WAIS-III and WMS-III performance in chronic Lyme disease

Retrograde and semantic amnesia in a case of post-treatment Lyme disease syndrome: did something lead to a psychogenic memory loss? A single-case study

OBJECTIVE

To describe a case of Post-Treatment Lyme Disease Syndrome (PTLDS) with an atypical cognitive profile.

METHOD

A 41-year-old PTLDS patient underwent comprehensive neuropsychological testing and psychological assessment.

RESULTS

The patient exhibited impaired intensive attention but preserved selective attention. Executive functions were normal. Short-term and anterograde memory were intact, while retrograde and semantic memory were significantly impaired. The patient also experienced identity loss, specific phobias, dissociative symptoms, and depressed mood.

CONCLUSIONS

Severe episodic-autobiographical and retrograde semantic amnesia was consistent with some reports of dissociative amnesia. Loss of identity and phobias were also highly suggestive of a psychogenic mechanism underlying amnesia.

Autocrine positive feedback of tumor necrosis factor from activated microglia proposed to be of widespread relevance in chronic neurological disease

Over a decade's experience of post-stroke rehabilitation by administering the specific anti-TNF biological, etanercept, by the novel perispinal route, is consistent with a wide range of chronically diminished neurological function having been caused by persistent excessive cerebral levels of TNF. We propose that this TNF persistence, and cerebral disease chronicity, largely arises from a positive autocrine feedback loop of this cytokine, allowing the persistence of microglial activation caused by the excess TNF that these cells produce. It appears that many of these observations have never been exploited to construct a broad understanding and treatment of certain chronic, yet reversible, neurological illnesses. We propose that this treatment allows these chronically activated microglia to revert to their normal quiescent state, rather than simply neutralizing the direct harmful effects of this cytokine after its release from microglia. Logically, this also applies to the chronic cerebral aspects of various other neurological conditions characterized by activated microglia. These include long COVID, Lyme disease, post-stroke syndromes, traumatic brain injury, chronic traumatic encephalopathy, post-chemotherapy, post-irradiation cerebral dysfunction, cerebral palsy, fetal alcohol syndrome, hepatic encephalopathy, the antinociceptive state of morphine tolerance, and neurogenic pain. In addition, certain psychiatric states, in isolation or as sequelae of infectious diseases such as Lyme disease and long COVID, are candidates for being understood through this approach and treated accordingly. Perispinal etanercept provides the prospect of being able to treat various chronic central nervous system illnesses, whether they are of infectious or non-infectious origin, through reversing excess TNF generation by microglia.

Neuropsychiatric Lyme Disease and Vagus Nerve Stimulation

Lyme disease, the most common tick-borne disease in the United States, is caused by infection with the spirochete Borrelia burgdorferi. While most patients with acute Lyme disease recover completely if treated with antibiotics shortly after the onset of infection, approximately 10-30% experience post-treatment symptoms and 5-10% have residual symptoms with functional impairment (post-treatment Lyme disease syndrome or PTLDS). These patients typically experience pain, cognitive problems, and/or fatigue. This narrative review provides a broad overview of Lyme disease, focusing on neuropsychiatric manifestations and persistent symptoms. While the etiology of persistent symptoms remains incompletely understood, potential explanations include persistent infection, altered neural activation, and immune dysregulation. Widely recognized is that new treatment options are needed for people who have symptoms that persist despite prior antibiotic therapy. After a brief discussion of treatment approaches, the article focuses on vagus nerve stimulation (VNS), a neuromodulation approach that is FDA-approved for depression, epilepsy, and headache syndromes and has been reported to be helpful for other diseases characterized by inflammation and neural dysregulation. Transcutaneous VNS stimulates the external branch of the vagus nerve, is minimally invasive, and is well-tolerated in other conditions with few side effects. If well-controlled double-blinded studies demonstrate that transcutaneous auricular VNS helps patients with chronic syndromes such as persistent symptoms after Lyme disease, taVNS will be a welcome addition to the treatment options for these patients.

