[Pathway to diagnosis and real-life experience of patients believing they are affected by "chronic Lyme disease"]

Persistent Symptoms After Lyme Disease: Clinical Characteristics, Predictors, and Classification

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.

Seroprevalence of Infection by Borrelia Species Responsible for Lyme Disease in the French Alps: Analysis of 27,360 Serology Tests, 2015-2020

Objectives: Lyme borreliosis incidence is increasing in several areas; moreover, it has recently gained the public's attention. Apart from erythema migrans, Lyme disease diagnosis relies (among others) on serology test; however, the prevalence of positive enzyme-linked immunosorbent assay (ELISA) and western blot (WB) assay has been poorly studied in the general population. We aimed to approach the seroprevalence of infection by Borrelia species responsible for Lyme disease in the French Isere department using city laboratories data. Patients and Methods: We retrieved all serological tests for Borrelia species responsible for Lyme disease performed in the two main networks of city laboratories between 2015 and 2020. All patients with both ELISA and WB IgG were considered seropositive. Results: We analyzed 27,360 tests (ELISA/ELISA+WB). Mean age was 50.9 ± 20.3 years (ranges: 0-101), with 57.1% females. Overall, 11.7% had IgG detected by ELISA, and 4.7% had IgG detected by both ELISA and WB assay. Seropositive status was more frequent in males (7.0% vs. 2.9%, p < 0.001). Seropositivity rate increased with age after a first peak in childhood; men aged 61-70 years had the highest seropositivity rate (10.3%). In addition, seropositivity rate was higher in persons from a rural area. In multivariate analysis, older age, male gender and living in a rural area were independently associated with seropositivity. Seropositivity rate was stable on the 2017-2020 period. Conclusion: The seroprevalence of infection by Borrelia species responsible for Lyme disease is high in Isere; this probably reduces the predictive positive value for Lyme disease of ELISA and WB IgG, suggesting that this serological test should not be performed for nonspecific symptoms.

Lyme borreliosis and medical wandering: what do patients think about multidisciplinary management? A qualitative study in the context of scientific and social controversy

INTRODUCTION

To answer to patients' medical wandering, often due to "unexplained symptoms" of "unexplained diseases" and to misinformation, multidisciplinary care centers for suspected Lyme borreliosis (LB), such as the 5 Tick-Borne Diseases (TBDs) Reference Centers (TBD-RC), were created a few years ago in France, the Netherlands and Denmark. Our study consisted of a comprehensive analysis of the satisfaction of the patients managed at a TBD-RC for suspected LB in the context of scientific and social controversy.

METHODS

We included all adults who were admitted to one of the TBD-RC from 2017 to 2020. A telephone satisfaction survey was conducted 12 months after their first consultation. It consisted of 5 domains, including 2 free-text items: "What points did you enjoy?" and "What would you like us to change or to improve?". In the current study, the 2 free-items were analyzed with a qualitative method called reflexive thematic analysis within a semantic and latent approach.

RESULTS

The answer rate was 61.3% (349/569) and 97 distinctive codes from the 2-free-text items were identified and classified into five themes: (1) multidisciplinarity makes it possible to set up quality time dedicated to patients; (2) multidisciplinarity enables seamless carepaths despite the public hospital crisis compounded by the COVID-19 pandemic; (3) multidisciplinarity is defined as trust in the team's competences; (4) an ambivalent opinion and uncertainty are barriers to acceptance of the diagnosis, reflecting the strong influence of the controversy around LB; and (5) a lack of adapted communication about TBDs, their management, and ongoing research is present.

CONCLUSION

The multidisciplinary management for suspected LB seemed an answer to medical wandering for the majority of patients and helped avoid misinformation, enabling better patient-centered shared information and satisfaction, despite the context of controversy.

Diagnosis and treatment of "chronic Lyme": primum non nocere

BACKGROUND

Approximately 10% of patients experience prolonged symptoms after Lyme disease. PTLDS (post treatment Lyme disease syndrome) is a controversial topic. It has been described as a source of overdiagnosis and off-label treatment. This review aims to describe the diagnostic errors and adverse events associated with the diagnosis and treatment of PTLDS.

METHODS

systematic review of the literature in the Medline and Cochrane Library databases, according to PRISMA criteria, including randomized clinical trials (RCT), observational studies, and case reports addressing diagnostic errors and adverse events published between January 2010 and November 2020 in English or French. Selection used a quadruple reading process on the basis of the titles and abstracts of the different articles, followed by a full reading.

