Unorthodox alternative therapies marketed to treat Lyme disease

A Multimodal Ayurveda and Mind-Body Therapeutic Intervention for Chronic Symptoms Attributed to a Postinfectious Syndrome: A Pilot Study

Objective: Evaluate feasibility and impact of a multimodal integrative therapeutic intervention in patients presenting with chronic symptoms attributed to a postinfectious syndrome. Design: This was a prospective longitudinal single-center pilot study conducted from January 2019 to December 2020. Setting/Location: University of Maryland Lyme Program, Baltimore Maryland. Subjects: Persons presenting for Lyme evaluation for symptoms attributed to Lyme disease. Interventions: Participants attended two 1-h individual instructional sessions consisting of Ayurveda-based dietary intervention and breath-coordinated mind-body practice to be used for home practice. Outcome measures: Standard measures of impact were obtained at baseline, 1, 3, 6, and 12 months using the following validated survey instruments: Perceived Stress Scale (PSS), PROMIS Global Health v1.2 (GH), and PROMIS 29 v2.0 survey. Results: From 216 patients presenting for Lyme evaluation, 19 participants enrolled with 84% completing the study (N = 16). Baseline PROMIS GH scores consisting of general Physical Health (GPH) and general Mental Health (GMH) scores were lower in the study population than in the general U.S. population. PROMIS 29 scores were higher for fatigue, anxiety, and pain than those in the general U.S. population. Over 12-month period, improvement in both the GPH and GMH was 6.09 (confidence interval [95% CI] = 2.71-9.46; p < 0.001) and 4.65 (95% CI = 1.50-7.80; p = 0.004), respectively. PROMIS 29 scores showed the greatest improvement in fatigue at -7.91 (95% CI = -12.34 to -3.48; p < 0.001), pain interference -5.08 (95% CI = -9.20 to -0.96; p = 0.016), and ability to participate in social roles and activities 7.48 (95% CI = 3.21-11.75; p = 0.001) and least with depression -1.82 (95% CI = -4.74 to 1.10; p = 0.223). Employment status had significant effects on almost all outcome scores. Postinfectious state was associated with improvement in anxiety and PSS scores. Conclusions: A multimodal Ayurvedic and breath-coordinated mind-body therapeutic intervention is feasible and a potential nonpharmacologic therapeutic option for persons presenting with pain, stress, fatigue, physical dysfunction, and sleep disturbance attributed to a postinfectious syndrome. Further research is needed to determine efficacy in this population and in other groups with similar symptom complexes due to postinfectious syndromes.

Cost of illness in patients with post-treatment Lyme disease syndrome in Belgium

BACKGROUND

A proportion of patients with Lyme borreliosis (LB) report long-term persisting signs and symptoms, even after recommended antibiotic treatment, which is termed post-treatment Lyme disease syndrome (PTLDS). Consensus on guidance regarding diagnosis and treatment is currently lacking. Consequently, patients suffer and are left searching for answers, negatively impacting their quality of life and healthcare expenditure. Yet, health economic data on PTLDS remain scarce. The aim of this article is therefore to assess the cost-of-illness related to PTLDS, including the patient perspective.

METHODS

PTLDS patients (N = 187) with confirmed diagnosis of LB were recruited by a patient organization. Patients completed a self-reported questionnaire on LB-related healthcare utilization, absence from work and unemployment. Unit costs (reference year 2018) were obtained from national databases and published literature. Mean costs and uncertainty intervals were calculated via bootstrapping. Data were extrapolated to the Belgian population. Generalized linear models were used to determine associated covariates with total direct costs and out-of-pocket expenditures.

RESULTS

Mean annual direct costs amounted to €4618 (95% CI €4070-5152), of which 49.5% were out-of-pocket expenditures. Mean annual indirect costs amounted to €36 081 (€31 312-40 923). Direct and indirect costs at the population level were estimated at €19.4 and 151.5 million, respectively. A sickness or disability benefit as source of income was associated with higher direct and out-of-pocket costs.

CONCLUSIONS

The economic burden associated with PTLDS on patients and society is substantial, with patients consuming large amounts of non-reimbursed healthcare resources. Guidance on adequate diagnosis and treatment of PTLDS is needed.

A Comprehensive Review of Herbal Supplements Used for Persistent Symptoms Attributed to Lyme Disease

Context

Lyme disease is the most common, tick-borne disease in the USA. While most patients successfully recover with antibiotics, some patients experience persistent symptoms for months to years. Patients who attribute chronic symptoms to Lyme disease commonly use herbal supplements. The complexity, variability in dose and formulation, and lack of data for these herbal compounds make it difficult to assess their efficacy and safety.

