Lyme Misdiagnosis Can Divert Patients From Correct Treatment

Larry Hand

November 04, 2014

Misdiagnosis of chronic Lyme disease can cause delays in diagnosis and treatment for the actual conditions, according to a research letter published online November 3 in JAMA Internal Medicine.

Christina Nelson, MD, MPH, from the Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, write that chronic Lyme disease "is a loosely defined diagnosis given by a small number of physicians — who are not usually infectious disease experts — to patients with various nonspecific symptoms, including patients with no objective evidence of Lyme disease."

The authors list the clinical features of Lyme disease as including erythema migrans rash, facial palsy, arthritis, and peripheral neuropathy.

They present three cases in which a misdiagnosis of chronic Lyme disease led to delayed diagnosis of the real problem and harm to the individuals.

One man in his 30s had a 12-year history of joint pain and memory loss and 2 years of paresthesias in both hands, but negative serologic results for Lyme disease. Despite treatment meant for Lyme disease, his symptoms worsened and he developed syncope and visual field deficit. A physician later determined that he had a pituitary tumor and elevated insulin-like growth factor consistent with acromegaly. Only a portion of the tumor could be removed, and the patient was left with permanent facial changes, cardiomyopathy, joint pain, and obstructive sleep apnea.

Another man in his late 30s had a 4-year history of fatigue, abdominal pain, and loose stools and negative serologic results for Lyme disease, but was prescribed antibiotics. He later discontinued that treatment, and a gastroenterologist and oncologist found from a gastric biopsy that he had stage IV mucosa-associated lymphoid tissue lymphoma. A mesenteric lymph node biopsy led to diagnosis of stage IV classic Hodgkin lymphoma. The patient died 2 years later from complications.

A third man, in his late 50s, had a 2-week history of fatigue and a 3-day history of fever, headache, and myalgias, but no known tick bite. However, he did have positive serum enzyme immunoassay results for Lyme disease. Soon, he had an erythematous rash that resolved, but malaise and fatigue continued. He had an 18-pack-year history of smoking, and a clinician found a nodular mass in the right upper lobe. He turned out to have stage I non-small cell adenocarcinoma, which clinicians successfully removed.

"Patients 1 and 2 had no evidence of ever having Lyme disease. Patient 3 likely had true Borrelia burgdorferi infection for which antibiotic therapy was appropriate; however, subsequent symptoms were incorrectly attributed to persistent infection," the CDC authors write.

They conclude, "We are not suggesting that every patient with nonspecific symptoms, such as fatigue, joint pain, or abdominal pain, should be aggressively evaluated for cancer. Rather, we present these cases to demonstrate delays in diagnosis that come from assuming that patients have chronic Lyme disease."

The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online November 3, 2014. Extract


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