Language Fluency Deficits in Post-treatment Lyme Disease Syndrome

OBJECTIVE

Recent neurocognitive studies of patients with post-treatment Lyme disease syndrome (PTLDS) find consistent deficits in memory and processing speed. Language fluency deficits are observed as well but may be secondary to poor memory and slowing rather than an independent deficit.

METHOD

This study performed a secondary analysis of data presented previously, including individuals with PTLDS and comparison samples of healthy volunteers (HC) and patients with major depressive disorder (MDD), to determine if language fluency deficits could be accounted for by poor performance in these other neurocognitive domains.

RESULTS

Basic verbal abilities, memory, and processing speed were all significantly associated with fluency performance. MDD patients' fluency deficits relative to HC were accounted for by these covariates. However, PTLDS patients' poorer fluency performance relative to both other groups was not.

CONCLUSIONS

Language fluency appears to be an independent area of neurocognitive deficit within the constellation of PTLDS symptoms.

Assessment of cognitive function, structural brain changes and fatigue 6 months after treatment of neuroborreliosis

BACKGROUND

Complete recovery after adequately treated neuroborreliosis is common, but studies report that some patients experience persistent symptoms like self-reported cognitive problems and fatigue. Persisting symptoms are often termed post-Lyme disease syndrome, of which etiology is not clearly understood. The aim of this study was to investigate cognitive function, possible structural changes in brain regions and level of fatigue. We have not found previous studies on neuroborreliosis that use standardized neuropsychological tests and MRI with advanced image processing to investigate if there are subtle regional changes in cortical thickness and brain volumes after treatment.

METHODS

We examined 68 patients treated for neuroborreliosis 6 months earlier and 66 healthy controls, with a comprehensive neuropsychological test protocol, quantitative structural MRI analysis of the brain and Fatigue Severity Scale.

RESULTS

We found no differences between the groups in either cognitive function, cortical thickness or brain volumes. The patients had higher score on Fatigue Severity Scale 3.8 vs. 2.9 (p = 0.001), and more patients (25.4%) than controls (5%) had severe fatigue (p = 0.002), but neither mean score nor proportion of patients with severe fatigue differed from findings in the general Norwegian population.

CONCLUSION

The prognosis regarding cognitive function, brain MRI findings and fatigue after adequately treated neuroborreliosis is favorable.

A multimodal neuroimaging study of brain abnormalities and clinical correlates in post treatment Lyme disease

Lyme disease is the most common vector-borne infectious disease in the United States. Post-treatment Lyme disease (PTLD) is a condition affecting 10-20% of patients in which symptoms persist despite antibiotic treatment. Cognitive complaints are common among those with PTLD, suggesting that brain changes are associated with the course of the illness. However, there has been a paucity of evidence to explain the cognitive difficulties expressed by patients with PTLD. This study administered a working memory task to a carefully screened group of 12 patients with well-characterized PTLD and 18 healthy controls while undergoing functional MRI (fMRI). A subset of 12 controls and all 12 PTLD participants also received diffusion tensor imaging (DTI) to measure white matter integrity. Clinical variables were also assessed and correlated with these multimodal MRI findings. On the working memory task, the patients with PTLD responded more slowly, but no less accurately, than did controls. FMRI activations were observed in expected regions by the controls, and to a lesser extent, by the PTLD participants. The PTLD group also hypoactivated several regions relevant to the task. Conversely, novel regions were activated by the PTLD group that were not observed in controls, suggesting a compensatory mechanism. Notably, three activations were located in white matter of the frontal lobe. DTI measures applied to these three regions of interest revealed that higher axial diffusivity correlated with fewer cognitive and neurological symptoms. Whole-brain DTI analyses revealed several frontal lobe regions in which higher axial diffusivity in the patients with PTLD correlated with longer duration of illness. Together, these results show that the brain is altered by PTLD, involving changes to white matter within the frontal lobe. Higher axial diffusivity may reflect white matter repair and healing over time, rather than pathology, and cognition appears to be dynamically affected throughout this repair process.