Objective

This review examines the evidence for the antimicrobial activity, safety, and drug-drug interactions of 18 herbal supplements that patients commonly use for treatment of persistent symptoms attributed to Lyme disease.

Design

The research team performed a narrative review by searching the PubMed, Embase, Scopus, Natural Medicines databases, and NCCIH website. The search used the keywords for 18 herbal compounds: (1) andrographis (Andrographis paniculate), (2) astragalus (Astragalus propinquus), (3) berberine, (4) cat's claw bark (Uncaria tomentosa), (5) cordyceps (Cordyceps sinensis), (6) cryptolepis (Cryptolepis sanguinolenta), (7) Chinese skullcap (Scutellaria baicalensis), (8) garlic (Allium sativum), (9) Japanese knotwood (Polygonum cuspidatum), (10) reishi mushrooms (Ganoderma lucidum), (11) sarsaparilla (Smilax medica), (12) Siberian ginseng (Eleutherococcus senticosus), (13) sweet wormwood (Artemisia annua), (14) teasle root (Dipsacus fullonum), (15) lemon balm (Melissa officinalis), (16) oil of oregano (Origanum vulgare), (17) peppermint (Mentha x piperita), and (18) thyme (Thymus vulgaris). The team also searched for terms related to protocols, including Dr. Rawls' protocol and the Buhner protocol.

Setting

University of Maryland Medical Center, Baltimore MD.

Results

Seven of the 18 herbs reviewed had evidence for in-vitro activity against B. burgdorferi. These compounds included: (1) cat's claw (2) cryptolepis, (3) Chinese skullcap, (4) Japanese knotweed, (5) sweet wormwood, (6) thyme, and (7) oil of oregano. With the exception of oil of oregano these compounds also have anti-inflammatory activity. In vivo data and clinical trials are lacking. Clinicians should be cautious as many of the identified compounds have drug interactions and additive effects that could lead to increased risks for bleeding, hypotension, and hypoglycemia.

Conclusions

Many of the herbs that alternative and integrative practitioners use to treat Lyme disease have anti-inflammatory effects that may contribute to patients' perceptions of symptomatic improvement. Some herbs have limited demonstrated anti-borrelial activity in vitro, but in-vivo data and clinical trial data is lacking. Further research is required to determine the efficacy, safety and appropriate use of these herbs for this patient population.

When the patient is making the (wrong?) diagnosis: a biographical approach to patients consulting for presumed Lyme disease

BACKGROUND

Media coverage of Lyme disease (LD) has led to an increase in consultations for presumed LD in Europe. However, LD is confirmed in only 10%-20% of patients, with a significant number remaining in a diagnostic dead-end.

OBJECTIVES

To reach a deeper understanding of how patients themselves contribute to the diagnostic process. To describe the genesis of the LD hypothesis in care pathways.

METHODS

In 2019, 30 patients from a prospective cohort consulting in the infectious diseases department at University Hospital in Marseille for presumed LD were recruited for semistructured interviews. The inclusion criteria were: suffering from subjective symptoms for 6 months, no clinical or paraclinical argument suggesting current LD. The patients' medical trajectories were collected using a biographical approach.

RESULTS

The diagnosis of LD was primarily triggered by identification with personal testimonies found on the Internet. Most of patients were leading their own diagnostic investigation. The majority of participants were convinced they had LD despite the lack of medical evidence and the scepticism of their referring GP.

CONCLUSION

GPs should first systematically explore patients' aetiologic representations in order to improve adherence to the diagnosis especially in the management of medically unexplained symptoms. Long COVID-19 syndrome challenge offers an opportunity to promote active patient involvement in diagnosis.

The Role of the Infectious Disease Consultation in Lyme Disease

A consultation regarding Lyme disease can be challenging for the infectious disease physician when the referral question centers on the use of prolonged or empirical antibiotic treatment of Lyme disease and associated tick-borne infections. Patients who have been infected with Borrelia burgdorferi, and many who have been misdiagnosed, are confronted with a seemingly endless array of misinformation that is not in keeping with the current understanding of the clinical spectrum of Lyme disease and its response to evidence-based treatment. Preparing for these conversations with a good grasp of the public beliefs regarding Lyme disease and its treatment can be beneficial.

Epidemiology of Lyme Disease

Lyme disease is the most common vector-borne illness in North America and Europe. The etiologic agent, Borrelia burgdorferi sensu lato, is transmitted to humans by certain species of Ixodes ticks, which are found widely in temperate regions of the Northern hemisphere. Clinical features are diverse but death is rare. The risk of human infection is determined by the distribution and abundance of vector ticks, ecologic factors influencing tick infection rates, and human behaviors that promote tick bite. Rates of infection are highest among children aged 5 to 15 years and adults aged more than 50 years. In the northeastern United States where disease is most common, exposure occurs primarily in areas immediately around the home. Knowledge of disease epidemiology is important for patient management and proper diagnosis.

