by Brian Schwartz, M.D., M.S.
A patient presents with diffuse joint pain. She recalls a history of a 4 inch red rash approximately 5 months ago and lives in an endemic area for Lyme disease. The physical examination reveals the joints to be diffusely tender to light palpation but without warmth, effusion, or erythema. The remainder of the examination is normal. The sedimentation rate, rheumatoid factor, anti-nuclear antibody, and Lyme ELISA are all negative. She is concerned about Lyme disease and asks for antibiotic treatment.
Lyme arthritis most commonly presents as a large joint, monoarticular arthritis, classically of the knee, but can also present as an oligoarticular arthritis involving large or small joints. Patients will have several weeks of frank arthritis, with joint pain, effusion, and erythema, followed by symptom-free intervals. Without evidence of frank arthritis on examination and without serologic evidence of Lyme disease, this patient should not be considered to have Lyme arthritis and should not be offered antibiotic therapy. Physicians should also resist the temptation to repeatedly serologically test such patients, because the probability of a false positive test result increases with each test. Many patients are tested six or seven times before a test is positive, then receive prolonged courses of antibiotic therapy. This should be avoided.
A patient presents very worried about Lyme disease, having received a recent tick bite. He is asymptomatic. Should he be offered prophylactic treatment with antibiotics?
There are two schools of thought in this regard. Many academic researchers in Lyme disease note that the overall average risk of infection with B. burgdorferi after a single tick bite is low (probably around 1-3%); that in endemic areas, people can have numerous tick bites each season; and that no randomized trials have shown that prophylactic antibiotics can definitely prevent Lyme disease when given shortly after a tick bite. Other physicians note that the risk of Lyme disease is higher when the tick fed to engorgement, and that certain subgroups (e.g., pregnant women) can have severe morbidity (especially to the fetus) if they become infected. The first group strongly advises against prophylactic administration of antibiotics, but instead suggests that patients be educated to look for the development of a rash, and be treated should one appear. The second group counsels that some patients are very worried about the development of Lyme disease, that the side effects of doxycycline or amoxicillin are low, and that these are inexpensive antibiotics, so prophylactic administration is warranted in selected cases. It seems that strategies advising that all or no such patients should be given prophylactic antibiotics are not warranted. Rather, an individualized approach considering likely tick feeding duration, associated medical problems, degree of patient anxiety about Lyme disease, and likely morbidity should Lyme disease occur should be used and it may be reasonable to offer a small subset of patients prophylactic antibiotics after an I. scapularis bite. Needless to say, bites from other ticks or insects should not be prophylaxed to prevent Lyme disease.
A patient presents with erythema migrans and left-sided facial palsy. A Lyme disease serologic test is positive and the cerebrospinal fluid reveals a lymphocytic pleocytosis and slightly elevated protein, but CSF Lyme antibody testing is negative. A diagnosis of Lyme disease is made and the patient receives 3 weeks of intravenous ceftriaxone, with good response. One month after completion of antibiotics, the patient returns complaining of joint pain and fatigue. The physical examination is normal. What should be done next?
A small proportion of patients adequately treated for Lyme disease develop fatigue, headache, joint pain, paresthesias, cognitive difficulties, and tender points on examination. This clinical presentation is very similar to that of chronic fatigue syndrome or fibromyalgia. Some physicians believe such patients represent antibiotic treatment failure and recommend long duration (months to years) oral or intravenous antibiotic therapy. Some of these physicians recommend unusual dosing protocols, such as two doses per week followed by weeks without treatment. There are no data that suggest that such long-term or unusual regimens are necessary or better than the standard regimens referred to previously. In the other camp, some physicians diagnose such patients as having post-Lyme disease fibromyalgia, or simply, post-Lyme disease syndrome, and treat them with anti-depressants, physical therapy, and exercise programs. In fact, new studies have reported that “chronic Lyme disease” does not respond to antibiotics and there is increasing evidence that this is not infectious. An increasing literature discusses post-Lyme disease symptom persistence, possible explanations for persistent symptoms, and options for therapy. Unfortunately, the literature also suggests that some such patients have been administered years of antibiotic therapy by their physicians without clear objective benefit.