Lyme Disease:
diagnostic and treatment facts and fiction in 2017
Jon Konzen, DO
Neurology
Chippewa Valley Neurosciences
Eau Claire
Lyme arthritis was first introduced as a clinical entity in 1977. It was found to be due to tick infection of the organism, Borrelia Burgdorferi, in 1982. At that time it mainly dealt with issues of bone and joint involvement, but since that time, it is known to affect multiple body systems, hence becoming known as Lyme disease as the sentinel case occurred in Lyme, Connecticut. However, some of its clinical features, particularly the bull’s-eye rash have been described as far back as 1910. In the 1920’s, tick bite associated neurological changes, consistent with Lyme disease, were also described. The disease has been reported in 47 states. However, only 16 of these states report more than 100 cases per year. Wisconsin, though, is one of these areas with a high number of ticks containing the disease.
Symptoms of Lyme Disease
Lyme infection can affect multiple body systems including bone and joint, cardiac, and the nervous system. In the case of the nervous system, this occurs about 10–15% of the time. The disease is introduced by a tick bite. Avoidance of tick bites can often be accomplished by simply adjusting outdoor wear to include long sleeve and long pant clothing in areas of brush and long grass whether treated or untreated with insect repellent.
Treatment of Lyme Disease
An important fact to remember is the attachment of the tick must be for many hours before transmission of the disease is likely. This is usually avoided by a simple and thorough check at the end of a day outside, which will often suffice to remove ticks before they can bite. Another important fact to know is that in areas with high infection rates, even a single dose, 200 mg, of doxycycline have been shown to reduce the risk of infection following a tick bite. But, studies have shown the risk of drug reactions need to be weighed against the need to treat 50 people with bites to prevent one case of Lyme disease. However, if a tick is found embedded and/or producing the classic “bull’s-eye rash” antibiotic treatment, in areas such as Wisconsin, is reasonable. Many studies now say that in most infections, oral amoxicillin 1.5 g daily or doxycycline 200 mg daily for 2–4 weeks is effective treatment. It should also be noted that a number of studies have shown that oral doxycycline can be effective in treating some brain infections. IV antibiotic therapy may be considered in patients with cardiac or neurological findings. A major fallacy is that many people need additional antibiotic treatment if symptoms persist after treatment of 2–4 weeks with antibiotics.
Diagnosis of Lyme Disease
The decision whether the patient actually has Lyme disease and if those patients have been effectively treated, rests on the ability to make a correct diagnosis. This has been challenging for Lyme disease. The most accurate diagnosis would be to directly grow the organism from infected patients. This is difficult to do this in laboratory culture with Borrelia Burgdorferi. This leaves blood or cerebrospinal fluid tests to demonstrate the presence of antibodies that have been produced to fight infection. This has two limitations. The first is that it often takes at least 4 weeks or more for the antibodies to be produced in an infection, even with abnormalities found on physical examination. Second, once these antibodies have been produced they may remain present in the blood for years, even if the infection was successfully treated. Some of these antibodies could also be produced from different types of infections. This can be especially confusing for patients that may still have some symptoms after being successfully treated with antibiotic therapy. Concern that patients may not be fully treated with ongoing active infection have not been reported by multiple studies. This has led to two tier blood testing with ELISA and Western blot testing. Criteria, for interpreting the tests together based on patterns demonstrated in large numbers of patients with and without Borrelia Burgdorferi, now leads to less errors in diagnosis. Similar testing can also be performed on cerebrospinal fluid, if an infection is suspected in the brain. Not all patients with positive blood tests require CSF examination. This is especially important when patients may have just peripheral nervous system involvement which is the cranial nerves (e.g. isolated facial weakness) or the nerves in the extremities (e.g. feelings of numbness, tingling, burning or weakness). Also if there are no neurologic findings at all. However, when the patient clearly has exam findings of brain or spinal cord involvement and are properly diagnosed and treated, there is rarely significant permanent impairment that occurs.
A major patient concern that often leads to request for consultations in neurology and infectious disease are patients who have symptoms that continue after antibiotic treatment, particularly dealing with issues of fatigue and thinking difficulties after being appropriately treated with antibiotics for Lyme disease. This often is called “post Lyme syndrome”. However, studies have clearly demonstrated that repeated courses of antibiotics do not cure these patients. In fact, many studies actually have demonstrated harm to the patient with chronic antibiotic therapy. Some patients also report transient improvement with intermittent repeated antibiotic therapy, but it is never long-lasting improvement, hence the continued repeated dosing of antibiotics. This type of treatment has also failed to show true benefit in the literature and is not acceptable treatment by the American Academy of Neurology
practice parameters.
Conclusion
In summary, Lyme disease affects multiple organ systems, but only about 10–15% of the time affects the nervous system. With proper diagnosis, appropriate antibiotic therapy is highly effective. Rarely will there be significant neurological impairment. Over-treatment with antibiotic therapy is ineffective and potentially unsafe.
Jon Konzen, DO – Chippewa Valley Neurosciences
For information or to schedule an appointment:
715-831-0811 | www.oakleafmedical.com
Dr. Konzen sees patients in Eau Claire.