Persistent Symptoms After Treatment of Lyme Disease

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.

Mistaken Identity: Many Diagnoses are Frequently Misattributed to Lyme Disease

BACKGROUND

Prior studies have demonstrated that Lyme disease is frequently over-diagnosed. However, few studies describe which conditions are misdiagnosed as Lyme disease.

METHODS

This retrospective observational cohort study evaluated patients who lacked evidence for Borrelia burgdorferi infection referred for Lyme disease to a Mid-Atlantic academic center from 2000-2013. The primary outcome is clinically described diagnoses contributing to symptoms. Secondary outcomes included symptom duration and determination whether diagnoses were new or attributed to existing medical conditions.

RESULTS

Of 1261 referred patients, 1061 (84%) had no findings of active Lyme disease, with 690 (65%) receiving other diagnoses; resulting in 405 (59%) having newly diagnosed medical conditions, 134 (19%) attributed to pre-existing medical issues, and 151 (22%) with both new and pre-existing conditions. Among the 690 patients, the median symptom duration was 796 days, and a total of 139 discrete diagnoses were made. Infectious disease diagnoses comprised only 3.2%. Leading diagnoses were anxiety/depression 222 (21%), fibromyalgia 120 (11%), chronic fatigue syndrome 77 (7%), migraine disorder 74 (7%), osteoarthritis 62 (6%), and sleep disorder/apnea 48 (5%). Examples of less frequent but non-syndromic diseases newly diagnosed included multiple sclerosis (n = 11), malignancy (n = 8), Parkinson's disease (n = 8), sarcoidosis (n = 4), or amyotrophic lateral sclerosis (n = 4).

CONCLUSIONS

Most patients with long-term symptoms have either new or pre-existing disorders accounting for their symptoms other than Lyme disease, suggesting overdiagnosis in this population. Patients referred for consideration of Lyme disease for chronic symptoms deserve careful assessment for diagnoses other than Borrelia burgdorferi infection.

Herbal hepatitis due to use of alternative medicines for Lyme disease

Lyme disease often leaves patients with chronic symptoms of fatigue, easy confusion, and even cardiac arrhythmias. We report a case in which Lyme disease was treated with an herbal mixture due to protracted symptoms despite intravenous antibiotics. This mixture was associated with hepatotoxicity. General providers should be aware of the fact that homeopathic remedies may be associated with hepatotoxicity, and herbalists need better understanding of the safety risks of the individual components in remedy mixtures.

Relations of peri-residential temperature and humidity in tick-life-cycle-relevant time periods with human Lyme disease risk in Pennsylvania, USA

How weather affects tick development and behavior and human Lyme disease remains poorly understood. We evaluated relations of temperature and humidity during critical periods for the tick lifecycle with human Lyme disease. We used electronic health records from 479,344 primary care patients in 38 Pennsylvania counties in 2006-2014. Lyme disease cases (n = 9657) were frequency-matched (5:1) by year, age, and sex. Using daily weather data at ~4 km² resolution, we created cumulative metrics hypothesized to promote (warm and humid) or inhibit (hot and dry) tick development or host-seeking during nymph development (March 1-May 31), nymph activity (May 1-July 30), and prior year larva activity (Aug 1-Sept 30). We estimated odds ratios (ORs) of Lyme disease by quartiles of each weather variable, adjusting for demographic, clinical, and other weather variables. Exposure-response patterns were observed for higher cumulative same-year temperature, humidity, and hot and dry days (nymph-relevant), and prior year hot and dry days (larva-relevant), with same-year hot and dry days showing the strongest association (4th vs. 1st quartile OR = 0.40; 95% confidence interval [CI] = 0.36, 0.43). Changing temperature and humidity could increase or decrease human Lyme disease risk.

A Review of Post-treatment Lyme Disease Syndrome and Chronic Lyme Disease for the Practicing Immunologist