Cognitive function in patients with neuroborreliosis: A prospective cohort study from the acute phase to 12 months post treatment

BACKGROUND

Long-term cognitive problems after neuroborreliosis treatment remain a subject of debate. We have previously shown that cognitive problems are not present in the acute phase of neuroborreliosis, although fatigue is common. The aim of this study was to re-assess the same patient cohort and evaluate long-term outcomes.

METHODS

In this follow-up, we re-assessed 58 patients with well-characterized neuroborreliosis 12 months after completing treatment. The same protocol with eight subtests measuring attention and processing speed and the Fatigue Severity Scale (FSS) were used to compare the results from the acute phase to 12 months post treatment.

RESULTS

We found no changes in attention or processing speed but a reduction in the level of fatigue (median score on FSS: 4.9 vs. 3.9, p < .001) from the acute phase to 12 months post treatment.

CONCLUSION

The patient group did not develop problems with attention or processing speed post treatment, while the level of fatigue decreased.

Chronic cerebral aspects of long COVID, post-stroke syndromes and similar states share their pathogenesis and perispinal etanercept treatment logic

The chronic neurological aspects of traumatic brain injury, post‐stroke syndromes, long COVID‐19, persistent Lyme disease, and influenza encephalopathy having close pathophysiological parallels that warrant being investigated in an integrated manner. A mechanism, common to all, for this persistence of the range of symptoms common to these conditions is described. While TNF maintains cerebral homeostasis, its excessive production through either pathogen‐associated molecular patterns or damage‐associated molecular patterns activity associates with the persistence of the symptoms common across both infectious and non‐infectious conditions. The case is made that this shared chronicity arises from a positive feedback loop causing the persistence of the activation of microglia by the TNF that these cells generate. Lowering this excess TNF is the logical way to reducing this persistent, TNF‐maintained, microglial activation. While too large to negotiate the blood‐brain barrier effectively, the specific anti‐TNF biological, etanercept, shows promise when administered by the perispinal route, which allows it to bypass this obstruction.

Long-Term Sequelae and Health-Related Quality of Life Associated With Lyme Disease: A Systematic Review

Lyme disease (LD) is the most commonly reported vector-borne disease, but its clinical consequences remain uncertain. We conducted a systematic review of the long-term sequelae and health-related quality of life (HRQoL) associated with LD in North America and Europe. We performed searches in 6 electronic databases up to December 2018 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including observational studies reporting long-term sequelae, HRQoL, and prognostic factors. We included 46 studies, published between 1994 and 2019. Based on 21 studies reporting attributable outcomes, higher proportions of sequelae reported from exposed patients were: neck pain, myalgia, arthralgia, paresthesia, sleep disorder, poor appetite, and concentration difficulties. Patients with PTLDS reported impaired HRQoL compared to the general US population. Included studies were highly heterogeneous in terms of study design, settings, patient characteristics, and quality. Patients with LD are more likely to report nonspecific long-term sequelae, especially those experiencing persistent symptoms posttreatment. Opportunities exist for prospective longitudinal studies to better understand LD outcomes.

Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis

Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis.

This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults.

Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany).

The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.

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.

Effects of sepsis on hippocampal volume and memory function

BACKGROUND

This study aimed to determine the effects of sepsis on brain integrity, memory, and executive function.

METHODS

Twenty sepsis patients who were not diagnosed with sepsis-associated encephalopathy (SAE) but had abnormal electroencephalograms (EEGs) were included. The control group included twenty healthy persons. A neuropsychological test of memory and executive function and a brain magnetic resonance imaging scan were performed. The volumes of cortex and subcortex were measured using the FreeSurfer software. Acute Physiology and Chronic Health Evaluation II (APACHE II) score was used to determine the disease severity.

