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Baarsma ME, Hovius JW. Persistent Symptoms After Lyme Disease: Clinical Characteristics, Predictors, and Classification. J Infect Dis 2024; 230:S62-S69. [PMID: 39140720 DOI: 10.1093/infdis/jiae203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
Persistent symptoms after an infection have been described for a number of infectious diseases, including Lyme disease. Studies have confirmed a moderate but consistent increase in the prevalence of such symptoms after Lyme disease, though the risk increase varies dependent on study design and the definition of persistent symptoms. Various possible predictors have been proposed, including a dysregulation of the immune system, metabolic changes, increased sensitization to pain signals, cognitive-behavioral factors, or-controversially-the persistence of the causative Borrelia bacteria or remnants thereof. Research on the precise roles of any of these factors is still ongoing. The lack of biological underpinning also makes it difficult to assess with certainty which patients' (generally nonspecific) persistent symptoms are etiologically related to the previous Lyme disease episode and which are not, particularly as these symptoms occur in the general population relatively frequently. The diagnostic criteria for posttreatment Lyme disease syndrome have shown their usefulness in both clinical and research settings but leave out a number of patients whose symptoms may fall just outside said criteria. Though the relationship between these symptoms and the previous Lyme disease episode may be very uncertain, we would argue that a uniform description and classification of these patients will aid in future research and patient management, regardless of the eventual underlying cause. Thus, we argue for an inclusive classification system for all persistent symptoms attributed to Lyme disease in order to promote validation of patient experiences and perspectives, while also maintaining scientific nuance regarding the very uncertain etiology of these patients' symptoms.
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Affiliation(s)
- M E Baarsma
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Immunology and Infectious Diseases, Amsterdam, The Netherlands
| | - Joppe W Hovius
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Immunology and Infectious Diseases, Amsterdam, The Netherlands
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Dersch R, Torbahn G, Rauer S. Treatment of post-treatment Lyme disease symptoms-a systematic review. Eur J Neurol 2024; 31:e16293. [PMID: 38606630 PMCID: PMC11235603 DOI: 10.1111/ene.16293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/01/2024] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND AND PURPOSE Residual symptoms after treatment of Lyme disease, sometimes called post-treatment Lyme disease symptoms (PTLDs), are a matter of ongoing controversy. To guide treatment recommendations, a systematic review was performed of the available literature on specific treatment for PTLDs. METHODS A systematic literature search of MEDLINE and CENTRAL was performed. No restrictions on case definitions, study types or specific interventions were applied to enable a comprehensive overview of the available literature. Risk of bias was assessed using the Cochrane risk of bias tools for randomized controlled trials. Certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. Outcomes of interest were quality of life, fatigue, depression and cognition as well as adverse events. RESULTS After screening 1274 records, eight eligible randomized controlled trials were included. Heterogeneity was observed regarding inclusion criteria, intervention, length of treatment and outcome measures. For efficacy outcomes, results are presented narratively due to heterogeneity. Eligible studies show no statistically significant difference between antibiotics and placebo regarding quality of life, cognition and depression. Results for fatigue were inconsistent whilst studies with low risk of bias showed no statistically significant difference between antibiotics and placebo. Meta-analysis of safety outcomes showed statistically significantly more adverse events for antibiotics compared to placebo. CONCLUSIONS Available literature on treatment of PTLDs is heterogeneous, but overall shows evidence of no effect of antibiotics regarding quality of life, depression, cognition and fatigue whilst showing more adverse events. Patients with suspected PTLDs should not be treated with antibiotics.
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Affiliation(s)
- Rick Dersch
- Clinic of Neurology and NeurophysiologyMedical Center—University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Gabriel Torbahn
- Department of PediatricsParacelsus Medical UniversityKlinikum NürnbergUniversitätsklinik der Paracelsus Medizinischen Privatuniversität NürnbergNurembergGermany
| | - Sebastian Rauer
- Clinic of Neurology and NeurophysiologyMedical Center—University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
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Abstract
Most patients with Lyme disease will fully recover with recommended antibiotic therapy. However, some patients report persisting nonspecific symptoms after treatment, referred to as posttreatment Lyme disease symptoms (PTLDs) or syndrome (PTLDS), depending on the degree to which the individual's symptoms impact their quality of life. PTLDs occur in a portion of patients diagnosed with chronic Lyme disease (CLD), a controversial term describing different patient populations, diagnosed based on unvalidated tests and criteria. Practitioners should review the evidence for the Lyme disease diagnosis and not overlook unrelated conditions. Current evidence shows that prolonged antibiotic therapy provides little benefit and carries significant risk. Further research to elucidate the mechanisms underlying persistent symptoms after Lyme disease and to understand CLD is needed.
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Affiliation(s)
- Adriana Marques
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, BG 10 RM 12C118 MSC 1888 10 Center, Bethesda, MD 20892-1888, USA.
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Brellier F, Pujades-Rodriguez M, Powell E, Mudie K, Mattos Lacerda E, Nacul L, Wing K. Incidence of Lyme disease in the United Kingdom and association with fatigue: A population-based, historical cohort study. PLoS One 2022; 17:e0265765. [PMID: 35320297 PMCID: PMC8942220 DOI: 10.1371/journal.pone.0265765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 03/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background Estimations of Lyme disease incidence rates in the United Kingdom vary. There is evidence that this disease is associated with fatigue in its early stage but reports are contradictory as far as long-term fatigue is concerned. Methods and findings A population-based historical cohort study was conducted on patients treated in general practices contributing to IQVIA Medical Research Data: 2,130 patients with a first diagnosis of Lyme disease between 2000 and 2018 and 8,510 randomly-sampled patients matched by age, sex, and general practice, followed-up for a median time of 3 years and 8 months. Main outcome measure was time to consultation for (1) any fatigue-related symptoms or diagnosis; or (2) myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Adjusted hazard ratios (HRs) were estimated from Cox models. Average incidence rate for Lyme disease across the UK was 5.18 per 100,000 person-years, increasing from 2.55 in 2000 to 9.33 in 2018. In total, 929 events of any types of fatigue were observed, leading to an incidence rate of 307.90 per 10,000 person-years in the Lyme cohort (282 events) and 165.60 in the comparator cohort (647 events). Effect of Lyme disease on any subsequent fatigue varied by index season: adjusted HRs were the highest in autumn and winter with 3.14 (95%CI: 1.92–5.13) and 2.23 (1.21–4.11), respectively. For ME/CFS, 17 events were observed in total. Incidence rates were 11.76 per 10,000 person-years in Lyme patients (12 events) and 1.20 in comparators (5 events), corresponding to an adjusted HR of 16.95 (5.17–55.60). Effects were attenuated 6 months after diagnosis but still clearly visible. Conclusions UK primary care records provided strong evidence that Lyme disease was associated with subsequent fatigue and ME/CFS. Albeit weaker on the long-term, these effects persisted beyond 6 months, suggesting patients and healthcare providers should remain alert to fatigue symptoms months to years following Lyme disease diagnosis.
