Lyme Disease Info
Lyme disease, a multisystemic illnesscaused by the spirochete
Borrelia burgdorferi (Bb), is the most common vector-borne illness in the US. Approximately
20,000 new cases are reported to the CDC each year and the CDC acknowledges that
90% of cases go unreported.[Adler, J. (2004). Lyme: battles with illness, emotions,
insurance. (NJ) Herald News.] Infected black-legged ticks transmit Bb to humans
via a bite. These ticks are quite small and easily overlooked; most patients do
not recall being bitten prior to becoming ill. Lyme disease has both early and late
disease manifestations. Patients may exhibit one or both of these stages; many patients
initially present with late Lyme disease. Any organ system can be involved, but
Bb commonly strikes skin, joint, heart and nervous tissue, including the brain.
Early Lyme disease
disease begins 3-30 days after a tick
bite and is readily identified by an erythema migrans (EM) rash. EMs vary in appearance.
The most common rash is a homogeneously colored oval lesion. The classic "bull's
eye" accounts for less than 20% of all EM cases; [Smith R et al, Ann Intern Med.
2002;136:421-428, Tibbles C, JAMA 2007; 297:2617-27.] 30% of patients never have
a rash.[MMWR 56(23); 573-576] Flu-like symptoms such as fever, fatigue, headache,
myalgias, arthralgias and neck stiffness may accompany an EM or be the only evidence
of early Lyme disease.[Steere A et al, Am J Med. 2003; 114(1):58-62]
Late Lyme disease
develops weeks - years later and is
the result of disseminated infection. Early disseminated Lyme disease may cause
multiple EM rashes, Bell's palsy or other cranial neuropathies, meningitis, meningoradiculitis,
carditis, lymphadenopathy and arthralgia; constitutional symptoms may be present.
In endemic areas, Lyme disease is implicated in 50% of all cases of Bell's palsy
in children.[Cook SP et al, Am J Otolaryngol 1997; 18(5):320-3]
International Lyme and Associated Diseases Society
A professional medical and Research organization
P.O. Box 341461
Bethesda, MD 20827-1461
Information from this article supplied by ILADS
In the US, arthritis and disorders of the nervous system are seen in late disseminated
Lyme disease. Arthritis can affect any joint; knees are the most common site. Up
to 60% of untreated patients will experience arthritis.
Neurologic conditions include peripheral sensory neuropathies, motor neuropathies,
cranial neuropathies, autonomic dysfunction, movement disorders, neuropsychiatric
illnesses and encephalopathy. Neuroborreliosis is the term used when Lyme infects
the brain. 15 – 40% of Lyme disease patients have neurologic disorders due to the
infection. [Caliendo et al, Psychosomatics 1995; 36:69-74] Late disease can be severe
with marked morbidity and poor treatment outcomes.
Symptoms
The symptoms of Lyme disease are widespread and variable; relapsing/remitting patterns
are common. The validity of individual symptoms has been documented in numerous
reports and studies on Lyme disease.
Frequently reported symptoms include:
- Extreme fatigue, often interfering with activities
- Headaches of all types
- Recurrent fevers, chills, night sweats
- Myalgias and arthralgias; either may be migratory
- Muscle fasciculations and weakness
- Paresthesias and neuropathic pain syndromes
- Sleep disturbances
- Cranial nerve dysfunction
- Neuropsychiatric problems – irritability, depression, anxiety, panic attacks, new
onset ADHD, mood swings similar to bipolar disease, rage attacks, OCD
- Cognitive losses: memory impairment, difficulty multi-tasking, slowed mental processing,
speech and language problems, poor concentration, loss of math skills, impaired
visual/spatial processing
- Children may have behavioral changes, declining school performance, headache, fatigue,forgetfulness,
complex partial seizures, depression and be misdiagnosed with primary ADHD.
Although Lyme disease symptoms overlap with symptoms of other conditions such as
fibromyalgia, chronic fatigue syndrome, MS, early ALS, RA, lupus and psychiatric
disorders, patients with Lyme disease often have symptom patterns which are atypical
for these other illnesses. Making sense of the multitude of reported symptoms can
be challenging; but bear in mind that symptoms which appear unrelated may be linked
via an underlying autonomic neuropathy or encephalopathy.
Co-infections
Ticks also carry Babesia, Anaplasma, Ehrlichia, Bartonella, Mycoplasma and
other pathogens. The presence of these organisms complicates the diagnosis, testing
and treatment of Lyme disease patients. In animal models, co-infections alter the
immune response, pathogen load and disease severity.[Thomas V. Infect. Immun. 2001;69:3359–3371.]
In humans, coinfections
increase morbidity and delay recove
Physical Exam in Lyme Disease
Lyme disease patients may have exam findings when carefully assessed but
findings may be few or absent in some cases. In addition to a general exam, detailed
neurologic, dermatologic and rheumatologic exams should be performed.
Serologic Testing in Lyme DiseaseBorrelia burgdorferi
is very difficult to culture, thus serologic tests are used to detect the presence
of antibodies to Bb. In 1995 the CDC, in an move to standardize testing procedures
and Western blot interpretations, published guidelines for laboratory testing in
Lyme disease.[MMWR 1995; 44:590-1] The CDC recommended a two-tier testing algorithm.
Step 1 is an ELISA or IFA; positive or equivocal results advance to step 2, IgM
and IgG Western blotting. Samples negative in step 1 are not tested further. The
purpose of standardization was to establish parameters for laboratory confirmation
of Lyme disease surveillance cases, not clinical diagnosis.[Mead P. CT Dept of Public
Health Hearing Jan 29, 2004]
Western Blot Testing:
9 cross reactive for borrelia
12 specific for Bb
18 unknown
20 cross reactive for borrelia
21 unknown
22 specific for Bb probably the 23/25 band
23/25 OspC specific for Bb
28 unknown
30 unknown, probably Osp common in Europe
31 OspA specific for Bb
34 OspB specific for Bb
25 specific for Bb
37 specific for Bb
38 cross reactive for Bb
39 major protein of Bb flagellin Bb specific
41 flagellin protein of all spirochetes; one of the first to appear, Bb specific
45 cross reactive for all borrelia
50 cross reactive for all borrelia
55 cross reactive for all borrelia
57 cross reactive for all borrelia
58 unknown but may be heat shock Bb protein
60 cross reactive for all borrelia
66 cross reactive for all borrelia
83 specific antigen for the lyme bacterium, probably a cytoplasmic membrane
93 unknown, probably the same protein as 83, just measure incorrectly
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Two-tier testing doesn't work.
The step 1 tests are insufficiently sensitive to be used as "screening" tests.
[Trevejo R, JID 1999; 179:931–8.] Western blots, increase specificity but, following
a step 1 test, further decrease overall sensitivity.
The bands included in the Western blot interpretation schemes were chosen on a statistical,
rather than a clinical, basis.[Dressler F. JID 1993; 167:392-400.] Recently, the
C6 peptide ELISA alone was proposed as an alternative to the two-tier approach.
Unfortunately, the C6 ELISA also lacks adequate sensitivity for clinical use.[Bacon
R. J Infect Dis 2003; 187:1187- 99.]
Lyme disease, like many other diseases, is a clinical diagnosis;
with testing playing a supportive role.
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