RESULTS

In the sepsis group, the levels of immediate free recall, immediate cued recall, and delayed cued recall in the California Verbal Learning Test-II (CVLT-II) were significantly lower; the explicit memory (recollection process) in the process dissociation procedure test was lower; and the volumes of the left and right hippocampi were significantly lower compared with the control group. The volume of the presubiculum in the hippocampus of sepsis patients showed statistically significant decrease. In the sepsis group, the volumes of the left and right hippocampi were negatively correlated with the APACHE II score and positively with immediate free recall, immediate cued recall, and delayed cued recall in the CVLT-II; moreover, the hippocampal volume was significantly correlated with recollection but not with familiarity.

CONCLUSIONS

Patients with abnormal EEGs during hospitalization but with no SAE still have reduced hippocampal volume and memory deficits. This finding indicates that sepsis leads to damage to specific parts of the hippocampus.

Cognitive impairments in patients with persistent symptoms attributed to Lyme disease

Background

Persistent symptoms attributed to Lyme borreliosis often include self-reported cognitive impairment. However, it remains unclear whether these symptoms can be substantiated by objective cognitive testing.

Methods

For this observational study, cognitive performance was assessed in 280 adults with persistent symptoms attributed to Lyme borreliosis (as part of baseline data collected for the Dutch PLEASE study). Cognitive testing covered the five major domains: episodic memory, working memory / attention, verbal fluency, information-processing speed and executive function. Patients’ profiles of test scores were compared to a large age-, education- and sex-adjusted normative sample using multivariate normative comparison. Performance validity was assessed to detect suboptimal effort, and questionnaires were administered to measure self-reported cognitive complaints, fatigue, anxiety, depressive symptoms and several other psychological factors.

Results

Of 280 patients, one was excluded as the test battery could not be completed. Of the remaining 279 patients, 239 (85.4%) displayed sufficient performance validity. Patients with insufficient performance validity felt significantly more helpless and physically fatigued, and less orientated. Furthermore, they had a lower education level and less often paid work. Of the total study cohort 5.7% (n = 16) performed in the impaired range. Among the 239 patients who displayed sufficient performance validity, 2.9% (n = 7) were classified as cognitively impaired. No association between subjective cognitive symptoms and objective impairment was found.

Conclusions

Only a small percentage of patients with borreliosis-attributed persistent symptoms have objective cognitive impairment. Performance validity should be taken into account in neuropsychological examinations of these patients. Self-report questionnaires are insufficiently valid to diagnose cognitive impairment.

Trial registration

ClinicalTrials.gov NCT01207739. Registered 23 September 2010.

Neurocognition in Post-Treatment Lyme Disease and Major Depressive Disorder

OBJECTIVE

Neurocognitive dysfunction in patients with residual or emergent symptoms after treatment for Lyme Disease is often attributed to comorbid depression. In this study, patients with Post-Treatment Lyme Disease Syndrome (PTLDS) were compared to patients with Major Depressive Disorder (MDD), as well as healthy comparison subjects (HC), on neurocognitive measures administered through the same laboratory, to determine if patterns of performance were similar.

METHODS

Two analyses were conducted. First, performance on the Wechsler Adult Intelligence Scale (WAIS-III) and on subtests from the Wechsler Memory Scale (WMS-III) was compared among the groups. Second, comparable subgroups of PTLDS and MDD patients with at least one low WMS-III score were compared on an additional set of measures assessing motor function, psychomotor performance, attention, memory, working memory, and language fluency, to determine if the overall profile of performance was similar in the two subgroups.

RESULTS

In the first analysis, PTLDS patients performed more poorly than both MDD and HC on tasks assessing verbal abilities, working memory, and paragraph learning. Processing speed in the two patient groups, however, was equally reduced. In the second analysis, MDD patients with low WMS-III exhibited concomitantly greater difficulties in psychomotor speed and attention, while low-WMS-III PTLDS patients exhibited greater difficulties in language fluency.

CONCLUSIONS

MDD and PTLDS can be confused neuropsychologically because both exhibit similar levels of psychomotor slowing. However, problems on memory-related tasks, though mild, are more pronounced in PTLDS. PTLDS patients with poorer memory also exhibit poorer language fluency, and less deficit in processing speed and attention compared to MDD.