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Affiliation(s)
| | | | - Emma Powell
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kathleen Mudie
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eliana Mattos Lacerda
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Luis Nacul
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- British Columbia Womens Hospital and Health Centre, Complex Chronic Diseases Program, Vancouver, Canada
- Department of Family Practice, University of British Columbia, Vancouver, Canada
| | - Kevin Wing
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ursinus J, Vrijmoeth HD, Harms MG, Tulen AD, Knoop H, Gauw SA, Zomer TP, Wong A, Friesema IH, Vermeeren YM, Joosten LA, Hovius JW, Kullberg BJ, van den Wijngaard CC. Prevalence of persistent symptoms after treatment for lyme borreliosis: A prospective observational cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2021; 6:100142. [PMID: 34557833 PMCID: PMC8454881 DOI: 10.1016/j.lanepe.2021.100142] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Concerns about long-lasting symptoms attributed to Lyme borreliosis (LB) are widespread in the Western world, while such symptoms are highly prevalent in the general population. METHODS In the largest prospective study to date, adults with physician-confirmed LB were included at the start of antibiotic treatment. Primary outcomes, prevalence of persistent symptoms and symptom severity, were assessed using three-monthly standardised questionnaires during one year. Persistent symptoms were defined as impaired scores for fatigue (CIS, subscale fatigue), cognitive impairment (CFQ) or pain (SF-36, subscale bodily pain) ≥6 months, with onset <6 months. Outcomes were compared with a longitudinal general population and a tick-bite cohort without LB as a reference. FINDINGS Of 1135 LB patients (94•8% erythema migrans, 5•2% disseminated LB), 1084 fulfilled primary analysis criteria, as well as 1942 population and 1887 tick-bite controls. Overall prevalence of persistent symptoms in LB patients was 27•2% (95%CI, 24•7%-29•7%); 6•0% and 3•9% higher than in population (21•2%, 95%CI, 19•3%-23•1%; p < 0•0001) and tick-bite (23•3%, 95%CI 21•3%-25•3%; p = 0•016) cohorts, respectively. At 12 months, fatigue, cognitive impairment, and pain were significantly more severe in erythema migrans patients than in reference cohorts, while in disseminated LB patients, only pain was more severe. INTERPRETATION In treated LB patients, persistent symptoms were significantly more prevalent and symptoms were more severe than in individuals without LB, although the background prevalence was substantial. This suggests an association, either direct or indirect, between persistent symptoms and LB in a relatively small subset of patients. FUNDING ZonMw; Dutch Ministry of Health, Welfare and Sport.
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Key Words
- ACA, Acrodermatitis chronica atrophicans
- CFQ, Cognitive Failure Questionnaire
- CIS, Checklist Individual Strength
- EM, Erythema migrans
- LB, Lyme borreliosis
- PCR, Polymerase Chain Reaction
- PHQ-15, Patient Health Questionnaire
- PTLDS, Post-treatment Lyme Disease Syndrome
- SF-36, SF-36 item Health Survey
- TiC-P, Treatment Inventory of Costs in Patients with psychiatric disorders
- s.l., sensu lato
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Affiliation(s)
- Jeanine Ursinus
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, Netherlands
| | - Hedwig D. Vrijmoeth
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases (RCI), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Margriet G. Harms
- National Institute for Public Health and the Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, Netherlands
| | - Anna D. Tulen
- National Institute for Public Health and the Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, Netherlands
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, Netherlands
| | - Stefanie A. Gauw
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, Netherlands
| | - Tizza P. Zomer
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300 DS, Apeldoorn, Netherlands
| | - Albert Wong
- National Institute for Public Health and the Environment (RIVM), Department for Statistics, Informatics and Modeling, P.O. Box 1, 3720 BA, Bilthoven, Netherlands
| | - Ingrid H.M. Friesema
- National Institute for Public Health and the Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, Netherlands
| | - Yolande M. Vermeeren
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300 DS, Apeldoorn, Netherlands
| | - Leo A.B. Joosten
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases (RCI), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Joppe W. Hovius
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, Netherlands
| | - Bart Jan Kullberg
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases (RCI), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Cees C. van den Wijngaard
- National Institute for Public Health and the Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, Netherlands
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Pascal C, Arquembourg J, Vorilhon P, Lesens O. Emergence of Lyme disease as a social problem: analysis of discourse using the media content. Eur J Public Health 2021; 30:504-510. [PMID: 31688903 DOI: 10.1093/eurpub/ckz198] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Chronic Lyme disease (LD) is a matter of debate worldwide and has emerged as a social problem. We aim to analyze the media content and describe the transformation process of a collective pain into a social problem in France. METHODS Using social science methodology, a corpus of articles from 20 newspapers and videos from seven major TV stations from 1987 to 2017 were analyzed for discourse content. The speaking times and the frequency of interventions between doctors supporting the official guidelines and those against them were compared using the Mann-Whitney test and the Chi-square test, respectively. RESULTS In France, the media discourse is carried through testimonials from patient organizations and a professor of infectiology who acted as a whistleblower (WB). We showed that the emergence of the LD alert in the media corresponds to the process described by social sciences as 'naming, blaming, claiming'. Since his first article in 2014, the WB has featured in 24% (22/89) of newspaper articles compared with 20% (18/89) for doctors defending the official guidelines (P = 0.52). Since his first appearance on a TV newscast in 2014, the WB has appeared in 45% (22/49) of news reports on LD with 24% of the speaking time compared with 22% (11/49) for doctors defending the official guidelines (P = 0.018). CONCLUSIONS Media coverage of LD has been unbalanced since 2014 and promotes associations as well as the WB, who seems to be better identified than any of the different doctors defending the official guidelines.
