Emergence of Lyme Disease on the French Riviera, a Retrospective Survey

Background

The French Riviera has been declared free of Lyme Borreliosis (LB) for years. Many patients are referred for presumed LB, sometimes with atypical clinical signs and/or doubtful serology, calling the diagnosis into question.

Methods

Patients were assessed for LB diagnosis, depending on clinical presentation, laboratory findings, and further examination by other medical professionals.

Results

Among 255 patients, 45 (18%) were classified as confirmed LB cases [including 28 ongoing LB (10%) and 17 past LB (8%)], and for 210 (82%) a Lyme borreliosis diagnosis was ruled out. Among ongoing LB, 56% had been exposed to or bitten by ticks, exclusively in rural locations of the Alpes-Maritimes. As a result of the diagnostic procedure, 132 (52%) patients had been treated. An alternative diagnosis was established for 134 (52%) patients, covering a wide range of conditions, including mainly psychological (28%) and neurological conditions (25%) or inflammatory and systemic diseases (22%).

Conclusions

Our results strongly suggest the endemicity of LB in the Alpes-Maritimes region. Confirmed LB accounted for 18% of patients while 52% were diagnosed with other conditions.

Coping strategies and quality of life in patients with chronic symptoms visiting a Lyme Center in a Dutch teaching hospital

INTRODUCTION

Little is known on coping strategies in patients with chronic symptoms suspected of Lyme borreliosis (LB). Different coping strategies might influence quality of life (QoL). We assessed coping strategies and QoL in patients with chronic symptoms suspected of LB.

METHODS

Adult patients referred to the Lyme Center Apeldoorn were included (November 2019-April 2021). Participants completed the RAND-36 to assess QoL and the Utrecht Coping List to assess coping strategies. Patient data were extracted from medical records. Patients were categorized based on clinical LB and serology. Linear regression analyses were conducted to examine an association between coping strategies and QoL subscales.

RESULTS

Included were 201 patients. Patients suspected of LB had a different coping profile and lower QoL compared to the reference population. Patients with negative serology and no clinical LB scored lowest on all QoL subscales. In multivariate analyses, correcting for age, gender, comorbidity, and patient category, a negative association was found between passive coping and the QoL subscales physical functioning (β(SE) = - 1.1(0.5)), social functioning (β(SE) = - 3.3(0.5)), role limitations (emotional) (β(SE) = - 5.5(0.8)), mental health (β(SE) = - 3.7(0.3)), vitality (β(SE) = - 2.3(0.3)), pain (β(SE) = - 2.3(0.5)), and general health (β(SE) = - 2.7(0.3)). A negative association was also found between palliative coping and the QoL subscale role limitations (physical) (β(SE) = - 1.8(0.6)) and between expressing emotions and mental health (β(SE) = - 1.3(0.6)). A positive association was found between active coping and the QoL subscales mental health (β(SE) = 1.0(0.3)) and role limitations (emotional) (β(SE) = 1.9(0.8)).

CONCLUSION

In patients suspected of LB, dysfunctional coping strategies were associated with worse quality of life. There is a need for interventions that can guide patients with chronic symptoms suspected of LB towards more active coping and increase QoL.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease

This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.

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.

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.

Nonspecific Symptoms in Children Referred to a Lyme Borreliosis Center

BACKGROUND

Nonspecific symptoms in children suspected of Lyme borreliosis (LB) are challenging for clinicians. We assessed whether nonspecific symptoms are more prevalent among children with positive immunoglobulin G (IgG) serology or a history of clinical LB.

METHODS

We included children (<18 years) suspected of LB who visited the Lyme Center Apeldoorn of Gelre Hospital between 2008 and 2017. Serum samples were taken, and questionnaires on nonspecific symptoms completed. Clinical data were collected from patients' medical records. The prevalence of nonspecific symptoms was compared between patients with positive versus negative IgG serology and between patients with versus without previous LB with the χ and Fisher exact tests with Bonferroni correction. A history of LB was anamnestically determined. Patients with active Lyme manifestations were excluded.

RESULTS

Included were 149 children (66% female; median age 13 years); 29 (19%) had positive IgG serology; 36 (24%) had previous LB; 12 (8%) had both. Common nonspecific symptoms were sleep disturbances (58%), severe fatigue (57%) and headache (42%). The prevalence of nonspecific symptoms was similar in children with positive versus negative IgG serology. None of the nonspecific symptoms occurred more frequently in children with previous LB compared with children without. More prevalent in children without previous LB were sleep disturbances (40 vs. 66%; P = 0.002) and tingling (6 vs. 34%; P < 0.001).