RESULTS

17 studies were included: 1 RCT, 6 observational studies and 10 case reports. In the 6 observational studies, overdiagnosis rates were very high, ranging from 80 to 100%. The new diagnoses were often psychiatric, rheumatological and neurological. Disorders with somatic symptoms were often cited. Diagnostic delays were identified for cancers and frontoparietal dementia. In the RCT and observational studies, prolonged anti-infective treatments were also responsible for adverse events, with emergency room visits and/or hospitalization. The most common adverse events were diarrhea, sometimes with Clostridium difficile colitis, electrolyte abnormalities, sepsis, bacterial and fungal infections, and anaphylactic reactions.

CONCLUSION

This review highlights the risks of prolonged anti-infective treatments that have not been proven to be beneficial in PTLDS. It emphasizes the ethical imperative of the "primum non nocere" principle, which underscores the importance of not causing harm to patients. Physicians should exercise caution in diagnosing PTLDS and consider the potential risks associated with off-label treatments.

Knowing the entire story – a focus group study on patient experiences with chronic Lyme-associated symptoms (chronic Lyme disease)

Background

Healthcare providers frequently struggle to provide effective care to patients with chronic Lyme-associated symptoms (chronic Lyme disease, CLD), potentially causing these patients to feel misunderstood or neglected by the healthcare system. This study is the first to use a combined medical and communication science approach, and aims to assess patients’ experiences with CLD & CLD-related care, identify themes and repertories in these patients’ narrations, and provide potential ways to improve communication with them.

Methods

Informed by the principles of ‘clean language’, we conducted focus groups with self-identified CLD patients (N = 15). We asked participants about their experiences with CLD and CLD-related healthcare. We performed thematic analyses using a bottom-up approach based in discourse analysis. We also sought to identify specific types of verbalizations (repertoires) across themes.

Results

Participants thematised a heterogeneous set of CLD-associated symptoms, which they frequently labelled as ‘invisible’ to others. Their illness significantly affected their daily lives, impacting their work, social activities, relationships with loved ones, hobbies and other means of participating in society. Negative experiences with healthcare providers were near-universal, also in patients with short-lived CLD-associated symptoms. Verbalizations were notable for frequent use of communicative modes that implicitly create common ground between participants and that give a certain validity to personal experiences (impersonal ‘you’ and other forms of presupposition).

Conclusion

Central themes found in CLD patients’ communication are 1. the experience of significant symptoms, 2. for which adequate relief is only rarely found from conventional medical practitioners, and 3. that are largely invisible to the outside world. Verbalizing these themes, patients use various repertoires for their shared experiences, such as a feeling of abandonment or not being heard by the medical system, feelings of loss with respect to their previous health, and the idea that they might have been better off had they been diagnosed sooner. Working with these repertoires will enable healthcare providers to establish a shared perspective with their CLD patients, thus engaging in more fruitful doctor-patient communication. We hypothesize that these findings are not unique to CLD, but may also be applicable to other conditions with an uncertain aetiology, such as Long COVID.

Perceptions, Representations, and Experiences of Patients Presenting Nonspecific Symptoms in the Context of Suspected Lyme Borreliosis

BACKGROUND

Some subjective symptoms may be reported at all stages of Lyme borreliosis (LB) and may persist for several months after treatment. Nonspecific symptoms without any objective manifestation of LB are sometimes attributed by patients to a possible tick bite. The aim of our study was to explore the perceptions, representations, and experiences that these patients had of their disease and care paths.

METHODS

We performed a qualitative study through individual interviews (October 2017-May 2018), based on grounded theory, following the COREQ checklist. A balanced sample of patients with diverse profiles was recruited at consultations with general practitioners and infectious disease physicians.

RESULTS

Twelve patients were interviewed. Data saturation was reached at the twelfth interview. For codes, 293 were identified, and classified into 5 themes: (1) the experience of disabling nonspecific symptoms, especially pain, causing confusion and fear, (2) long and difficult care paths for the majority of the patients, experienced as an obstacle course, (3) a break with the previous state of health, causing a negative impact on every sphere of the patient's life, (4) empowerment of the patients and the self-management of their disease, and (5) the strong expression of a desire for change, with better listening, greater recognition of the symptoms, and simpler care paths.

CONCLUSIONS

This study allows for the understanding of a patient's behaviours and the obstacles encountered, the way they are perceived, and the necessary solutions. The patients' expectations identified here could help physicians better understand the doctor-patient relationship in these complex management situations, which would reduce the burden of the disease. The current development of specialised reference centres could help meet the patients' demands and those of family physicians.

Genesis and dissemination of a controversial disease: Chronic Lyme

OBJECTIVES

To describe the role of the internet and cognitive biases in the controversy surrounding chronic Lyme disease. The attribution of chronic but aspecific symptoms to Lyme borreliosis is a source of worldwide controversy.