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Affiliation(s)
- Clélia Pascal
- Infectious and Tropical Diseases Department, CRIOA, CHU Clermont-Ferrand, Clermont-Ferrand, France.,UMR CNRS 6023, Laboratoire Microorganismes: Génome Environnement (LMGE), Université Clermont Auvergne, Clermont-Ferrand, France
| | - Jocelyne Arquembourg
- Sciences de l'Information et de la Communication, Université Sorbonne Nouvelle - Paris3, Paris, France
| | - Philippe Vorilhon
- Department of General Practice, Institut Pascal, CNRS, SIGMA Clermont, Clermont Auvergne University, Clermont-Ferrand, France
| | - Olivier Lesens
- Infectious and Tropical Diseases Department, CRIOA, CHU Clermont-Ferrand, Clermont-Ferrand, France.,UMR CNRS 6023, Laboratoire Microorganismes: Génome Environnement (LMGE), Université Clermont Auvergne, Clermont-Ferrand, France
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7
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van Middendorp H, Berende A, Vos FJ, Ter Hofstede HHM, Kullberg BJ, Evers AWM. Expectancies as predictors of symptom improvement after antimicrobial therapy for persistent symptoms attributed to Lyme disease. Clin Rheumatol 2021; 40:4295-4308. [PMID: 34031759 PMCID: PMC8463383 DOI: 10.1007/s10067-021-05760-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION/OBJECTIVE Expectancies about symptom improvement or deterioration are reliable predictors of symptom progression and treatment outcomes (symptom resolution or symptomatic improvement) in many (non-)pharmacological studies and treatments. This study examined predictors of symptom improvement after antimicrobial therapy for persistent symptoms attributed to Lyme disease, hypothesizing particularly pre-treatment expectancies regarding symptom improvement to be predictive. METHODS A predictive study was performed on pre-treatment and post-treatment individual characteristics, including expectancies, and physical and mental health-related quality of life (HRQoL) from the PLEASE-trial comparing randomized 12-weeks of doxycycline, clarithromycin-hydroxychloroquine, or placebo following 2 weeks of intravenous ceftriaxone. At end-of-treatment (14 weeks after trial start) and follow-up (52 weeks), complete data of 231 and 170 (of initial 280) patients with persistent symptoms temporally related to a history of erythema migrans or otherwise confirmed symptomatic Lyme disease, or accompanied by B. burgdorferi IgG or IgM antibodies, were examined through hierarchical regression analyses. RESULTS In addition to pre-treatment HRQoL, pre-treatment expectancies regarding symptom improvement were consistently associated with stronger physical and mental HRQoL improvements at both end-of-treatment and follow-up (95% CI range: .09;.54, p < .01 to .27;.92, p < .001). Post-treatment expectancies regarding having received antibiotics vs. placebo was associated with more HRQoL improvement at end-of-treatment, but not at follow-up (95% CI-range 1.00;4.75, p = .003 to -7.34; -2.22, p < .001). CONCLUSIONS The present study shows that, next to pre-treatment functioning, patients' pre-treatment and post-treatment expectancies regarding improvement of persistent symptoms attributed to Lyme disease relate to a more beneficial symptom course. Expectancies of patients may be relevant to explain and potentially improve patient outcomes (e.g., by optimized communication about treatment success). TRIAL REGISTRATION ClinicalTrials.gov, NCT01207739 (Registration date: 23-09-2010) Key Points • As there is currently no sufficient symptom resolution or symptomatic improvement for many patients with persistent symptoms attributed to Lyme disease, it is relevant to know which factors determine symptom progression and predict heterogeneity in treatment response. • Next to pre-treatment functioning, expectancies regarding symptom improvement and having received antimicrobial study medication are associated with a more beneficial symptom course after both shorter-term and longer-term antimicrobial treatment. • Expectancies are relevant to consider in treatment studies and may be useful in clinical settings to improve symptom course and treatment outcome (e.g., by optimized communication about treatment success).
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Affiliation(s)
- Henriët van Middendorp
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, PO Box 9555, 2300 RB, Leiden, The Netherlands.
| | - Anneleen Berende
- Department of Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Gelre Ziekenhuizen, Apeldoorn, The Netherlands
| | - Fidel J Vos
- Department of Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Hadewych H M Ter Hofstede
- Department of Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart Jan Kullberg
- Department of Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, PO Box 9555, 2300 RB, Leiden, The Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
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Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:e1-e48. [PMID: 33417672 DOI: 10.1093/cid/ciaa1215] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
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Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
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9
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Macnofsky R, Chow EJ. Seasons of Coronavirus Disease 2019. Open Forum Infect Dis 2021; 8:ofab146. [PMID: 34136586 PMCID: PMC8083713 DOI: 10.1093/ofid/ofab146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/23/2021] [Indexed: 11/25/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality. Although much of the focus has been on the management and treatment of acute COVID-19, some patients have experienced prolonged symptoms after their acute infection had resolved. In this perspective, a patient shares her experience of postacute COVID-19, highlighting a journey of a revolving door of symptoms. Her infectious disease physician summarizes the next steps required to better care for this growing group of patients.
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Affiliation(s)
| | - Eric J Chow
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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10
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Abstract
PURPOSE OF REVIEW Lyme disease is an important, vector-borne infection found throughout the temperate Northern hemisphere. The disease causes rash, acute systemic illness, and in some untreated patients, inflammatory arthritis. This review examines the emergence, clinical features and management of early Lyme disease and Lyme arthritis. RECENT FINDINGS There has been continuing progress in characterizing the clinical manifestations, diagnostic testing and treatment of Lyme disease. Almost all patients with early Lyme disease can be cured with antibiotic treatment. In most cases, Lyme arthritis also responds to antibiotics, but some patients require additional treatment approaches. SUMMARY The diagnosis of Lyme disease is based on clinical manifestations and adjunctive laboratory testing. For the rheumatologist, Lyme arthritis should be recognized by a pattern of attacks of asymmetric, oligo-arthritis, recognizable by clinical manifestations in the same way that other rheumatic diseases, such as gout or rheumatoid arthritis, are diagnosed.