Lyme disease is an infection caused by Borrelia burgdorferi sensu lato, which is transmitted to humans through the bite of an infected Ixodes tick. The majority of patients recover without complications with antibiotic therapy. However, for a minority of patients, accompanying non-specific symptoms can persist for months following completion of therapy. The constellation of symptoms such as fatigue, cognitive dysfunction, and musculoskeletal pain that persist beyond 6 months and are associated with disability have been termed post-treatment Lyme disease syndrome (PTLDS), a subset of a broader term "chronic Lyme disease." Chronic Lyme disease is a broad, vaguely defined term that is used to describe patients with non-specific symptoms that are attributed to a presumed persistent Borrelia burgdorferi infection in patients who may or may not have evidence of either previous or current Lyme disease. The diagnoses of chronic Lyme disease and of PTLDS have become increasingly relevant to the practice of immunologists due to referrals for consultation or for intravenous immunoglobulin (IVIG) treatment. This review aims to explore the relationship between chronic Lyme disease, post-treatment Lyme disease syndrome, and the immune system. Here, we review the current literature on (1) issues in conventional and alternative diagnostic testing for Lyme disease, (2) the hypothesis that B. burgdorferi infection can persist despite appropriate use of recommended antibiotics, (3) current theories regarding B. burgdorferi's role in causing both immune dysregulation and protracted symptoms, and (4) the use of IVIG for the treatment of Lyme disease.

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.

Experience and knowledge of Lyme disease: A scoping review of patient-provider communication

There has been limited research on patient-provider communication dynamics regarding Lyme disease (LD) diagnosis and treatment. Evidence suggests communication in the clinical encounter improves when both patient and healthcare provider (HCP) have concordant orientations (or beliefs) on discussed topics, resulting in higher patient satisfaction and care outcomes. The purpose of this scoping review was to characterize and summarize current research findings on patient and provider knowledge and experiences regarding LD - two factors that may influence the orientation of both patients and providers toward LD in the clinical setting. None of the articles included in the review specifically addressed patient-provider interaction and relationships as the main objective. However, the existing literature indicates notable HCP uncertainty regarding LD diagnosis, treatment, and applied practice patterns. Current research also describes limited knowledge of LD among patient populations and a high prevalence of negative perceptions of care received in mainstream healthcare settings among individuals with persistent symptoms. We identified a critical gap in research that seeks to understand the dynamic of patients and HCPs communicating on the topic of LD in the clinical setting. Future research may identify opportunities where the patient-provider communication dynamic can be improved.

Committee Opinion No. 399: Management of Tick Bites and Lyme Disease During Pregnancy

OBJECTIVE

Lyme disease is an emerging infection in Canada caused by the bacterium belonging to the Borrelia burgdorferi sensu lato species complex, which is transmitted via the bite of an infected blacklegged tick. Populations of blacklegged ticks continue to expand and are now established in different regions in Canada. It usually takes more than 24 hours of tick attachment to transfer B. burgdorferi to a human. The diagnosis of early localized Lyme disease is made by clinical assessment, as laboratory tests are not reliable at this stage. Most patients with early localized Lyme disease will present with a skin lesion (i.e., erythema migrans) expanding from the tick bite site and/or non-specific "influenza-like" symptoms (e.g., arthralgia, myalgia, and fever). Signs and symptoms may occur from between 3 and 30 days following the tick bite. The care of pregnant patients with a tick bite or suspected Lyme disease should be managed similarly to non-pregnant adults, including the consideration of antibiotics for prophylaxis and treatment. The primary objective of this committee opinion is to inform practitioners about Lyme disease and provide an approach to managing the care of pregnant women who may have been infected via a blacklegged tick bite.

INTENDED USERS

Health care providers who care for pregnant women or women of reproductive age.

TARGET POPULATION

Women of reproductive age.

EVIDENCE

In November 2018, Medline, EMBASE, PubMed, and CENTRAL databases were searched for 2 main categories: (1) Lyme disease and (2) other tick-borne diseases. Because the main focus was Lyme disease, and considering the limited number of the articles, no further filters were applied for publication time or type of study. For other tick-borne diseases, the results were restricted to a publication date within the last 10 years (2008-2018). The search terms were developed using MeSH terms and keywords including Lyme Disease, Pregnancy, Pregnant Women, Pregnancy Complications, Ehrlichiosis, Anaplasmosis, Rocky Mountain Spotted Fever, Babesiosis, Tularemia, Powassan Virus, Encephalitis Viruses, Tick-Borne, Tick-Borne Diseases, Colorado Tick Fever, Q Fever, Relapsing Fever, and Southern Tick-Associated Rash Illness. All articles on Lyme disease and other tick-borne diseases with a target population of pregnant women were included; other groups and populations were excluded.

VALIDATION METHODS

The content and recommendations of this committee opinion were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication.

Emergence of Lyme disease as a social problem: analysis of discourse using the media content

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.

Peripherally Inserted Central Catheter-Associated Nocardia nova Endocarditis in a Patient Receiving Intravenous Antibiotics for Chronic Lyme Disease

Long-term antibiotics are not effective for the therapy of patients with persistent symptoms and a history of Lyme disease. However, some clinicians still prescribe these therapies. We present a case of peripherally inserted central catheter-associated Nocardia nova endocarditis in a patient who had been receiving intravenous antibiotics for the management of chronic Lyme disease. This case highlights an important risk associated with the unscientific use of indwelling peripheral catheters and intravenous antibiotics for the management of such patients.

