Chronic Lyme Disease: The Controversies and the Science

Paul M Lantos

Disclosures

Expert Rev Anti Infect Ther. 2011;9(7):787-797. 

In This Article

Abstract and Introduction

Abstract

The diagnosis of chronic Lyme disease has been embroiled in controversy for many years. This is exacerbated by the lack of a clinical or microbiologic definition, and the commonality of chronic symptoms in the general population. An accumulating body of evidence suggests that Lyme disease is the appropriate diagnosis for only a minority of patients in whom it is suspected. In prospective studies of Lyme disease, very few patients go on to have a chronic syndrome dominated by subjective complaints. There is no systematic evidence that Borrelia burgdorferi, the etiology of Lyme disease, can be identified in patients with chronic symptoms following treated Lyme disease. Multiple prospective trials have revealed that prolonged courses of antibiotics neither prevent nor alleviate such post-Lyme syndromes. Extended courses of intravenous antibiotics have resulted in severe adverse events, which in light of their lack of efficacy, make them contraindicated.

Introduction

Each year, tens of thousands of North Americans and Europeans become infected with Borrelia burgdorferi sensu lato, the group of related tick-borne spirochetes that cause Lyme disease (Box 1). It is widely assumed that this disease is under-reported, and the actual incidence may approach the hundreds of thousands. Its variety of manifestations continues to pose a challenge to clinicians. As many as 80–90% of patients present with the characteristic erythema migrans rash of early Lyme disease, but if unrecognized and untreated, the organism can disseminate to skin, the heart, the central or peripheral nervous system, and joints. The resultant disease manifestations are usually recognizable based on objective clinical findings, such as aseptic meningitis, nerve palsies, cardiac conduction delays and frank arthritis, and have been definitively attributed to B. burgdorferi based on culture nucleic acid detection, or seroreactivity.

It is well-established that some patients experience prolonged somatic or neurocognitive symptoms during convalescence from Lyme disease, and a subset suffer significant functional impairment.[1–8] Whether this phenomenon occurs frequently or rarely, and whether it is caused by persistent infection with B. burgdorferi, lie at the heart of the often acrimonious controversy over what has been termed 'chronic Lyme disease'. This controversy primarily exists in the public dialogue, as the concept of chronic Lyme disease is not widely accepted within the scientific or clinical community. At least 19 independent societies representing the USA and numerous European countries have produced remarkably similar clinical practice guidelines for Lyme disease, discouraging the diagnosis of chronic Lyme disease and recommending against treating patients with prolonged or repeated antibiotic courses.[9–27,201] These recommendations are also shared by national public health agencies throughout the Lyme-endemic world. A small minority of physicians accounts for most diagnoses of chronic Lyme disease: one study found that only six of 285 (2.1%) randomly surveyed physicians in Connecticut, USA, gave patients this diagnosis.[28] Still fewer depart from published guidelines by prescribing extended courses of antibiotics.[29]

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