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11
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Abstract
PURPOSE OF REVIEW Since recognition in 1975, Lyme disease has become the most common vector-borne illness in North America and Europe. The clinical features are well-characterized and treatment is usually curative, but misperceptions about morbidity persist. The purpose of this review is to examine advances in the diagnosis and treatment of Lyme disease, as well as ongoing management challenges. RECENT FINDINGS It is useful to recognize that Lyme disease occurs in stages, with early- and late-stage disease. Clinical expression is in part determined by Borrelial variability. For example, some strains of Borrelia burgdorferi, the causative organism in North America, are particularly arthritogenic. Most patients with early Lyme disease can be cured with a single course of oral antibiotic therapy, in contrast to some patients with Lyme arthritis, a late-stage manifestation, who are more antibiotic refractory and require other treatment strategies. Successful treatment of Lyme disease begins with successful diagnosis and with an understanding of the emergence, clinical features, and impact of Lyme disease over the past half century.
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Affiliation(s)
- Robert T Schoen
- Section of Rheumatology, Allergy and Clinical Immunology, Yale University School of Medicine, 60 Temple Street, Suite 6A, New Haven, CT, 06510, USA.
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12
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van de Schoor FR, Baarsma ME, Gauw SA, Joosten LAB, Kullberg BJ, van den Wijngaard CC, Hovius JW. Validation of cellular tests for Lyme borreliosis (VICTORY) study. BMC Infect Dis 2019; 19:732. [PMID: 31429716 PMCID: PMC6700813 DOI: 10.1186/s12879-019-4323-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/26/2019] [Indexed: 11/21/2022] Open
Abstract
Background Lyme borreliosis (LB) is a tick-borne disease caused by spirochetes belonging to the Borrelia burgdorferi sensu lato species. Due to a variety of clinical manifestations, diagnosing LB can be challenging, and laboratory work-up is usually required in case of disseminated LB. However, the current standard of diagnostics is serology, which comes with several shortcomings. Antibody formation may be absent in the early phase of the disease, and once IgG-seroconversion has occurred, it can be difficult to distinguish between a past (cured or self-cleared) LB and an active infection. It has been postulated that novel cellular tests for LB may have both higher sensitivity earlier in the course of the disease, and may be able to discriminate between a past and active infection. Methods VICTORY is a prospective two-gate case-control study. We strive to include 150 patients who meet the European case definitions for either localized or disseminated LB. In addition, we aim to include 225 healthy controls without current LB and 60 controls with potentially cross-reactive conditions. We will perform four different cellular tests in all of these participants, which will allow us to determine sensitivity and specificity. In LB patients, we will repeat cellular tests at 6 weeks and 12 weeks after start of antibiotic treatment to assess the usefulness as ‘test-of-cure’. Furthermore, we will investigate the performance of the different cellular tests in a cohort of patients with persistent symptoms attributed to LB. Discussion This article describes the background and design of the VICTORY study protocol. The findings of our study will help to better appreciate the utility of cellular tests in the diagnosis of Lyme borreliosis. Trial registration NL7732 (Netherlands Trial Register, trialregister.nl). Electronic supplementary material The online version of this article (10.1186/s12879-019-4323-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F R van de Schoor
- Radboudumc, Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI) and Radboud Institute of Health Sciences (RIHS), P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - M E Baarsma
- Amsterdam UMC, University of Amsterdam, Center for Experimental and Molecular Medicine, Amsterdam Institute of Infection and Immunology, P.O. Box 22660, 1100, DD, Amsterdam, The Netherlands
| | - S A Gauw
- Amsterdam UMC, University of Amsterdam, Center for Experimental and Molecular Medicine, Amsterdam Institute of Infection and Immunology, P.O. Box 22660, 1100, DD, Amsterdam, The Netherlands
| | - L A B Joosten
- Radboudumc, Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI) and Radboud Institute of Health Sciences (RIHS), P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - B J Kullberg
- Radboudumc, Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI) and Radboud Institute of Health Sciences (RIHS), P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - C C van den Wijngaard
- National Institute for Public Health and the Environment (RIVM), Center of Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands
| | - J W Hovius
- Amsterdam UMC, University of Amsterdam, Center for Experimental and Molecular Medicine, Amsterdam Institute of Infection and Immunology, P.O. Box 22660, 1100, DD, Amsterdam, The Netherlands.
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Abstract
PURPOSE OF REVIEW This article presents an overview of the current diagnosis and management of two spirochetal infections of the nervous system, neuroborreliosis (Lyme disease) and neurosyphilis, focusing on similarities and differences. Although neuroborreliosis was first identified almost a century ago, much confusion remains about how to accurately diagnose this quite treatable nervous system infection. Well-established diagnostic tools and therapeutic regimens exist for neurosyphilis, which has been well-known for centuries. RECENT FINDINGS Serologic testing targeting the C6 antigen may simplify diagnostic testing in neuroborreliosis while improving accuracy. Historically, screening for syphilis has used a reaginic test followed by a treponeme-specific assay; alternative approaches, including use of well-defined recombinant antigens, may improve sensitivity without sacrificing specificity. In neuroborreliosis, measurement of the chemokine CXCL13 in CSF may provide a useful marker of disease activity in the central nervous system. SUMMARY Lyme disease causes meningitis, cranial neuritis, radiculitis, and mononeuropathy multiplex. Cognitive symptoms, occurring either during (encephalopathy) or after infection (posttreatment Lyme disease syndrome) are rarely, if ever, due to central nervous system infection. Posttreatment Lyme disease syndrome is not antibiotic responsive. Syphilis causes meningitis, cranial neuritis, chronic meningovascular syphilis, tabes dorsalis, and parenchymal neurosyphilis. The organism remains highly sensitive to penicillin, but residua of chronic infection may be irreversible.