Lyme disease: diagnosis and treatment

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.

Lyme Disease in Humans

Lyme disease (Lyme borreliosis) is a tick-borne, zoonosis of adults and children caused by genospecies of the Borrelia burgdorferi sensu lato complex. The ailment, widespread throughout the Northern Hemisphere, continues to increase globally due to multiple environmental factors, coupled with increased incursion of humans into habitats that harbor the spirochete. B. burgdorferi sensu lato is transmitted by ticks from the Ixodes ricinus complex. In North America, B. burgdorferi causes nearly all infections; in Europe, B. afzelii and B. garinii are most associated with human disease. The spirochete's unusual fragmented genome encodes a plethora of differentially expressed outer surface lipoproteins that play a seminal role in the bacterium's ability to sustain itself within its enzootic cycle and cause disease when transmitted to its incidental human host. Tissue damage and symptomatology (i.e., clinical manifestations) result from the inflammatory response elicited by the bacterium and its constituents. The deposition of spirochetes into human dermal tissue generates a local inflammatory response that manifests as erythema migrans (EM), the hallmark skin lesion. If treated appropriately and early, the prognosis is excellent. However, in untreated patients, the disease may present with a wide range of clinical manifestations, most commonly involving the central nervous system, joints, or heart. A small percentage (~10%) of patients may go on to develop a poorly defined fibromyalgia-like illness, post-treatment Lyme disease (PTLD) unresponsive to prolonged antimicrobial therapy. Below we integrate current knowledge regarding the ecologic, epidemiologic, microbiologic, and immunologic facets of Lyme disease into a conceptual framework that sheds light on the disorder that healthcare providers encounter.

Lessons Learned from a Rhode Island Academic Out-Patient Lyme and Tick-Borne Disease Clinic

Although the prevalence of Lyme and tick-borne diseases (TBDs) continues to rise, there is conflicting information regarding the best approach to management. The Lifespan Lyme Disease Clinic (LDC) is an academic out- patient clinic for Lyme and other TBDs. A chart review of 218 new patients between March and November 2018 was conducted. Symptoms most commonly reported included fatigue (66.5%), joint pain (58.2%), cognitive difficulty (32.1%), and headaches (27.9%). Most (87.1%) patients had received TBD-directed antibiotic treatment prior to their first appointment. Of the 136 patients who had experienced more than 6 months of symptoms attributed to Lyme, 55.1% had positive two-tiered serologies. Many patients characterized themselves as having "chronic Lyme" or had a diagnosis of "post-treatment Lyme disease syndrome," a condition for which there is no clear consensus on pathophysiology or treatment. Outlined here are some lessons learned and practical approaches used by LDC physicians in caring for this patient population.

Classification of patients referred under suspicion of tick-borne diseases, Copenhagen, Denmark

To provide better care for patients suspected of having a tick-transmitted infection, the Clinic for Tick-borne Diseases at Rigshospitalet, Copenhagen, Denmark was established. The aim of this prospective cohort study was to evaluate diagnostic outcome and to characterize demographics and clinical presentations of patients referred between the 1st of September 2017 to 31st of August 2019. A diagnosis of Lyme borreliosis was based on medical history, symptoms, serology and cerebrospinal fluid analysis. The patients were classified as definite Lyme borreliosis, possible Lyme borreliosis or post-treatment Lyme disease syndrome. Antibiotic treatment of Lyme borreliosis manifestations was initiated in accordance with the national guidelines. Patients not fulfilling the criteria of Lyme borreliosis were further investigated and discussed with an interdisciplinary team consisting of specialists from relevant specialties, according to individual clinical presentation and symptoms. Clinical information and demographics were registered and managed in a database. A total of 215 patients were included in the study period. Median age was 51 years (range 17-83 years), and 56 % were female. Definite Lyme borreliosis was diagnosed in 45 patients, of which 20 patients had erythema migrans, 14 patients had definite Lyme neuroborreliosis, six had acrodermatitis chronica atrophicans, four had multiple erythema migrans and one had Lyme carditis. Furthermore, 12 patients were classified as possible Lyme borreliosis and 12 patients as post-treatment Lyme disease syndrome. A total of 146 patients (68 %) did not fulfil the diagnostic criteria of Lyme borreliosis. Half of these patients (73 patients, 34 %) were diagnosed with an alternative diagnosis including inflammatory diseases, cancer diseases and two patients with a tick-associated disease other than Lyme borreliosis. A total of 73 patients (34 %) were discharged without sign of somatic disease. Lyme borreliosis patients had a shorter duration of symptoms prior to the first hospital encounter compared to patients discharged without a specific diagnosis (p<0.001). When comparing symptoms at presentation, patients discharged without a specific diagnosis suffered more often from general fatigue and cognitive dysfunction. In conclusion, 66 % of all referred patients were given a specific diagnosis after ended outpatient course. A total of 32 % was diagnosed with either definite Lyme borreliosis, possible Lyme borreliosis or post-treatment Lyme disease syndrome; 34 % was diagnosed with a non-tick-associated diagnosis. Our findings underscore the complexity in diagnosing Lyme borreliosis and the importance of ruling out other diseases through careful examination.