Cognitive Decline in Post-treatment Lyme Disease Syndrome

OBJECTIVE

Patient-reported cognitive complaints are common in those with post-treatment Lyme disease syndrome (PTLDS). Objective evidence of cognitive impairment in this population is variable in part due to methodological variability in existing studies. In this study, we sought to use a systematic approach to characterizing PTLDS based on the most current consensus diagnosis. We further examined PTLDS-related cognitive decline, operationalized as a significant decline in cognitive test performance relative to premorbid cognitive ability.

METHOD

We enrolled a case series of 124 patients with confirmed PTLDS defined by Infectious Diseases Society of America-proposed case definition. Cognitive functioning was evaluated using standardized neuropsychological measures.

RESULTS

The majority (92%) of participants endorsed some level of cognitive difficulty, yet 50% of the sample showed no statistically or clinically significant cognitive decline, 26% of the sample evidenced significant cognitive decline on measures of memory and variably on measures of processing speed, and 24% of the sample were excluded from analyses due to suboptimal test engagement.

CONCLUSIONS

The current findings are consistent with the literature showing that the most robust neurocognitive deficit associated with PTLDS is in verbal memory and with variable decline in processing speed. Compared to population normative comparison standards, PTLDS-related cognitive decline remains mild. Thus, further research is needed to better understand factors related to the magnitude of subjective cognitive complaints as well as objective evidence of mild cognitive decline.

Effect of prolonged antibiotic treatment on cognition in patients with Lyme borreliosis

Objective

To investigate whether longer-term antibiotic treatment improves cognitive performance in patients with persistent symptoms attributed to Lyme borreliosis.

Methods

Data were collected during the Persistent Lyme Empiric Antibiotic Study Europe (PLEASE) trial, a randomized, placebo-controlled study. Study participants passed performance-validity testing (measure for detecting suboptimal effort) and had persistent symptoms attributed to Lyme borreliosis. All patients received a 2-week open-label regimen of intravenous ceftriaxone before the 12-week blinded oral regimen (doxycycline, clarithromycin/hydroxychloroquine, or placebo). Cognitive performance was assessed at baseline and after 14, 26, and 40 weeks with neuropsychological tests covering the cognitive domains of episodic memory, attention/working memory, verbal fluency, speed of information processing, and executive function.

Results

Baseline characteristics of patients enrolled (n = 239) were comparable in all treatment groups. After 14 weeks, performance on none of the cognitive domains differed significantly between the treatment arms (p = 0.49–0.82). At follow-up, no additional treatment effect (p = 0.35–0.98) or difference between groups (p = 0.37–0.93) was found at any time point. Patients performed significantly better in several cognitive domains at weeks 14, 26, and 40 compared to baseline, but this was not specific to a treatment group.

Conclusions

A 2-week treatment with ceftriaxone followed by a 12-week regimen of doxycycline or clarithromycin/hydroxychloroquine did not lead to better cognitive performance compared to a 2-week regimen of ceftriaxone in patients with Lyme disease–attributed persistent symptoms.

ClinicalTrials.gov identifier

NCT01207739.

Classification of evidence

This study provides Class II evidence that longer-term antibiotics in patients with borreliosis-attributed persistent symptoms does not increase cognitive performance compared to shorter-term antibiotics.

Human Sensory LTP Predicts Memory Performance and Is Modulated by the BDNF Val66Met Polymorphism

Background: Long-term potentiation (LTP) is recognised as a core neuronal process underlying long-term memory. However, a direct relationship between LTP and human memory performance is yet to be demonstrated. The first aim of the current study was thus to assess the relationship between LTP and human long-term memory performance. With this also comes an opportunity to explore factors thought to mediate the relationship between LTP and long-term memory. The second aim of the current study was to explore the relationship between LTP and memory in groups differing with respect to brain-derived neurotrophic factor (BDNF) Val⁶⁶Met; a single-nucleotide polymorphism (SNP) implicated in memory function.