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14
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Vrijmoeth HD, Ursinus J, Harms MG, Zomer TP, Gauw SA, Tulen AD, Kremer K, Sprong H, Knoop H, Vermeeren YM, van Kooten B, Joosten LAB, Kullberg BJ, Hovius JWR, van den Wijngaard CC. Prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis: study protocol for an observational, prospective cohort study (LymeProspect). BMC Infect Dis 2019; 19:324. [PMID: 30987580 PMCID: PMC6466793 DOI: 10.1186/s12879-019-3949-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/03/2019] [Indexed: 01/23/2023] Open
Abstract
Background After antibiotic treatment of Lyme borreliosis, a subset of patients report persistent symptoms, also referred to as post-treatment Lyme disease syndrome. The reported prevalence of persistent symptoms varies considerably, and its pathophysiology is under debate. The LymeProspect study has been designed to investigate the prevalence, severity, and a wide range of hypotheses on the etiology of persistent symptoms among patients treated for Lyme borreliosis in the Netherlands. Methods LymeProspect is a prospective, observational cohort study among adults with proven or probable Lyme borreliosis, either erythema migrans or disseminated manifestations, included at the start of antibiotic treatment. During one year of follow-up, participants are subjected to questionnaires every three months and blood is collected repeatedly during the first three months. The primary outcome is the prevalence of persistent symptoms after treatment, assessed by questionnaires online focusing on fatigue (CIS, subscale fatigue severity), pain (SF-36, subscale pain) and neurocognitive dysfunction (CFQ). Potential microbiological, immunological, genetic, epidemiological and cognitive-behavioral determinants for persistent symptoms are secondary outcome measures. Control cohorts include patients with long-lasting symptoms and unconfirmed Lyme disease, population controls, and subjects having reported a tick bite not followed by Lyme borreliosis. Discussion This article describes the background and design of the LymeProspect study protocol. This study is characterized by a prospective, explorative and multifaceted design. The results of this study will provide insights into the prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis, and may provide a rationale for preventive and treatment recommendations. Trial registration NTR4998 (Netherlands Trial Register). Date of registration: 13 February 2015. Electronic supplementary material The online version of this article (10.1186/s12879-019-3949-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hedwig D Vrijmoeth
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Jeanine Ursinus
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands. .,National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands.
| | - Margriet G Harms
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Tizza P Zomer
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300, DS, Apeldoorn, the Netherlands
| | - Stefanie A Gauw
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands
| | - Anna D Tulen
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Kristin Kremer
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Hein Sprong
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands
| | - Yolande M Vermeeren
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300, DS, Apeldoorn, the Netherlands
| | - Barend van Kooten
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300, DS, Apeldoorn, the Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Bart-Jan Kullberg
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Joppe W R Hovius
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands
| | - Cees C van den Wijngaard
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
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15
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Weitzner E, Visintainer P, Wormser GP. Impact of patient age on clinical features, serologic test reactivity and long-term outcome of culture-confirmed early Lyme disease. Diagn Microbiol Infect Dis 2017; 89:300-302. [PMID: 29137719 DOI: 10.1016/j.diagmicrobio.2017.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 12/17/2022]
Abstract
Whether age at time of diagnosis impacts the clinical presentation or long-term outcome of early Lyme disease is unknown. Subjects enrolled in this study had culture-confirmed early Lyme disease and were followed up annually in a long-term prospective study. Subjects ≤50years of age were compared with those who were ≥51years of age at time of study entry. Of the 283 enrolled subjects, the ≥51year old age group was significantly more likely to be female (P=0.0095) and to be compliant with long-term follow-up of at least 11years duration (P=0.0119). There were no significant differences between the two age groups with regard to any of the other variables assessed at presentation. For the 128 subjects who were followed up for 11-20years, there was no significant difference between the two age groups in the frequency, number or type of residual symptoms. The older age group at study entry, however, was significantly more likely to develop an intercurrent comorbidity (P=0.0017), and there was a trend toward a greater likelihood of having an intercurrent hospitalization (P=0.0311). Among the 128 subjects followed up for 11-20years, the older age group at study entry returned for a significantly greater number of follow-up visits (P=0.0129). In conclusion, older age at the time of diagnosis of early Lyme disease did not impact the initial clinical features or long-term outcome of this infection. Not unexpectedly, older patients had more comorbidities during long-term follow-up.
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Affiliation(s)
- Erica Weitzner
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | | | - Gary P Wormser
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595.
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16
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Eliassen KE, Hjetland R, Reiso H, Lindbæk M, Tschudi-Madsen H. Symptom load and general function among patients with erythema migrans: a prospective study with a 1-year follow-up after antibiotic treatment in Norwegian general practice. Scand J Prim Health Care 2017; 35:75-83. [PMID: 28277054 PMCID: PMC5361422 DOI: 10.1080/02813432.2017.1288812] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Promptly treated erythema migrans (EM) has good prognosis. However, some patients report persistent symptoms. Do patients with EM have more symptoms than the general population? We describe individual symptoms and general function in EM-patients at time of diagnosis and one year after treatment. DESIGN Prospective study with 1-year follow up after treatment. Questionnaires included a modified version of the Subjective Health Complaints Inventory, comprising three additional Lyme borreliosis (LB) related symptoms. General function was assessed using a five-point scale modified from the COOP/WONCA charts. SETTING Norwegian general practice. SUBJECTS A total of 188 patients were included in a randomized controlled trial comparing three antibiotic regimens for EM, of whom 139 had complete data for this study. MAIN OUTCOME MEASURES Individual symptoms, symptom load and general function. RESULTS Mild symptoms were common, reported by 84.9% at baseline and by 85.6% at follow-up. At baseline, patients reported a mean of 5.4 symptoms, compared with 6.2 after one year. Severely bothersome symptoms and severely impaired general function were rare. Tiredness was the most reported symptom both at baseline and at follow-up. Palsy (other than facial) was the least reported symptom, but the only one with a significant increase. However, this was not associated to the EM. CONCLUSION The symptom load was comparable to that reported in the general population. We found an increase in symptom load at follow-up that did not significantly affect general function. IMPLICATION Monitoring patients' symptom loads prior to treatment reduce the probability of attributing follow-up symptoms to LB. Key points Erythema migrans has a good prognosis.Patients treated for erythema migrans have a slight increase in symptom load one year after treatment. This increase does not affect general function. The levels of subjective health complaints in patients treated for erythema migrans are comparable to the background population.