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.

Lyme Disease and the Epistemic Tensions of "Medically Unexplained Illnesses"

In the US, disagreement over the biological basis of "chronic Lyme disease" has resulted in the institutionalization of two standards of care: "mainstream" and "Lyme-literate." For mainstream physicians, chronic Lyme disease is a "medically unexplained illness" that presents with an abundance of "symptoms" in the absence of diagnostic "signs." For Lyme-literate physicians, and complementary and alternative medicine practitioners more generally, symptoms alone provide sufficient evidence for medical explanation. Drawing upon ethnographic research among mainstream and Lyme-literate physicians, I suggest that medically unexplained illness is not a biomedical anomaly but an intrinsic feature of biomedicine.

Adverse Events Associated With Antibiotics and Intravenous Therapies for Post-Lyme Disease Syndrome in a Commercially Insured Sample

Background

Non-guideline-endorsed posttreatment courses of antibiotics for post-Lyme disease syndrome (PLDS) have been linked to adverse patient outcomes, but these findings have yet to be validated in large systematic evaluations.

Methods

A retrospective cohort analysis of medical and pharmacy claims derived from the Truven Health Market Scan Commercial Claims and Encounters Database assessed 90-day incidence rates of adverse events (AEs) associated with PLDS treatment (PLDS-Tx). Patients were diagnosed with PLDS ≥6 months after initial diagnosis and standard antibiotic treatment for Lyme disease. Comparison cohorts included intravenous (IV) PLDS-Tx with or without oral antibiotics; oral antibiotic-only PLDS-Tx; or neither.

Results

Composite AE incidence rates were higher for patients treated with IV or oral PLDS-Tx than for patients not receiving either treatment (18.7%, 16.8%, and 13.4%, respectively; P = .019). Significant between-group differences in AE incidence rates were noted for electrolyte imbalance (4.0%, 1.5%, and 0.7%, respectively; P = .001) and infection (14.0%, 12.7%, and 9.3%; P = .006). Infection prevalence increased by 22.0% in the IV treatment group and 17.7% in the oral group. Incidence rates for all-cause and AE-related hospital stays and emergency department visits were higher for treated than nontreated patients, particularly when treatment was IV (all P < .01). Of IV-treated patients, 7.3% experienced an incident all-cause inpatient stay and 11.3% an incident all-cause emergency department visit, compared with, respectively, 2.2% and 3.4% of those treated with oral antibiotics and 0.9% and 1.9% of nontreated patients.

Conclusions

Use of IV therapies or oral antibiotics for PLDS was associated with increased patient morbidity within 90 days.

Is It Possible to Make a Correct Diagnosis of Lyme Disease on Symptoms Alone? Review of Key Issues and Public Health Implications

There is much confusion and misinformation about the diagnosis of Lyme disease, as well as its treatment. This review explains why one cannot make a correct diagnosis of Lyme disease based on symptoms alone. It also provides evidence to support the validity of two-tier testing for the laboratory diagnosis of Lyme disease. The public health consequences of failing to consider these issues are discussed.

Lyme Neuroborreliosis - The Mystifying Pitfall: "Neuropathology and Current Therapeutics"

Lyme's Disease (LD) is a severe, rapidly growing, broad spectrum chronic infection caused by the bacterium 'Borrelia (B.) burgdorferi', which can be easily transmitted through the bite of certain species of ticks. The prevalence of LD is swiftly mounting in the present scenario in many countries from species to species. Although Lyme's infection is now detectable via serologic examination of early and late Lyme neuroborreliosis (LNB), the management of persistent symptoms is still fraught with quora of doubt and debate. LD is a multisystem spirochete which results after the dissemination of B. burgdorferi from a dermal inoculation site after a tick bite. Lyme's infection can easily get transmitted to the central nervous system and develop various neurological symptoms due to inflammation and an autoimmune response from body may lead to life-threatening "Lyme Borreliosis". The neurological symptoms are well mixed in presentation, late and confusing to get differentiated easily from other diseases. The use of antibiotics in post Lyme infection with neurological complications is still a topic of debate. Babesiosisstates, and human ehrlichiosis' the two other diseases, are associated with the same ticks that spread the LD. However, the prevalence of diagnosed human cases is usually much lower than that of actual cases of LD due to misdiagnosis, late diagnosis or undiagnosis at y such lateral neuroinfection stage after the tick bite. The current review focuses on the molecular neuropathology and current advancements in LD. There are very few patents or discoveries made on borrelia infection, drawing attention towards more focused and targeted research for the cure.