Methods: Participants were split into three genotype groups (Val/Val, Val/Met, Met/Met) and were presented with both an EEG paradigm for inducing LTP-like enhancements of the visually-evoked response, and a test of visual memory.

Results: The magnitude of LTP 40 min after induction was predictive of long-term memory performance. Additionally, the BDNF Met allele was associated with both reduced LTP and reduced memory performance.

Conclusions: The current study not only presents the first evidence for a relationship between sensory LTP and human memory performance, but also demonstrates how targeting this relationship can provide insight into factors implicated in variation in human memory performance. It is anticipated that this will be of utility to future clinical studies of disrupted memory function.

Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist's Clinical Practice

There is increasing evidence and recognition that Lyme borreliosis (LB) causes mental symptoms. This article draws from databases, search engines and clinical experience to review current information on LB. LB causes immune and metabolic effects that result in a gradually developing spectrum of neuropsychiatric symptoms, usually presenting with significant comorbidity which may include developmental disorders, autism spectrum disorders, schizoaffective disorders, bipolar disorder, depression, anxiety disorders (panic disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, intrusive symptoms), eating disorders, decreased libido, sleep disorders, addiction, opioid addiction, cognitive impairments, dementia, seizure disorders, suicide, violence, anhedonia, depersonalization, dissociative episodes, derealization and other impairments. Screening assessment followed by a thorough history, comprehensive psychiatric clinical exam, review of systems, mental status exam, neurological exam and physical exam relevant to the patient's complaints and findings with clinical judgment, pattern recognition and knowledgeable interpretation of laboratory findings facilitates diagnosis. Psychotropics and antibiotics may help improve functioning and prevent further disease progression. Awareness of the association between LB and neuropsychiatric impairments and studies of their prevalence in neuropsychiatric conditions can improve understanding of the causes of mental illness and violence and result in more effective prevention, diagnosis and treatment.

Depressive Symptoms and Suicidal Ideation Among Symptomatic Patients With a History of Lyme Disease vs Two Comparison Groups

BACKGROUND

Depression has been reported in 8-45% of patients with posttreatment Lyme symptoms (PTLS), but little is known about suicidal ideation in these patients.

METHOD

Depression and suicidal ideation were assessed using the Beck Depression Inventory (BDI-II). Scores from the PTLS group (n = 81) were compared to those from 2 other groups: HIV+ patients being treated for fatigue (n = 70), and a nonpatient comparison group (NPCG; n = 44). ANOVA and t-tests were used to compare groups; logistic regression was used to identify the strongest correlates of suicidal ideation.

RESULTS

Mean BDI-II scores fell in the mildly depressed range for PTLS and HIV+ patients, with both groups having higher depression scores than the NPCG. Suicidal ideation was reported by 19.8% of the PTLS patients and 27.1% of the HIV+ patients, a nonsignificant difference. Among those with mild or no depression, suicidal ideation was uncommon (6.5% PTLS and 11.9% HIV+). Among the patients with moderate-to-severe depression, suicidal ideation was more common (63.2% of 19 PTLS and 50% of 28 HIV+); among these, 2 with PTLS and 1 with HIV+ expressed suicidal intent. Further, 4.5% (n = 2) of the NPCG had suicidal ideation, each had scores in the moderate-to-severe depression range. Higher scores on the cognitive symptoms subscale of the BDI-II predicted greater likelihood of suicidal ideation across patient groups.

CONCLUSION

As expected, suicidal ideation is increased among patients who are depressed. The fact that 1 in 5 patients with PTLS reported suicidal ideation highlights the importance of screening for depression and suicidality to optimize patient care.

Treating Depression and Compensatory Narcissistic Personality Style in a Man With Chronic Lyme Disease

The following case study illustrates a client-centered, cognitive-behavioral approach to the psychological treatment of Mr. M, a 41-year-old male diagnosed with chronic Lyme disease, a mood disorder from Lyme disease, and narcissistic personality disorder. Mr. M's personality difficulties are conceptualized as representing compensatory narcissism, a strategic way of coping with feelings of insecurity. The goals of treatment included positively integrating Mr. M's chronic illness into his identity, decreasing depressive symptoms, and improving his interpersonal skills. Treatment was successful in decreasing both Mr. M's depressive symptoms and his narcissistic orientation to thinking and interacting with others.