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Affiliation(s)
- Knut Eirik Eliassen
- Department of General Practice, Norwegian Antibiotic Centre for Primary Care, University of Oslo, Oslo, Norway
- CONTACT Knut Eirik Eliassen Department of General Practice, Norwegian Antibiotic Centre for Primary Care, University of Oslo, PO Box 1130 Blindern, N-0318 Oslo, Norway
| | - Reidar Hjetland
- Department of Microbiology, Førde General Hospital, Førde Health Trust, Førde, Norway
| | - Harald Reiso
- Norwegian National Advisory Unit on Tick-borne Diseases, Sørlandet Hospital, Arendal, Norway
| | - Morten Lindbæk
- Department of General Practice, Norwegian Antibiotic Centre for Primary Care, University of Oslo, Oslo, Norway
| | - Hedda Tschudi-Madsen
- Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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17
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Roaldsnes E, Eikeland R, Berild D. Lyme-nevroborreliose ved uspesifikke nevrologiske symptomer. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:101-104. [DOI: 10.4045/tidsskr.15.1115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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18
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Abstract
Appropriate, critical application of evidence-based diagnostic criteria enables both a clear definition of what constitutes neuroborreliosis-nervous system infection with Borrelia burgdorferi sensu stricto in the US, B garinii and less commonly B. afzelii and other species in Europe-and recognition that this disorder is quite similar in Europe and the US. Most commonly evidenced by lymphocytic meningitis and/or multifocal inflammation of the peripheral (common; cranial neuropathy, radiculopathy, mononeuropathy multiplex) or central (rare) nervous system, it is readily diagnosed and highly antibiotic responsive. Encephalopathy-altered cognition or memory-can occur as part of the systemic infection and inflammatory state, but is not evidence of neuroborreliosis. Post treatment Lyme disease syndrome-persistent neurobehavioral symptoms 6 months or more after usually curative antibiotic treatment-if real and not simply an example of anchoring bias-is unrelated to neuroborreliosis. The pathophysiology of neuroborreliosis remains unclear, but appears to involve both a requirement for viable micro-organisms and significant immune amplification.
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Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, Summit, NJ, USA. .,Neurology and Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, USA.
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19
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Tseng YJ, DeMaria A, Goldmann DA, Mandl KD. Claims-Based Diagnostic Patterns of Patients Evaluated for Lyme Disease and Given Extended Antibiotic Therapy. Vector Borne Zoonotic Dis 2016; 17:116-122. [PMID: 27855040 DOI: 10.1089/vbz.2016.1991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A Lyme disease (LD) diagnosis can be far from straightforward, particularly if erythema migrans does not develop or is not noticed. Extended courses of antibiotics for LD are not recommended, but their use is increasing. We sought to elucidate the patient patterns toward a diagnosis of LD, hypothesizing that a subset of patients ultimately receiving extended courses antibiotics may be symptomatic for an extended period before the first LD diagnosis. METHODS Claims submitted to a nationwide U.S. health insurance plan in 14 high-prevalence states were grouped into standardized diagnostic categories. The patterns of diagnostic categories over time were compared between patients evaluated for LD and given standard antibiotic therapy (PLDSA) and patients evaluated for LD and given extended antibiotic therapy (PLDEA) in 2011-2012. RESULTS The incidence of PLDSA was 40.45 (N = 3207) and that of PLDEA was 7.57 (N = 600) per 100,000 insured over 2011-2012. 50.3% of PLDEA were diagnosed in the nonsummer months. Seven diagnostic categories were associated with PLDEA. From 180 days before the first LD diagnosis, the risks of having claims associated with back problems (odds ratio [OR], 2.1; confidence interval [95% CI], 1.4-2.9; p < 0.001) and connective tissue disease (OR, 1.6; 95% CI, 1.1-2.3; p < 0.01) complaints were higher among PLDEA. From 90 days before the diagnosis, malaise and fatigue (OR, 1.7; 95% CI, 1.1-2.6; p < 0.05), other nervous system disorders (OR, 2.0; 95% CI, 1.3-3.1; p < 0.01), and nontraumatic joint disorder (OR, 1.4; 95% CI, 1.0-2.0; p < 0.05) were more likely found among PLDEA than PLDSA. From 30 days before the diagnosis, the risk for mental health (OR 1.6; 95% CI, 1.1-2.0; p < 0.01) and headache (OR 1.5; 95% CI, 1.1-2.0; p < 0.05) among PLDEA was elevated. CONCLUSIONS Among patients evaluated for LD and ultimately receiving an extended course of antibiotics for LD, 15.8% of them were symptomatic and seeking care for several months before their first LD diagnosis.