A description of 'Australian Lyme disease' epidemiology and impact: an analysis of submissions to an Australian senate inquiry

BACKGROUND

Many Australian patients are diagnosed and treated for the scientifically and politically controversial diagnosis of an endemic form of 'Australian Lyme Disease'. Patient advocacy led Senator John Madigan to propose an Australian Senate Inquiry into this illness.

AIM

To describe the symptomology and outcomes of patients diagnosed and treated with Lyme disease in Australia.

METHODS

All public, first-person submissions (n = 698) to the inquiry were reviewed and responses analysed for epidemiology, symptoms and impact against structured criteria.

RESULTS

The most common symptoms described were fatigue (62.6%), disordered thinking (51.9%) and sensory disturbance (46.1%). Respondents reported experiencing symptoms for a median of 10 years and spent a median of $30 000 on diagnosis and treatment. Almost 10% of respondents self-diagnosed after being exposed to a media report of Australian Lyme disease.

CONCLUSIONS

Patients diagnosed with Lyme disease in Australia display a symptomology similar to 'medically unexplained physical symptoms' syndromes, experience social and financial harms, and are at risk of nosocomial harms. Negative medical interactions and the media may contribute to patients seeking alternative and potentially non-evidence-based diagnoses and treatments.

Seven cases of probable endotoxin poisoning related to contaminated glutathione infusions

We report seven cases of probable endotoxin poisoning linked to contaminated compounded glutathione. Five of the cases were using the infusions for treatment of Lyme disease highlighting the risks of using compounded sterile preparations for unapproved indications, especially if the quality of source products cannot be assured.

NF‑κB is a key modulator in the signaling pathway of Borrelia burgdorferi BmpA‑induced inflammatory chemokines in murine microglia BV2 cells

Lyme disease, caused by the bacterial spirochete Borrelia burgdorferi, is a tick‑borne zoonosis. Lyme neuroborreliosis is a principal manifestation of Lyme disease and its pathogenesis remains incompletely understood. Recent studies have demonstrated that Borrelia burgdorferi lipoproteins caused similar inflammatory effects as exhibited in Lyme neuroborreliosis. Basic membrane protein A (BmpA) is one of the dominant lipoproteins in the Borrelia burgdorferi membrane. In addition, nuclear factor κ‑B (NF‑κB) modulates the regulation of gene transcription associated with immunity and inflammation; however, in unstimulated cells, NF‑κB is combined with the inhibitor of NF‑κB (IκB‑β). Therefore, it was hypothesized that NF‑κB may be associated with BmpA‑induced inflammation and the occurrence of Lyme neuroborreliosis. Therefore, the aim of the present study was to investigate the role that NF‑κB serves in the signaling pathway of rBmpA‑induced inflammatory chemokines. The present study measured the expression levels of NF‑κB, IκB‑β and inflammatory chemokines following recombinant BmpA (rBmpA) stimulation of murine microglia BV2 cells. Following stimulation with rBmpA, concentrations of pro‑inflammatory cytokines including C‑X‑C motif chemokine 2, C‑C motif chemokine (CCL) 5 and CCL22 were determined by ELISA analysis. Reverse transcription‑quantitative polymerase chain reaction and western blotting were used to detect the expression levels of NF‑κB p65 and IκB‑β. The data demonstrated that concentrations of these chemokines in cell supernatants increased significantly following rBmpA stimulation. NF‑κB was overexpressed, but IκB‑β expression was significantly decreased. In conclusion, these results suggested that NF‑κB serves an important stimulatory role in the signaling pathway of rBmpA‑induced inflammatory chemokines in BV2 cells.