CONCLUSIONS

Nonspecific symptoms were not more prevalent in children with positive IgG serology nor in children with previous LB, where some were significantly less prevalent. Hence, questionnaires on nonspecific symptoms cannot be used to identify children for serologic testing in Lyme centers.

Holistic Approach in Patients With Presumed Lyme Borreliosis Leads to Less Than 10% of Confirmation and More Than 80% of Antibiotic Failures

BACKGROUND

There is no precise idea whether patients with chronic symptoms attributed to Lyme borreliosis (LB) have LB or another disease.

METHODS

We evaluated patients consulting for a presumed LB with a holistic approach including presumptive treatment. We included symptomatic patients consulting for presumed LB. They were classified as confirmed LB when they met four criteria, and possible LB if three with a positive clinical response to presumptive treatment.

RESULTS

Amongst the 301 patients, 275 (91%) were exposed to tick bites, and 165 (54%) were bitten by a tick. At presentation, 151 patients (50.1%) had already been treated with a median of one (1-22) course of antimicrobials, during 34 (28-730) days. Median number of symptoms was three (1-12) with a median duration of 16 (1-68) months. Median number of signs was zero (0-2). ELISA was positive in 84/295 (28.4%) for IgM and 86/295 (29.1%) for IgG, and immunoblot was positive in 21/191 (10.9%) for IgM and 50/191 (26.1 %) for IgG. Presumptive treatment after presentation failed in 46/88 patients (52%). Diagnosis of LB was confirmed in 29 patients (9.6%), and possible in 9 (2.9%). Of the 243 patients with non-LB diagnosis, diseases were psychological, musculoskeletal, neurological or other origin in 76 (31.2%), 48 (19.7%), 37 (15.2%) and 82 (33.7%) patients respectively. Patients with other diseases were significantly younger, having more symptoms, longest duration of symptoms, less clinical signs and less frequent LB positive serologies.

CONCLUSIONS

Overdiagnosis and overtreatment of LB is worsening. Health authorities should investigate this phenomenon.

Proposed Lyme Disease Guidelines and Psychiatric Illnesses

The Infectious Disease Society of America, American Academy of Neurology, and American Academy of Rheumatology jointly proposed Lyme disease guidelines. Four areas most relevant to psychiatry were reviewed—the disclaimer, laboratory testing, and adult and pediatric psychiatric sections. The disclaimer and the manner in which these guidelines are implemented are insufficient to remove the authors and sponsoring organizations from liability for harm caused by these guidelines. The guidelines and supporting citations place improper credibility upon surveillance case definition rather than clinical diagnosis criteria. The guidelines fail to address the clear causal association between Lyme disease and psychiatric illnesses, suicide, violence, developmental disabilities and substance abuse despite significant supporting evidence. If these guidelines are published without very major revisions, and if the sponsoring medical societies attempt to enforce these guidelines as a standard of care, it will directly contribute to increasing a national and global epidemic of psychiatric illnesses, suicide, violence, substance abuse and developmental disabilities and the associated economic and non-economic societal burdens. The guideline flaws could be improved with a more appropriate disclaimer, an evidence-based rather than an evidence-biased approach, more accurate diagnostic criteria, and recognition of the direct and serious causal association between Lyme disease and psychiatric illnesses.

Evaluation of Prospectively Followed Adult Patients with Erythema Migrans Using the Beck Depression Inventory Second Edition

BACKGROUND

The Beck Depression Inventory (BDI-II) may be used to evaluate individuals for symptoms of depression.

METHODS

In a 1-year prospective study, 52 adult Lyme disease patients with erythema migrans and 104 matched control subjects were clinically assessed and completed the BDI-II at study entry and approximately 6 and 12 months later following antibiotic treatment.

RESULTS

The mean BDI-II score was significantly higher at the baseline visit among Lyme disease patients compared with controls (P = .002), but no significant differences between the groups were observed at either the 6- or 12-month study visits. Over the course of the study, the mean BDI-II scores decreased an average of approximately 0.22 points per month (P < .0005) for Lyme disease patients, whereas the mean scores changed very little for controls (mean change = -0.02 per month, P = .50). The total number of somatic symptoms, of the 12 symptoms evaluated, strongly and directly correlated with the BDI-II scores at the baseline visit for the Lyme disease patients.

CONCLUSIONS

The mean BDI-II scores of patients with early Lyme disease significantly exceeded that of matched controls at study entry, but by 6 months the values did not differ significantly. There was a good-to-excellent direct correlation between the BDI-II score and the total number of symptoms, suggesting that the BDI-II scores were reflecting somatic rather than affective depressive symptoms. When using the BDI-II as an assessment tool of patients with Lyme disease, infection-related somatic symptoms per se need to be considered in the interpretation of the results.