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Affiliation(s)
- Yi-Ju Tseng
- 1 Computational Health Informatics Program, Boston Children's Hospital , Boston, Massachusetts.,2 Department of Information Management, Chang Gung University , Taoyuan, Taiwan .,3 Department of Laboratory Medicine, Chang Gung Memorial Hospital , Taoyuan, Taiwan
| | - Alfred DeMaria
- 4 Bureau of Infectious Disease and Laboratory Sciences , Massachusetts Department of Public Health, Boston, Massachusetts
| | - Donald A Goldmann
- 5 Institute for Healthcare Improvement , Cambridge, Massachusetts.,6 Division of Infectious Diseases, Boston Children's Hospital , Boston, Massachusetts
| | - Kenneth D Mandl
- 1 Computational Health Informatics Program, Boston Children's Hospital , Boston, Massachusetts.,7 Department of Pediatrics, Harvard Medical School , Boston, Massachusetts.,8 Department of Biomedical Informatics, Harvard Medical School , Boston, Massachusetts
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20
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Wormser GP, Sudhindra P, Lopez E, Patel L, Rezai S, Brumbaugh AD, McKenna D, Scavarda C, Shapiro ED, Karmen CL, Visintainer P. Fatigue in patients with erythema migrans. Diagn Microbiol Infect Dis 2016; 86:322-326. [PMID: 27553702 DOI: 10.1016/j.diagmicrobio.2016.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/21/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
Fatigue is a common symptom in patients with Lyme disease. The purpose of this study was to characterize fatigue in untreated adult patients presenting with erythema migrans. Selected variables were assessed to determine if any correlated with the presence or severity of fatigue. Fatigue was assessed on the day of the evaluation by a Visual Analogue Scale (VAS), over the past 14days by the 11-item Fatigue Severity Scale (FSS-11) and over the past 28days based on a question from the 36-item Short Form General Health Survey version 2. Fifty-one patients with erythema migrans whose mean age was 49.8years, and 33 (64.7%) of whom were male, were evaluated in this study. The 3 measures of fatigue were positively correlated with one another (P≤0.01). Twenty-six (51%) had fatigue based on a VAS score above 0. Ten (19.6%) had severe fatigue based on an FSS-11 score of ≥4. The strongest correlate for higher fatigue scores was having a greater total number of symptoms. Based on the FSS-11 assessment tool, approximately 20% of early Lyme patients have severe fatigue. Having a high total number of symptoms was associated with both the presence and severity of fatigue. Because prior studies have demonstrated the presence of elevated levels of proinflammatory cytokines and other molecules in the serum of highly symptomatic patients with erythema migrans, the symptom of fatigue in early Lyme disease may be a component of what has been referred to as the acute sickness response.
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Affiliation(s)
- Gary P Wormser
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595.
| | - Praveen Sudhindra
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | - Eliana Lopez
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | - Lisa Patel
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | - Sara Rezai
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | - Aaron D Brumbaugh
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | - Donna McKenna
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | - Carol Scavarda
- Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595
| | - Eugene D Shapiro
- Departments of Pediatrics, of Epidemiology and Public Health, and of Investigative Medicine, Yale University, New Haven, CT 06520
| | - Carol L Karmen
- Division of General Internal Medicine, New York Medical College, Valhalla, NY 10595
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21
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Weitzner E, Visintainer P, Wormser GP. Comparison of males versus females with culture-confirmed early Lyme disease at presentation and at 11-20 years after diagnosis. Diagn Microbiol Infect Dis 2016; 85:493-5. [PMID: 27230991 DOI: 10.1016/j.diagmicrobio.2016.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/18/2016] [Accepted: 04/20/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lyme disease is the most common vector-borne infection in the United States with 300,000 estimated cases per year. OBJECTIVE The purpose of this study was to compare the presenting clinical features and long-term outcome of males versus females with culture-confirmed early Lyme disease. METHODS 174 males and 109 females with culture-confirmed erythema migrans were entered into a prospective study with follow-up visits scheduled at six months, 12 months and annually thereafter for up to 20 years. RESULTS Males and females with early Lyme disease had a similar likelihood of having multiple erythema migrans skin lesions and had a similar number of additional subjective symptoms, such as fatigue, at study entry. Among the 71 males and 57 females able to be followed up for 11-20 years, there were no significant differences in baseline symptoms, rate of seroreactivity to Borrelia burgdorferi, or in frequency of post-treatment symptoms. Females, however, were significantly more likely than males to return for follow-up visits (P = 0.0003). CONCLUSION Males and females with culture-confirmed early Lyme disease had similar clinical features, rates of seropositivity, and long-term outcomes.
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Affiliation(s)
- Erica Weitzner
- Division of Infectious Diseases, New York Medical College, Valhalla, NY, 10595
| | | | - Gary P Wormser
- Division of Infectious Diseases, New York Medical College, Valhalla, NY, 10595.
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22
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Abstract
Chronic Lyme disease is a poorly defined diagnosis that is usually given to patients with prolonged, unexplained symptoms or with alternative medical diagnoses. Data do not support the proposition that chronic, treatment-refractory infection with Borrelia burgdorferi is responsible for the many conditions that get labeled as chronic Lyme disease. Prolonged symptoms after successful treatment of Lyme disease are uncommon, but in rare cases may be severe. Prolonged courses of antibiotics neither prevent nor ameliorate these symptoms and are associated with considerable harm.
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Affiliation(s)
- Paul M Lantos
- Divisions of Pediatric Infectious Diseases and General Internal Medicine, Duke University School of Medicine, DUMC 100800, Durham, NC 27710, USA.
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23
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Abstract
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.
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Affiliation(s)
- Robert B Nadelman
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Skyline Office #2NC20, 40 Sunshine Cottage Road, Valhalla, NY 10595, USA.
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24
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Wormser GP, Weitzner E, Dornbush R, Visintainer P. Reply to Crawford. Clin Infect Dis 2015; 61:1209-10. [PMID: 26129750 DOI: 10.1093/cid/civ533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Rhea Dornbush
- Department of Psychiatry, New York Medical College, Valhalla, New York
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25
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Weitzner E, McKenna D, Nowakowski J, Scavarda C, Dornbush R, Bittker S, Cooper D, Nadelman RB, Visintainer P, Schwartz I, Wormser GP. Long-term Assessment of Post-Treatment Symptoms in Patients With Culture-Confirmed Early Lyme Disease. Clin Infect Dis 2015; 61:1800-6. [PMID: 26385994 DOI: 10.1093/cid/civ735] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lyme disease patients with erythema migrans are said to have post-treatment Lyme disease symptoms (PTLDS) if there is persistence of subjective symptoms for at least 6 months following antibiotic treatment and resolution of the skin lesion. The purpose of this study was to characterize PTLDS in patients with culture-confirmed early Lyme disease followed for >10 years. METHODS Adult patients with erythema migrans with a positive skin or blood culture for Borrelia burgdorferi were enrolled in a prospective study beginning in 1991 and followed up at 6 months and annually thereafter to determine the long-term outcome of this infection. The genotype of the infecting strain of B. burgdorferi was evaluated in subjects with PTLDS. RESULTS One hundred twenty-eight subjects with culture-confirmed early Lyme disease, of whom 55% were male, were followed for a mean ± SD of 14.98 ± 2.71 years (median = 15 years; range = 11-20 years). Fourteen (10.9%) were regarded as having possible PTLDS, but only 6 (4.7%) had PTLDS documented at their last study visit. Nine (64.3%) had only a single symptom. None of the 6 with PTLDS at their last visit was considered to be functionally impaired by the symptom(s). PTLDS was not associated with a particular genotype of B. burgdorferi. CONCLUSIONS PTLDS may persist for >10 years in some patients with culture-confirmed early Lyme disease. Such long-standing symptoms were not associated with functional impairment or a particular strain of B. burgdorferi.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ira Schwartz
- Department of Microbiology and Immunology, New York Medical College, Valhalla
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26
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Abstract
Nervous system involvement occurs in 10% to 15% of patients infected with the tick-borne spirochetes Borrelia burgdorferi, B afzelii, and B garinii. Peripheral nervous system involvement is common. Central nervous system (CNS) involvement, most commonly presenting with lymphocytic meningitis, causes modest cerebrospinal fluid (CSF) pleocytosis. Parenchymal CNS infection is rare. If the CNS is invaded, however, measuring local production of anti-B burgdorferi antibodies in the CSF provides a useful marker of infection. Most cases of neuroborreliosis can be cured with oral doxycycline; parenteral regimens should be reserved for patients with particularly severe disease.