Predictors of Persistent Medically Unexplained Physical Symptoms: Findings From a General Population Study

Objective: To explore the persistency of Medically Unexplained Symptoms (MUS) and its prognostic factors in the general adult population. Knowledge of prognostic factors of MUS may indicate possible avenues for intervention development. Methods: Data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face cohort study among the Dutch general population aged 18-64 years. We selected subjects with MUS at baseline and who participated at follow-up (N = 324) and reassessed those subjects for having MUS at 3 year follow-up. Logistic regression analyses were used to determine risk factors for persistency of MUS. Results: 36.4% of the subjects had persistent MUS at follow-up. In logistic regression analyses adjusted for sex and age, persistency of MUS was predicted by the number of comorbid chronic medical disorder(s), lower education, female sex, not having a paid job, parental psychopathology as well as lower functioning. In the logistic regression analysis in which all significant variables adjusted for sex and age were entered simultaneously, three variables predicted persistent MUS: parental psychopathology, the number of comorbid chronic medical disorder(s) and physical functioning, with odds ratios of 2.01 (1.20-3.38), 1.19 (1.01-1.40), and 0.99 (0.97-1.00), respectively. Conclusion: In the adult general population, MUS were persistent in over one third of the subjects with MUS at baseline. Persistency was significantly predicted by parental psychopathology, number of comorbid chronic medical disorders, and physical functioning. These findings warrant further research into early intervention and treatment options for persons with an increased risk of persistent MUS.

Unraveling Diagnostic Uncertainty Surrounding Lyme Disease in Children with Neuropsychiatric Illness

Lyme disease is endemic in parts of the United States, including New England, the Atlantic seaboard, and Great Lakes region. The presentation has various manifestations, many of which can mimic psychiatric diseases in children. Distinguishing manifestations of Lyme disease from those of psychiatric illnesses is complicated by inexact diagnostic tests and misuse of these tests when they are not clinically indicated. This article aims to describe manifestations of Lyme disease in children with an emphasis on Lyme neuroborreliosis. Clinical scenarios will be presented and discussed. Finally, recommendations for clinical psychiatrists who encounter children with possible Lyme disease are presented.

Lyme disease: why the controversy?

Some Australians have become convinced of the existence of locally acquired Lyme disease (LD). The history of LD, since its recognition in the early 1970s, is reviewed as a model for investigative approaches to unknown syndromes. Australian Management Guidelines for LD include the requirement for diagnostic testing by National Association of Testing Authorities-accredited laboratories using Therapeutic Goods Administration-licensed tests, which result in the efficient diagnosis of LD in overseas travellers. Despite this, patients who have not left Australia pay many thousands of dollars for non-specialist consultations and testing at overseas laboratories. Unproven long-term therapy with multiple antibiotics has resulted in serious complications, including allergies, line sepsis, pancreatitis and pseudomembranous colitis. Studies have shown that LD vectors are not found in Australia, and Lyme Borrelia has not been found in Australian vectors, animals or patients with autochthonous illnesses. I propose that (i) A non-controversial name for the chronic syndrome should be adopted, 'Australian Multisystem Disorder'. (ii) Research funding should enable the development of a consensus case definition and studies of the epidemiology of this syndrome with laboratory investigations to identify an aetiology and surrogate markers of disease. Prospective, randomised treatment studies could then be undertaken using ethical protocols.

Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease - United States

The term "chronic Lyme disease" is used by some health care providers as a diagnosis for various constitutional, musculoskeletal, and neuropsychiatric symptoms (1,2). Patients with a diagnosis of chronic Lyme disease have been provided a wide range of medications as treatment, including long courses of intravenous (IV) antibiotics (3,4). Studies have not shown that such treatments lead to substantial long-term improvement for patients, and they can be harmful (1,5). This report describes cases of septic shock, osteomyelitis, Clostridium difficile colitis, and paraspinal abscess resulting from treatments for chronic Lyme disease. Patients, clinicians, and public health practitioners should be aware that treatments for chronic Lyme disease can carry serious risks.

Lyme borreliosis

Lyme borreliosis is a tick-borne disease that predominantly occurs in temperate regions of the northern hemisphere and is primarily caused by the bacterium Borrelia burgdorferi in North America and Borrelia afzelii or Borrelia garinii in Europe and Asia. Infection usually begins with an expanding skin lesion, known as erythema migrans (referred to as stage 1), which, if untreated, can be followed by early disseminated infection, particularly neurological abnormalities (stage 2), and by late infection, especially arthritis in North America or acrodermatitis chronica atrophicans in Europe (stage 3). However, the disease can present with any of these manifestations. During infection, the bacteria migrate through the host tissues, adhere to certain cells and can evade immune clearance. Yet, these organisms are eventually killed by both innate and adaptive immune responses and most inflammatory manifestations of the infection resolve. Except for patients with erythema migrans, Lyme borreliosis is diagnosed based on a characteristic clinical constellation of signs and symptoms with serological confirmation of infection. All manifestations of the infection can usually be treated with appropriate antibiotic regimens, but the disease can be followed by post-infectious sequelae in some patients. Prevention of Lyme borreliosis primarily involves the avoidance of tick bites by personal protective measures.