Chronic Lyme disease: a survey of Connecticut primary care physicians

Neuropsychiatric Manifestations and Cognitive Decline in Patients With Long-Standing Lyme Disease: A Scoping Review

Lyme disease (LD), or Lyme borreliosis, is a vector-borne disease that is caused by the transmission of the bacterium Borrelia burgdorferi through a tick bite. The symptoms of LD can persist in individuals chronically, even after the treatment and resolution of the initial infection. These symptoms include various neuropsychiatric manifestations and cognitive decline. The purpose of this review was to report the neuropsychiatric manifestations, cognitive decline, and effects of a delayed diagnosis on symptom severity in patients with long-standing LD (LSLD). A scoping review was conducted utilizing the electronic databases Embase, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), and Web of Science. A total of 744 articles were retrieved and considered for inclusion. After a rigorous screening process, 10 articles that met the inclusion criteria for this review were included (i.e., reported neuropsychiatric manifestations and cognitive decline in patients with LSLD and the effects of a delayed diagnosis). Neuropsychiatric manifestations in the patients consisted of suicidal ideation, homicidal tendencies, extreme anger, depressive symptoms, aggression, and anxiety. Cognitive symptoms included dysfunctions in working memory, verbal learning/memory, non-verbal learning/memory, alertness, visuoconstructive, and frontal executive functioning. A delayed LD diagnosis increased symptom severity in most patients. The findings of this review indicate that neuropsychiatric and cognitive symptoms tend to present for a chronic period, even after disease recovery. Although researchers have established a link between a delayed LD diagnosis and increased symptom severity, LSLD is often an overlooked diagnosis in patients with neuropsychiatric symptoms and cognitive decline. More research is needed to compare the time to diagnosis and symptom severity in patients with LSLD.

Access to Care in Lyme Disease: Clinician Barriers to Providing Care

Patients with persistent Lyme disease/chronic Lyme disease (PLD/CLD) encounter significant barriers to accessing medical care. Although this health inequity has been explored from the patient perspective, the obstacles clinicians encounter when providing care to this group of patients have not been examined. The primary goal of this study was to identify the challenges faced by clinicians who provide care for patients with PLD/CLD. Clinicians who treat PLD/CLD were surveyed regarding their professional backgrounds, general challenges to providing care, supply and demand constraints, insurance restrictions, and regulatory and legal challenges. Clinicians treating patients with PLD/CLD have developed substantial clinical expertise but encounter multiple clinical, regulatory and financial impediments to providing care. Clinician-encountered barriers may be powerful disincentives for providing care patients with PLD/CLD and make it difficult to retain and recruit clinicians who will care for the rapidly expanding PLD/CLD populations. Understanding these barriers and identifying potential solutions is essential to resolving the current supply/demand imbalance that makes it difficult for patients to receive the care they need to become well.

Post-Treatment Lyme Disease Syndrome: Need for Diagnosis and Treatment

With the continued surge in Lyme disease cases, post-treatment Lyme disease syndrome (PTLDS) is becoming a more pressing health concern. The aim of this review is to identify comprehensive treatment strategies for PTLDS patients. Unfortunately, universal guidelines for diagnosing and treating PTLDS do not currently exist. Consequently, physicians cannot adequately address concerns of possible PTLDS patients. Patients are left suffering and searching for answers, and their activities of daily living and quality of life are adversely impacted. This review highlights that PTLDS clinical trials have focused mainly on treatment with antibiotics, yielding challenging results that lack consistency in inclusion criteria across trials. It will remain exceedingly difficult to extrapolate the outcomes of such studies if a standard for PTLDS diagnosis is not well-established. By focusing on treatment trials rather than establishing diagnostic criteria, research in this field ignores a critical step in investigating PTLDS. The first significant step is to create comprehensive guidelines for the diagnosis of PTLDS, which can generate uniformity and validate PTLDS treatment trials.

Post-treatment Lyme Disease as a Model for Persistent Symptoms in Lyme Disease

It has long been observed in clinical practice that a subset of patients with Lyme disease report a constellation of symptoms such as fatigue, cognitive difficulties, and musculoskeletal pain, which may last for a significant period of time. These symptoms, which can range from mild to severe, have been reported throughout the literature in both prospective and population-based studies in Lyme disease endemic regions. The etiology of these symptoms is unknown, however several illness-causing mechanisms have been hypothesized, including microbial persistence, host immune dysregulation through inflammatory or secondary autoimmune pathways, or altered neural networks, as in central sensitization. Evaluation and characterization of persistent symptoms in Lyme disease is complicated by potential independent, repeat exposures to B. burgdorferi, as well as the potential for co-morbid diseases with overlapping symptom profiles. Antibody testing for B. burgdorferi is an insensitive measure after treatment, and no other FDA-approved tests currently exist. As such, diagnosis presents a complex challenge for physicians, while the lived experience for patients is one marked by uncertainty and often illness invalidation. Currently, there are no FDA-approved pharmaceutical therapies, and the safety and efficacy of off-label and/or complementary therapies have not been well studied and are not agreed-upon within the medical community. Post-treatment Lyme disease represents a narrow, defined, mechanistically-neutral subset of this larger, more heterogeneous group of patients, and is a useful definition in research settings as an initial subgroup of study. The aim of this paper is to review the current literature on the diagnosis, etiology, risk factors, and treatment of patients with persistent symptoms in the context of Lyme disease. The meaning and relevance of existing patient subgroups will be discussed, as will future research priorities, including the need to develop illness biomarkers, elucidate the biologic mechanisms of disease, and drive improvements in therapeutic options.