Correlates of perceived health-related quality of life in post-treatment Lyme encephalopathy

BACKGROUND

Marked functional impairment has been reported by patients with post-treatment Lyme disease syndrome (PTLDS).

OBJECTIVE

We sought to identify the clinical features that contribute most strongly to the impaired health status associated with PTLDS.

METHODS

Enrolled patients had a well-documented history of Lyme disease, prior treatment with at least 3 weeks with intravenous ceftriaxone, a positive IgG Western blot, and objective problems with memory. An index score to capture aggregate cognitive functioning, Short-Form 36 physical and mental component summary scores, and scores on other clinical and demographic measures were examined. Multiple linear regressions were performed to determine significant predictors of perceptions of impaired life functioning as delineated by the Short-Form 36.

RESULTS

Fatigue was the most important contributor to perceived impairments in overall physical functioning, and fatigue and depression significantly predicted perceived impairments in overall mental functioning.

CONCLUSIONS

Because fatigue and depression contribute prominently to reports of impaired physical functioning and mental functioning among patients with PTLDS, clinicians should assess patients for these symptoms and consider targeting these symptoms in the selection of treatment interventions. Future controlled studies should examine the effectiveness of such agents for patients with PTLDS.

Risk factors for a non-favorable outcome after treated European neuroborreliosis

AIM

To identify possible risk factors for reduced health-related quality of life (HRQoL) and fatigue after treated Lyme neuroborreliosis (LNB).

METHODS

We included 50 patients with LNB and analyzed associations between their demographic, clinical, and laboratory characteristics at baseline and outcome at 30 months assessed by the self-report questionnaires Short Form-36 (SF-36) and Fatigue Severity Scale (FSS).

RESULTS

Lower scores in the SF-36 domain Physical Component Summary were associated with pretreatment symptom duration >6 weeks (B = -11.0, P = 0.001) and non-complete recovery at 4 months (B = -5.5, P = 0.037) (R(2) = 0.35). Lower scores in the SF-36 domain Mental Component Summary were associated with non-complete recovery at 4 months (B = -8.9, P = 0.01 (R(2) = 0.14). Higher FSS scores were associated with pretreatment symptom duration >6 weeks (B = 1.4, P = 0.006), high scores on the composite clinical score pretreatment (B = 0.1, P = 0.003), and non-complete recovery at 4 months (B = 1.6, P = 0.005) (R(2) = 0.46). No laboratory test results were associated with these predefined outcomes.

CONCLUSIONS

Delayed treatment start, more symptoms and findings before treatment, and non-complete recovery at 4 months after treatment are possible predictors of a poorer HRQoL and more fatigue 30 months after treated LNB. We did not find age, gender, educational level, involvement of the central nervous system, coexisting diseases, or cerebrospinal fluid findings to be associated with reduced HRQoL or fatigue. Our findings should be replicated in future studies before any conclusions can be drawn.

European neuroborreliosis: neuropsychological findings 30 months post-treatment

BACKGROUND

The aim of this study was to compare neuropsychological (NP) functioning in patients with Lyme neuroborreliosis (LNB) 30months after treatment to matched controls.

METHODS

We tested 50 patients with LNB and 50 controls with the trail-making test (TMT), Stroop test, digit symbol test, and California Verbal Learning test (CVLT). A global NP sumscore was calculated to express the number of low scores on 23 NP subtasks.

RESULTS

Mean scores were lower amongst LNB-treated patients than amongst controls on tasks assessing attention/executive functions: (Stroop test 4: 77.6 vs. 67.0, P=0.015), response/processing speed (TMT 5: 23.4 vs. 19.2, P=0.004), visual memory (digit symbol recall: 6.6 vs. 7.2, P=0.038), and verbal memory (CVLT list B: 4.68 vs. 5.50, P=0.003). The proportion of patients and controls with NP sumscores within one SD from the mean in the control group (defined as normal) and between one and two SD (defined as deficit) were similar, but more LNB-treated patients than controls had a sumscore more than two SD from the mean (defined as impairment) (8 vs. 1, P=0.014).

