Re: Current CDC on Lyme Diagnosis

From: Phyllis Mervine (pmerv_at_direcway.com)
Date: 07/29/04 

Date: 28 Jul 2004 22:10:02 -0700

>
> > He expressed surprise at the finding that 18% presented with
> > nonspecific symptoms without EM (N Engl J Med. 2003 Jun
> > 12;348(24):2472-4.)
>
> If you could post that article, I'd be interested.
>
> I thought he rejected the idea of "non specific symptoms" ever being
> Lyme? I know others have. (Query: what is a "non specific symptom"--I
> think it is like minor surgery which is defined as surgery on someone
> else. I wonder how "non specific" the symptoms would be if Dr Steere
> were experiencing them?).

non-specific means it could be Lyme or it could be something else -
not specific to any one disease.
Here's the letter for the quote above:
N Engl J Med. 2003 Jun 12;348(24):2472-4.

 The presenting manifestations of lyme disease and the outcomes of
treatment.

 To the Editor: A trial of vaccination against Lyme disease provided
an opportunity for us to determine the relative frequencies of the
presenting manifestations of Lyme disease and the outcomes of
treatment in a large population.1 Our goal was to identify all cases
of Borrelia burgdorferi infection that occurred among the 10,936
participants in 10 states where the infection is endemic during the
20-month study period.

 Of the 1917 participants who were evaluated for Lyme disease, 269 met
the prospectively defined criteria for definite, possible, or
asymptomatic infection.1 After completion of the study, post hoc
analyses were performed for patients who had microbiologically
confirmed erythema migrans,2 systemic symptoms without erythema
migrans,3 or asymptomatic seroconversion.4 In addition, for the latter
two groups, serum samples were retested with a sensitive and specific
enzyme-linked immunosorbent assay that used a peptide of the sixth
invariant region of the VlsE lipoprotein of B. burgdorferi5; this test
had not been available during the vaccine study.

 Seventy to 80 percent of the patients presented with erythema migrans
(Table 1), the initial skin lesion that often occurs at the site of a
tick bite. The unexpected finding was that about 18 percent of the
participants presented during the summer with nonspecific systemic
symptoms without erythema migrans. Headache and arthralgia, sometimes
associated with fever, were their most common symptoms; upper
respiratory tract and gastrointestinal symptoms were absent.3 Only 2
to 3 percent of the patients presented with later systemic involvement
associated with disseminated infection, such as facial palsy,
trigeminal neuropathy, or Lyme arthritis; among them was one patient
who initially had asymptomatic seroconversion.4

 Table 1. Frequency of Presenting Manifestations of Lyme Disease.
[Table Removed from Email]

 The patients with early infection were treated with oral doxycycline
or amoxicillin for two to four weeks, except for two patients with
facial palsy and erythema migrans, who received intravenous
ceftriaxone.2,3 Although 11 to 16 percent of these patients had
subjective symptoms for weeks or months after treatment, late
manifestations of Lyme disease did not develop in any patient.

 The important point is that most of the study participants with Lyme
disease had early symptoms of the infection and had a good response to
treatment. Particularly when erythema migrans is not present early in
the illness, patients may not go to a physician or Lyme disease may
not be recognized until the more debilitating, harder-to-treat late
manifestations of the infection become apparent. The challenge for
patients and physicians is early recognition and treatment of the
infection, particularly when patients present during the summer with
nonspecific systemic symptoms.