PATIENTS AND METHODS

Some patients attribute their aspecific symptoms to Lyme borreliosis even though, in fact, they have a functional somatic syndrome.

RESULTS

These patients' diagnostic and therapeutic wandering contributes to the above attribution and to their suffering. The Internet has deregulated the information market. Cognitive confirmation bias contributes to confinement in belief. Negativity bias explains the tendency of the human brain to select the most alarming information available. The narrative force of alarmist videos or personal testimonies acts like a nocebo effect. The social exclusion generated by adherence to this belief is a factor of reinforcement and aggravation.

CONCLUSIONS

Deconstructing chronic Lyme disease with empathy and conviction is in patients' best interests.

Triggers and Clinical Presentations of Functional Neurological Disorders: Lessons from World War 1

INTRODUCTION

The psychological contribution to functional neurological and somatic symptom disorders is a major topic in current medical debate.

OBJECTIVE

For an understanding of the processes leading to functional somatic symptoms, it is paramount to explore their relationship with stress and life events and to elucidate the contribution of cultural factors.

METHODS

A total of 937 case records of civilian and military patients with functional somatic disorders treated in London during World War 1 were analysed. Group differences in symptom profiles and contemporaneous diagnoses were tested with χ2 tests.

RESULTS

Paralyses and speech disturbances were significantly more common in soldiers (43.3 and 17.2% of cases) than in civilian male (28.1 and 6.5%) and female patients (32.4 and 7.5%), whereas female patients had the highest rates of pain (48.6%) and somatic symptoms (67%). Triggers were identified in around two-thirds of cases and included accidents, physical illness, and work stress, in addition to the combat experience of the soldier patients. The nature of the trigger influenced symptom expression, with acute (combat and noncombat) events being particularly prone to trigger loss of motor function. Symptom profiles showed a great deal of multi-morbidity and overlap, although some symptom clusters were more (motor and speech disturbance) or less common (pain and loss of energy) in soldiers than civilians. Triggering life events in civilians were similar to those reported by patients with somatic symptom disorders today, with an important role of physical factors. Patterns of multi-morbidity and symptom clusters also resembled those of modern cohorts.

CONCLUSIONS

Analysis of historical records, illness trajectories, and treatments can enhance the understanding of the presentation, mechanisms, and course of functional neurological and related disorders and their consistency over time.

Somatic symptom disorder should be suspected in children with alleged chronic Lyme disease

We report a case series of seven children admitted to a tertiary level pediatric ward for long-lasting physical symptoms with a previous diagnosis of chronic Lyme disease. In these children, medical history and clinical features were strongly suggestive of a psychopathological disorder, mainly a somatic symptom disorder. What is Known: • There is an increasing number of diagnoses of chronic Lyme disease both in North America and in Europe. Adults receive this diagnosis to explain chronic physical complaints often with negative history and serology. What is New: • Somatic symptom disorder should be suspected in children and adolescents with non-specific symptoms diagnosed with chronic Lyme disease.

[One or more functional somatic syndromes? Comparison of the health status of fibromyalgia and electro-hypersensitive people]

INTRODUCTION

Functional somatic syndromes, grouping somatic symptoms without an organic explanation, are defined either by their predominant symptoms or by an attribution to an, often hypothetical, cause. Due to many similarities, some authors consider that there is only one FSS due to a general phenomenon of "somatization". The objective of this work was to compare two functional somatic syndromes, one defined by its symptoms, fibromyalgia, and the other by a specific contested attribution, electro-hypersensitivity.

METHOD

Fibromyalgia or electro-hypersensitive participants (EHS) were recruited from September 2016 to April 2017 through associations of patients in Auvergne-Rhône-Alpes. Home interviews included the collection of medical, psychopathological, and symptom histories. The assessment of psychological distress, quality of life and the search for other functional somatic syndromes was performed through structured questionnaires, self-administrated scales, and clinical examination.

RESULTS

Sixteen fibromyalgia subjects and sixteen EHS subjects were included. There are differences in symptomatology, although many symptoms are common to both conditions. Lifetime history of psychiatric disorders and current psychological distress and psychopathology are frequent in both groups but more prevalent in fibromyalgia subjects. The experience of the symptoms, their interpretation, the diagnostic itineraries and the therapeutic behaviours differ radically according to the group, even if for all socio-professional impact is high and quality of life are altered.

CONCLUSION

The health status of fibromyalgia persons is overall worse than the health status of electro-hypersensitive individuals in this small sample. Despite the overlap in symptoms and a similar impact on daily functioning, this exploratory study suggests that heterogeneous mechanisms of "somatization" may be at stake in functional somatic syndromes.