Re: Death from Inappropriate Therapy for Lyme Disease
- From: "BrentB" <borgersbrent@xxxxxxxxx>
- Date: 15 Sep 2006 08:50:52 -0700
Lymehelp wrote:
http://www.journals.uchicago.edu/CID/journal/issues/v31n4/994157/9941...
BRIEF REPORT
Death from Inappropriate Therapy for Lyme Disease
Robin Patel,1,4 Karen L. Grogg,2 William D. Edwards,2
Alan J. Wright,1 and Nina M. Schwenk3
1Divisions of Infectious Diseases, 2Anatomic Pathology, 3Area General
Internal Medicine, and 4Clinical Microbiology, Mayo Clinic and
Foundation, Rochester, Minnesota
A 30-year-old woman died as a result of a large Candida parapsilosis
septic thrombus located on the tip of a Groshong catheter. The catheter
had been in place for 28 months for administration of a 27 month course
of intravenous cefotaxime for an unsubstantiated diagnosis of chronic
Lyme disease.
Reprints or correspondence: Dr. Robin Patel, Divisions of
Infectious Diseases and Clinical Microbiology, Mayo Clinic, 200 First
St. SW, Rochester, MN 55905 (patel.ro...@xxxxxxxx).
A 30-year-old woman was admitted to the Mayo Clinic
(Rochester, MN) in May 1999 following a grand mal seizure. She reported
a several-week history of anorexia that was accompanied by a 23-kg
weight loss over an 8-month period; 4 days before admission, she
noticed twitching of her upper extremities. She appeared ill and had a
blood pressure of 124/82 mm Hg, a pulse rate of 85, a temperature of
37°C, and a respiratory rate of 20. The patient was confused and
unable to provide a coherent history. She was icteric and had diffuse
myoclonus. Cardiac auscultation revealed a prominent pulmonic second
sound. A Groshong catheter was in place. Hepatosplenomegaly was noted.
Her family provided a pertinent medical history. She had had
a history of bilateral knee pain since childhood. She resided in Iowa;
however, she had lived in Westchester County, New York, until the age
of 16 years and in northern California for a short period thereafter.
In 1994, she underwent cholecystectomy and since that time she had had
chronic abdominal pain, whole body pain, an episode of Bell's palsy,
occasional headaches, and periods of what were described as "mental
fogginess" and "transient numbness." She also reportedly had a periodic
rash that was thought to be a possible "Lyme rash." In 1996, she was
evaluated by an infectious diseases physician in New York who
specializes in chronic Lyme disease and was diagnosed with chronic Lyme
disease. This diagnosis was made despite 6 EIAs negative for Borrelia
burgdorferi, 7 Western blot assays negative or indeterminate for B.
burgdorferi, and 4 PCR assays of blood, 5 PCR assays of urine, and 1
PCR assay of CSF, all negative for B. burgdorferi. MRI of the brain, as
well as CSF examination, had been unremarkable in 1996. One PCR assay
of blood for the ospA gene (Boston Biomedica Inc., New Britain, CT) was
reportedly positive in January 1997.
She was initially treated with oral doxycycline, and then,
for an 8-month period (19951996), she was treated with iv ceftriaxone;
this treatment was followed by courses of oral clarithromycin and
minocycline as well as parenteral penicillin G benzathine. A Groshong
catheter was placed in January 1997, and a prolonged course of therapy
with iv cefotaxime (up to 4 g every 8 h) was started. Intravenous
doxycycline (300 mg every 12 h) was added to this therapeutic regimen
in 1998. The patient reported only partial relief of her chronic
symptoms during administration of this antibiotic regimen. Therapy with
iv antibiotics was discontinued 1 month before evaluation at our
institution, when a family physician noted abnormal results of liver
function tests and thrombocytopenia. Another infectious diseases
physician was consulted; this physician thought that the patient did
not have chronic Lyme disease.
The patient was also being treated for chronic diffuse body
pain, with several pain medications, including sustained release
morphine sulfate (300 mg t.i.d.) and immediate release morphine sulfate
(45 mg/d), according to the recommendations of a fourth physician in
Illinois.
At our institution, laboratory tests revealed the following
abnormal results: hemoglobin level, 6.3 g/dL; WBC count, 2.2 × 109
cells/L; platelet count, 16 × 109 cells/L; rare schistocytes and
helmet cells on a peripheral blood smear; prothrombin time, 19.9 s;
alkaline phosphatase level, 435 U/L; aspartate aminotransferase level,
131 U/L; bilirubin level, 5.2 mg/dL; and creatinine level, 6.5 mg/dL.
In our laboratory, EIA was reactive for B. burgdorferi, but a Western
blot assay showed only 1 66-kDa band. CSF examination was unremarkable,
and PCR assay of CSF was negative for B. burgdorferi.
One day after admission, the patient reportedly became
confused, and she fell, pulled and fractured her Groshong catheter, and
became unresponsive. Electromechanical dissociation was diagnosed, and
she died despite aggressive attempts at resuscitation. After her death,
cultures of blood obtained at the time of admission yielded Candida
parapsilosis.