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Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, 99 Beauvoir Avenue, Summit, NJ 07902, USA; Sidney Kimmel Medical College of Thomas Jefferson University, 132 South, 10th street, Philadelphia, PA 19107, USA.
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27
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Abstract
Lyme disease, caused by the Borrelia burgdorferi bacterium, is the most common vector-borne disease in the northern hemisphere. The clinical presentation varies with disease stage, and neurological manifestations (often referred to as Lyme neuroborreliosis) are reported in up to 12% of patients with Lyme disease. Most aspects of the epidemiology, clinical manifestation and treatment of Lyme neuroborreliosis are well known and accepted; only the management of so-called chronic Lyme disease is surrounded by considerable controversy. This term is used for disparate patient groups, including those who have untreated late-stage infection (for example, late neuroborreliosis), those with subjective symptoms that persist after treatment (termed 'post-treatment Lyme disease syndrome' [PTLDS]), and those with unexplained subjective complaints that may or may not be accompanied by positive test results for B. burgdorferi infection in serum (here called 'chronic Lyme disease'). The incidence of PTLDS is still a matter of debate, and its pathogenesis is unclear, but there is evidence that these patients do not have ongoing B. burgdorferi infection and, thus, do not benefit from additional antibiotic therapy. Chronic Lyme disease lacks an accepted clinical definition, and most patients who receive this diagnosis have other illnesses. Thus, a careful diagnostic work-up is needed to ensure proper treatment.
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Affiliation(s)
- Uwe Koedel
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
| | - Volker Fingerle
- Bavarian Health and Food Safety Authority &German National Reference Centre for Borrelia, Veterinärstrasse 2, 85764 Oberschleissheim, Germany
| | - Hans-Walter Pfister
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
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28
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Hjetland R, Reiso H, Ihlebæk C, Nilsen RM, Grude N, Ulvestad E. Subjective health complaints are not associated with tick bites or antibodies to Borrelia burgdorferi sensu lato in blood donors in western Norway: a cross-sectional study. BMC Public Health 2015; 15:657. [PMID: 26169496 PMCID: PMC4499943 DOI: 10.1186/s12889-015-2026-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/06/2015] [Indexed: 11/24/2022] Open
Abstract
Background There is controversy about chronic health consequences of tick-borne infections, especially Lyme borreliosis. This study aims to assess whether general function, physical fitness and subjective health complaints are associated with tick bites or antibodies to Borrelia burgdorferi sensu lato in blood donors. Methods Sera from 1,213 blood donors at four different blood banks in Sogn and Fjordane county in western Norway were obtained during January to June 2010, and analysed for specific IgG and IgM antibodies. A questionnaire including questions on tick bites, subjective health complaints, general function and physical fitness was completed. Results Tick bites had been experienced by 65.7 % of the study population. 78 (6.4 %) were positive for IgG (9.7 % in men, 2.4 % in women), and 69 (5.7 %) for IgM (6.1 % in men, 5.1 % in women), verified by immunoblot. No association between number of experienced tick bites or seropositivity for Borrelia antibodies and subjective health complaints, reduced general function or reduced physical fitness was found. Conclusion The results do not support any association between tick bites or Borrelia antibodies and subjective health complaints in blood donors in an endemic area for Lyme borreliosis. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2026-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Reidar Hjetland
- Department of Microbiology, Førde General Hospital, Helse Førde Hospital Trust, PO Box 1000, NO-6807, Førde, Norway.
| | - Harald Reiso
- Institute of Health and Society, Department of General Practice, University of Oslo, Oslo, Norway.
| | - Camilla Ihlebæk
- Section of public health, ILP, Norwegian University of Life Sciences, Aas, Norway.
| | - Roy M Nilsen
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.
| | - Nils Grude
- Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway.
| | - Elling Ulvestad
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Science, University of Bergen, Bergen, Norway.
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29
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Wormser GP, Weitzner E, McKenna D, Nadelman RB, Scavarda C, Molla I, Dornbush R, Visintainer P, Nowakowski J. Long-term assessment of health-related quality of life in patients with culture-confirmed early Lyme disease. Clin Infect Dis 2015; 61:244-7. [PMID: 25888674 DOI: 10.1093/cid/civ277] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 02/18/2015] [Indexed: 11/13/2022] Open
Abstract
The health-related quality of life of 100 subjects with culture-confirmed early Lyme disease enrolled in a prospective study with annual follow-up visits was evaluated using the 36-Item Short Form General Health Survey version 2 (SF-36v2) questionnaire at 11-20 years after diagnosis. The mean summary scores of physical and mental health were similar to those of the general population.
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Affiliation(s)
| | | | | | | | | | | | - Rhea Dornbush
- Department of Psychiatry, New York Medical College, Valhalla
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30
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Auwaerter PG. Editorial commentary: life after Lyme disease. Clin Infect Dis 2015; 61:248-50. [PMID: 25888673 PMCID: PMC4480264 DOI: 10.1093/cid/civ279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 11/16/2022] Open
Affiliation(s)
- Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
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