 Allen C. Steere, M.D. Massachusetts General Hospital Boston, MA 02129

 Vijay K. Sikand, M.D. Tufts University School of Medicine Boston, MA
02111

 References
1. Steere AC, Sikand VK, Meurice F, et al. Vaccination against Lyme
disease with recombinant Borrelia burgdorferi outer-surface
lipoprotein A with adjuvant. N Engl J Med 1998;339:209-215.
2. Smith RP, Schoen RT, Rahn DW, et al. Clinical characteristics and
treatment outcome of early Lyme disease in patients with
microbiologically confirmed erythema migrans. Ann Intern Med
2002;136:421-428.
3. Steere AC, Dhar A, Hernandez J, et al. Systemic symptoms without
erythema migrans as the presenting picture of early Lyme disease. Am J
Med 2003;114:58-62.
4. Steere AC, Sikand VK, Schoen R, Nowakowski J. Asymptomatic
infection with Borrelia burgdorferi. Clin Infect Dis (in press).
5. Liang FT, Steere AC, Marques AR, Johnson BJ, Miller JN, Philipp MT.
Sensitive and specific serodiagnosis of Lyme disease by enzyme-linked
immunosorbent assay with a peptide based on an immunodominant
conserved region of Borrelia burgdorferi vlsE. J Clin Microbiol
1999;37:3990-3996.

 
EM usually is considered an early sign of Lyme, but when you consider
that the spirochetes invade the CNS within HOURS of inoculation,
whereas typical EMs don't appear until the 3rd day, it puts a whole
new spin on things. (The following quotes likely came from JWissmille
- the REAL one - she has a great archive and can usually find
citations for anything)

source: Mandell, Douglas and Bennett's Principles
and Practice of Infectious Diseases
fourth edition
author : Allen Steere

pg. 2145
"...It has been shown that virulent strains of Borrelia burgdorferi
are able to resist elimination by phagocytic cells, thereby evading
the first line in the host defense system against infection....
Borrelia burgdorferi seems to cross a cell monolayer at intracellular
junctions, although it can penetrate through the cytoplasm of a cell.
In a rat model, permeability changes in the blood-brain barrier begin
within 12 hours after inoculation with the spirochete, and the
organism may be cultured from the cerebrospinal fluid within 24
hours..."

-----
CYTOTOXICITY OF BORRELIA BURGDORFERI FOR CULTURED RAT GLIAL CELLS.
Authors: Garcia-Monco JC Fernandez Villar B Szczepanski A Benach JL
Source: J Infect Dis 1991 Jun;163(6):1362-6
__________________

".......Neither the clinical presentation nor routine laboratory tests
accurately predicted which patients had B. burgdorferi DNA in their
CSF
....

from: Invasion of the Central Nervous System by Borrelia burgdorferi
in Acute Disseminated Infection
JAMA. 1992;267:1364-1367
authors: Benjamin J. Luft, ......Raymond J. Dattwyler
Our findings demonstrate that B. burgdorferi can disseminate to
the CNS very early on in the course of the infection with little or no
clinical evidence of CNS involvement....."

Relevant Pages

  • pt.2 JAMA - A 58-Year-Old Man With a Diagnosis of Chronic Lyme Disease
    ... What is the epidemiology of Lyme disease? ... When taking antibiotics he felt progressively better, ... In the Northeast and North Central United States, the infection is ... In untreated patients, Lyme disease usually occurs in stages, with different ...
    (sci.med.diseases.lyme)
  • Lyme-Associated Parkinsonism - lyme disease - borrelia
    ... Lyme-Associated Parkinsonism: A Neuropathologic Case Study and Review ... Neurological complications of Lyme disease include meningitis, ... burgdorferi infection of the central nervous system and clinical ... only found in about 60% of patients.1 Patients with long-standing Lyme ...
    (sci.med.diseases.lyme)
  • blood -brain barrier / why it isnt always easy to cure Lyme disease
    ... Disseminated Infection ... the recommended treatment of acute Lyme disease ...
    (sci.med.diseases.lyme)
  • STUDY SUPPORTS CHRONIC LYME
    ... Protective Niche for Borrelia burgdorferi to Evade Humoral Immunity ... The Lyme disease spirochete, Borrelia burgdorferi, is an extracellular ... murine infection. ... Lyme Disease Receptor Identified in Tick Guts ...
    (sci.med.diseases.lyme)
  • Re: Some Interesting Materials on the NIH Study
    ... that are either seropositive or seronegative for Lyme disease ... Treatment of Patients with Seropositive and Seronegative Chronic LD ... evidence of persistent infection with Bb can be found in patients ... the intravenous and oral antibiotics will be administered by the same ...
    (sci.med.diseases.lyme)