Postmortem examination revealed acute fatal obstruction of
the tricuspid valve orifice by a large infected thrombus located on the
fractured tip of her Groshong catheter (figure 1). Grocott-Gomori
methenaminesilver nitrate staining of microscopic sections of the
thrombus revealed extensive Candida organisms (figure 2). Other
significant findings at autopsy included an old Candida-infected
pulmonary thromboembolus with total occlusion of the left main artery
at the hilum as well as scattered old peripheral emboli bilaterally.
Marked splenomegaly with reactive follicular hyperplasia and congestion
were noted. At autopsy, there was no myositis, neuritis, meningitis,
vasculitis, or myocarditis suggestive of chronic Lyme disease.
Figure 1. Opened right atrium from a patient who died because
of inappropriate therapy for Lyme disease. The photo shows a large
infected thrombus on the fractured tip of the patient's Groshong
catheter.
Figure 2. Stained section of a right atrial thrombus in a
patient who died because of inappropriate therapy for Lyme disease. The
photomicrograph shows extensive Candida species (Grocott-Gomori
methenaminesilver nitrate stain; original magnification, × 360).
The premature death of our patient resulted from a
complication of her chronic indwelling central venous catheter, which
was used for prolonged iv administration of antimicrobial therapy for a
disease that was not fully documented. Lyme disease is curable with
antibiotic treatment, and, although resolution of true neurological
complications of Lyme disease may be slow after appropriate therapy,
there is no evidence that our patient ever had Lyme disease. Her
chronic symptoms were nonspecific, and results of her laboratory tests
were nondiagnostic and did not fit the criteria for Lyme disease [1].
Furthermore, chronic antibiotic therapy, such as that described here,
is never indicated for Lyme disease, and such therapy has a significant
risk of side effects. Even in cases of clear-cut Lyme disease, abnormal
test results return to baseline with no measurable sequelae after
appropriate treatment [2].
Lyme disease is primarily a clinical syndrome confirmed by
microbiological tests [3, 4]. For our patient, the diagnosis of Lyme
disease was made despite negative or indeterminate results of Western
blot assays, perhaps because the presence of only 1 or 2 highly
specific bands on a Western blot was considered a potential harbinger
of further expansion over time [5]. We are of the opinion that
acceptable diagnostic criteria for Lyme disease include the presence of
multiple bands of specific molecular weight and that the serological
analysis of the patient described here did not confirm a diagnosis of
Lyme disease [3]. Notably, in our laboratory, a Western blot assay
showed only 1 66-kDa band, thereby revealing no expansion over time.
The 1 positive PCR assay is intriguing, but this finding may have been
the result of DNA contamination.
It has been suggested that B. burgdorferi infection may
trigger parainfectious pain or fatigue syndromes, which may persist
indefinitely after eradication of the spirochete by antimicrobial
therapy. In addition, fibromyalgia, chronic pain syndromes, and chronic
fatigue syndrome may be incorrectly diagnosed as chronic Lyme disease
[1, 6]. Patients with these disorders have disabling and generalized
symptoms, including marked fatigue, severe headache, widespread
musculoskeletal pain, multiple symmetrical tender points in
characteristic locations, pain and stiffness in many joints,
dysesthesias, paresthesias, difficulty with concentration, memory loss,
and sleep disturbances; their symptoms are not relieved with
antimicrobial therapy [1, 68].
Of 788 patients referred to the New England Medical Center
(Boston) with a presumptive diagnosis of chronic Lyme disease, 23% had
active Lyme disease, 20% had previous Lyme disease and another current
illness (most commonly chronic fatigue syndrome or fibromyalgia), and
57% did not have Lyme disease (patients in this last group most
commonly had fatigue or pain syndromes) [1]. In another study [7], of
209 patients referred to the Yale University Lyme Clinic (New Haven,
CT) with a presumptive diagnosis of Lyme disease, 21% had active Lyme
disease, 19% had previous but not active Lyme disease, and 60% had no
evidence of current or previous Lyme disease. Patients with no evidence
of Lyme disease had a median of 4 serological tests for Lyme disease, 7
office visits, and 42 days of antibiotic treatment for Lyme disease and
were noted to have high levels of disability and distress.
Appropriate treatment of Lyme disease has been associated
with complications (e.g., ceftriaxone-associated biliary complications,
iv catheterassociated gram-positive and gram-negative bacterial
bloodstream infections, and Clostridium difficileassociated diarrhea).
Ceftriaxone-associated biliary complications have been described in
patients receiving ceftriaxone therapy for ...
The patient reported only partial relief of her chronic symptoms during
administration of this antibiotic regimen.
Thankfully she did get some relief before she passed on. What a spin
job.
.
- References:
- Death from Inappropriate Therapy for Lyme Disease
- From: Lymehelp
- Death from Inappropriate Therapy for Lyme Disease
- Prev by Date: Re: Death from Inappropriate Therapy for Lyme Disease
- Next by Date: schizoloon
- Previous by thread: Re: Death from Inappropriate Therapy for Lyme Disease
- Next by thread: Some doctors overtreat Lyme disease- no proven benefit for prolonged antibiotic treatment
- Index(es):
Relevant Pages
|