Chronic Lyme disease

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.

A Learner-led, Discussion-based Elective on Emerging Infectious Disease

Objective. To implement a learner-led, discussion-based course aimed at exposing second-year pharmacy learners to the study of emerging infectious diseases from a global health perspective and to assess the role and importance of pharmacists in the management of disease outbreaks. Design. Learners examined literature pertinent to an emerging infectious disease in a 3-credit, discussion-based course and participated in peer discussion led by a designated learner. Instructional materials included journal articles, audio-visual presentations, documentaries, book chapters, movies, newspaper/magazine articles, and other materials. Learning outcomes were measured based on the ability of learners to perform critical thinking and analysis, communicate with their peers, and participate in class discussions. Assessment. The course was offered to 2 consecutive cohorts consisting of 14 and 16 learners, respectively. Overall, every learner in the first cohort achieved a final grade of A for the course. In the second cohort, the overall grade distribution consisted of grades of A, B, and C for the course. Learner evaluations indicated that the active-learning, discussion-based environment significantly enhanced interest in the topic and overall performance in the course. Conclusion. The elective course on emerging infectious diseases provided in-depth exposure to disease topics normally not encountered in the pharmacy curriculum. Learners found the material and format valuable, and the course enhanced their appreciation of infectious diseases, research methodology, critical thinking and analysis, and their roles as pharmacists.

Incidence and Patterns of Extended-Course Antibiotic Therapy in Patients Evaluated for Lyme Disease

BACKGROUND

Most patients with Lyme disease (LD) can be treated effectively with 2-4 weeks of antibiotics. The Infectious Disease Society of America guidelines do not currently recommend extended treatment even in patients with persistent symptoms.

METHODS

To estimate the incidence of extended use of antibiotics in patients evaluated for LD, we retrospectively analyzed claims from a nationwide US health insurance plan in 14 high-prevalence states over 2 periods: 2004-2006 and 2010-2012.

RESULTS

As measured by payer claims, the incidence of extended antibiotic therapy among patients evaluated for LD was higher in 2010-2012 (14.72 per 100 000 person-years; n = 684) than in 2004-2006 (9.94 per 100 000 person-years; n = 394) (P < .001). Among these patients, 48.8% were treated with ≥2 antibiotics in 2010-2012 and 29.9% in 2004-2006 (P < .001). In each study period, a distinct small group of providers (roughly 3%-4%) made the diagnosis in >20% of the patients who were evaluated for LD and prescribed extended antibiotic treatment.

CONCLUSIONS

Insurance claims data suggest that the use of extended courses of antibiotics and multiple antibiotics in the treatment of LD has increased in recent years.

Lyme neuroborreliosis-epidemiology, diagnosis and management

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.

Experiences of patients identifying with chronic Lyme disease in the healthcare system: a qualitative study

Background

Chronic Lyme disease is a term that describes a constellation of persistent symptoms in patients with or without evidence of previous Borrelia burgdorferi infection. Patients labeled as having chronic Lyme disease have a substantial clinical burden. Little is known about chronic Lyme disease patient experiences in the healthcare system and their relationships with healthcare providers. The purpose of this study was to gather insights about the experiences of patients who carry a diagnosis of chronic Lyme disease in the United States healthcare system.

Methods

Qualitative, phenomenological study in 12 adult participants who identified themselves as having chronic Lyme disease. Semi-structured face-to-face in-depth interviews were conducted, 60–90 minutes in length, focusing on perceptions of disease burden and of their healthcare providers, using the dimensions of the Health Belief Model. Transcribed interviews were analyzed for emergent topics and themes in the categories of beliefs/understanding, personal history/narrative, consequences/limitations, management, and influences on care.

Results

Enrollment continued until theoretical saturation was obtained. Four major themes emerged from participants’ descriptions of their experiences and perceptions: 1) changes in health status and the social impact of chronic Lyme disease, 2) doubts about recovery and the future, 3) contrasting doctor-patient relationships, 4) and the use of unconventional therapies to treat chronic Lyme disease.

Conclusions

Participants reported a significant decline in health status associated with chronic Lyme disease and were often unsatisfied with care in conventional settings. Negative experiences were associated with reports of dismissive, patronizing, and condescending attitudes. Positive experiences were associated with providers who were reported to be attentive, optimistic, and supportive. Consultations with CAM practitioners and use of CAM therapies were common. Actively engaged and sympathetic clinical encounters may foster greater satisfaction in healthcare settings.

Lyme borreliosis

Lyme borreliosis (Lyme disease) is caused by spirochaetes of the Borrelia burgdorferi sensu lato species complex, which are transmitted by ticks. The most common clinical manifestation is erythema migrans, which eventually resolves, even without antibiotic treatment. However, the infecting pathogen can spread to other tissues and organs, causing more severe manifestations that can involve a patient's skin, nervous system, joints, or heart. The incidence of this disease is increasing in many countries. Laboratory evidence of infection, mainly serology, is essential for diagnosis, except in the case of typical erythema migrans. Diagnosed cases are usually treated with antibiotics for 2-4 weeks and most patients make an uneventful recovery. No convincing evidence exists to support the use of antibiotics for longer than 4 weeks, or for the persistence of spirochaetes in adequately treated patients. Prevention is mainly accomplished by protecting against tick bites. There is no vaccine available for human beings.