CONCLUSIONS

As a group, LNB-treated patients scored lower on four NP subtasks assessing processing speed, visual and verbal memory, and executive/attention functions, as compared to matched controls. The distribution of NP dysfunctions indicates that most LNB-treated patients perform comparable to controls, whilst a small subgroup have a debilitating long-term course with cognitive problems.

Lyme disease: the next decade

Although Lyme disease remains a controversial illness, recent events have created an unprecedented opportunity to make progress against this serious tick-borne infection. Evidence presented during the legally mandated review of the restrictive Lyme guidelines of the Infectious Diseases Society of America (IDSA) has confirmed the potential for persistent infection with the Lyme spirochete, Borrelia burgdorferi, as well as the complicating role of tick-borne coinfections such as Babesia, Anaplasma, Ehrlichia, and Bartonella species associated with failure of short-course antibiotic therapy. Furthermore, renewed interest in the role of cell wall-deficient (CWD) forms in chronic bacterial infection and progress in understanding the molecular mechanisms of biofilms has focused attention on these processes in chronic Lyme disease. Recognition of the importance of CWD forms and biofilms in persistent B. burgdorferi infection should stimulate pharmaceutical research into new antimicrobial agents that target these mechanisms of chronic infection with the Lyme spirochete. Concurrent clinical implementation of proteomic screening offers a chance to correct significant deficiencies in Lyme testing. Advances in these areas have the potential to revolutionize the diagnosis and treatment of Lyme disease in the coming decade.

Inflammation and central nervous system Lyme disease

Lyme disease, caused by the bacterium Borrelia burgdorferi, can cause multi-systemic signs and symptoms, including peripheral and central nervous system disease. This review examines the evidence for and mechanisms of inflammation in neurologic Lyme disease, with a specific focus on the central nervous system, drawing upon human studies and controlled research with experimentally infected rhesus monkeys. Directions for future human research are suggested that may help to clarify the role of inflammation as a mediator of the chronic persistent symptoms experienced by some patients despite antibiotic treatment for neurologic Lyme disease.

Memory and executive functions in adolescents with posttreatment Lyme disease

Although adults with late stage posttreatment Lyme disease often experience difficulties in memory, little is known about the relationship between cognition and Lyme disease in children and adolescents. Twenty-five adolescents with late stage posttreatment Lyme disease (symptoms > 6 months) and 25 participants without Lyme disease (matched on gender, IQ, age, socioeconomic status) were assessed for neuropsychological functioning, depression, school functioning, and predisease academic achievement. The Lyme group had significant deficits in cognition (short-term visual memory, short-term and delayed verbal memory, all forms of recognition memory), as well as worse attendance, grades, and subjective reports of memory problems, without differing in predisease achievement or depression. Deficits in visual memory exceeded deficits in verbal memory-a striking difference from what is reported in adults. These results reveal that adolescents with a history of treated Lyme disease are at risk for long-term problems in cognition and school functioning.

Certains symptômes cliniques aspécifiques ont-ils une origine borrélienne?

Chronic manifestations (knee arthritis, encephalomyelitis, axonal polyneuropathy) may occur in the late phase of Lyme disease. Contrasting with such well-defined manifestations, the "post-Lyme syndrome" includes symptoms such as fatigue, algia, malaise, cognitive disorders, after treatment of a documented Lyme disease. The analysis of clinical, neuropsychological, bacteriological, immunological, epidemiological, quality of life, and treatment data does not support the reality of such a syndrome. Moreover, no physiopathological data can relate Borrelia infection to such symptoms in patients without previously documented Lyme disease symptoms but who are seropositive (or even sometimes without serodiagnosis as for instance in the Munchausen by proxy, or Gulf war syndromes).