpura (2%). Serologic testing is not indicated for patients with erythema migrans, because initially, the result is usually negative. Successful treatment of a patient with erythema migrans can be accomplished with 20 days of oral doxycycline, amoxicillin, or cefuroxime axetil. Patients with Lyme arthritis usually present with a mildly painful swollen knee. Patients with Lyme arthritis have markedly positive serology and can usually be successfully treated with 28 days of oral doxycycline or amoxicillin. Some patients may have persistent effusion despite 4 to 8 weeks of antibiotics and may need synovectomy. Persistent effusion is not due to persistent infection. Antibiotic therapy for more than 8 weeks for patients with Lyme disease is not indicated. Chronic Lyme disease due to antibiotic resistant infection has not been demonstrated.
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Affiliation(s)
- Henry M Feder
- Division of Infectious Diseases, University of Connecticut Health Center, Farmington, CT 06030, USA.
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248
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Ogrinc K, Logar M, Lotric-Furlan S, Cerar D, Ruzić-Sabljić E, Strle F. Doxycycline versus ceftriaxone for the treatment of patients with chronic Lyme borreliosis. Wien Klin Wochenschr 2006; 118:696-701. [PMID: 17160610 DOI: 10.1007/s00508-006-0698-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic guidelines for treatment of late manifestations of Lyme borreliosis have not yet become well established. Patients with symptoms suggesting central nervous system involvement are often treated with courses of intravenous ceftriaxone. This is an expensive treatment approach with potentially severe side effects. We compared the efficacy, side effects and costs of doxycycline and ceftriaxone in the treatment of such patients. PATIENTS AND METHODS Adult patients qualified for the study if they had nonspecific symptoms suggesting central nervous system involvement for more than six months (but without overt clinical signs of the involvement), had positive serum borrelial antibody titers and/or erythema migrans prior to the onset of symptoms, had not been previously treated with antibiotics and did not have pleocytosis in the cerebrospinal fluid. Patients were given either 100 mg of oral doxycycline twice daily for 4 weeks (23 patients) or 2 g of intravenous ceftriaxone daily for 2 weeks followed by 100 mg of doxycycline twice daily for another 2 weeks (23 patients). Clinical outcome was assessed during a 12-month follow-up period. RESULTS Improvement in the frequency and/or the intensity of symptoms was reported by more than two-thirds of the 46 patients enrolled in the study. The two treatment regimens were found to be correspondingly effective. Photosensitivity reactions and gastrointestinal symptoms were noted more often among patients receiving doxycycline than in those receiving ceftriaxone. Treatment with doxycycline proved to be much cheaper than with ceftriaxone. CONCLUSIONS In patients with previously untreated chronic Lyme borreliosis with symptoms suggesting central nervous system involvement but without overt clinical signs of it, and without pleocytosis in the cerebrospinal fluid, treatment with doxycycline is as effective as with ceftriaxone. Treatment with doxycycline is cheap and relatively safe, but gastrointestinal symptoms and photosensitivity reactions can be expected more often than with ceftriaxone.
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Affiliation(s)
- Katarina Ogrinc
- Department of Infectious Diseases, University Medical Center Ljubljana, Slovenia.
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249
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Cameron DJ. Generalizability in two clinical trials of Lyme disease. EPIDEMIOLOGIC PERSPECTIVES & INNOVATIONS : EP+I 2006; 3:12. [PMID: 17044928 PMCID: PMC1626453 DOI: 10.1186/1742-5573-3-12] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 10/17/2006] [Indexed: 11/30/2022]
Abstract
Objective To examine the generalizability of two National Institutes of Health (NIH)-funded double-blind randomized placebo-controlled clinical trials in patients with chronic Lyme disease and to determine whether selection factors resulted in the unfavorable outcomes. Design Epidemiologic review of the generalizability of two trials conducted by Klempner et al. This paper considers whether the study group was representative of the general chronic Lyme disease population. Results In their article in The New England Journal of Medicine, Klempner et al. failed to discuss the limitations of their clinical trials. This epidemiologic review argues that their results are not generalizable to the overall Lyme disease population. The treatment failure reported by the authors may be the result of enrolling patients who remained ill after an average of 4.7 years and an average of 3 previous courses of treatment. The poor outcome cited in these trials may be explained by having selected patients who had undergone delayed treatment or multiple treatments unsuccessfully. These selection factors were not addressed by the studies' authors, nor have they been discussed by reviewers. The trials have been over-interpreted by the NIH and widely publicized in a press release. The results have been extrapolated to other groups of Lyme disease patients by commentators, by a case discussant in an influential medical journal, and by health insurance companies to deny antibiotic treatment. Conclusion The Klempner et al. trials are assumed to be internally valid based on a Randomized Control Trial (RCT) design. However, this review argues that the trials have limited generalizability beyond the select group of patients with characteristics like those in the trial. Applying the findings to target populations with characteristics that differ from those included in these trials is inappropriate and may limit options for chronic Lyme disease patients who might benefit from antibiotic treatment.
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Affiliation(s)
- Daniel J Cameron
- Division of Medicine, First Medical Associates, 175 Main Street, Mt Kisco, NY 10549, USA.
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Pícha D, Moravcova L, Lasikova S, Holeckova D, Maresova V. Symptoms of post-Lyme syndrome in long-term outcome of patients with neuroborreliosis. ACTA ACUST UNITED AC 2006; 38:747-8. [PMID: 16857637 DOI: 10.1080/00365540600810000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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