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Encyclopedia > Lyme disease controversy

While there is no doubt that Lyme disease exists, and most clinicians agree on the treatment of early Lyme disease,[1] there is considerable controversy as to the prevalence and historical emergence of the disease, the proper procedure for diagnosis and treatment of later stages, and the likelihood of a chronic, antibiotic-resistant Lyme infection. Lyme disease (Borreliosis) is a bacterial infection with a spirochete from the species complex Borrelia burgdorferi, which is most often acquired from the bite of an infected Ixodes, or black-legged, tick, also known as a deer tick. ...


On one side are those who believe that Lyme disease is relatively rare, easily diagnosed with available blood tests, and easily treated with two to four weeks of antibiotics.[2] On the other side are those who believe that Lyme disease is under-diagnosed, that available blood tests are unreliable, and that extended antibiotic treatment is often necessary.[3][4][5][6]


The majority of public health agencies such as the U.S. Centers for Disease Control maintain the former position. While this narrower position is sometimes described as the "mainstream" view of Lyme disease, published studies involving non-randomized surveys of physicians in endemic areas found physicians evenly split in their views, with the majority recognizing seronegative Lyme disease, and roughly half prescribing extended courses of antibiotics for chronic Lyme disease.[7][8] The Centers for Disease Control and Prevention (CDC) in Atlanta is recognized as the lead United States agency for protecting the public health and safety of people by providing credible information to enhance health decisions, and promoting health through strong partnerships with state health departments and other organizations. ... In epidemiology, an infection is said to be endemic in a population when that infection is maintained in the population without the need for external inputs. ... Seronegative is a general term that means absent from the blood. More specifically, it almost always is used to refer to antibodies being absent from the blood. ...


Both groups making up the dichotomy of the Lyme disease controversy have compelling empirical evidence to support their points of view and logical arguments. More research into Lyme and its infecting agent, Borrelia burgdorferi, is needed to elucidate the true nature of Lyme disease before definitive treatment guidelines are to be written. A dichotomy is a division into two non-overlapping or mutually exclusive and jointly exhaustive parts. ... Binomial name Borrelia burgdorferi Johnson RC et al 1984 Borrelia burgdorferi is a spirochete bacteria and the causative agent of Lyme disease. ...

Contents

Two standards of care

Because the legal standard of care is defined by the consensus of treating physicians (rather than published guidelines), two standards of care for Lyme disease are now recognized in the U.S., a situation with significant legal implications for both patients and clinicians.[9][10] In tort law, the standard of care is the degree of prudence and caution required of an individual who is under a duty of care. ...


Treatment guidelines from the Infectious Diseases Society of America (IDSA), make up the viewpoint of the more conservative party of treatment for Lyme. The ISDA released their most recent version of treatment guidelines in 2006. [11] The guidelines are published by the University of Chicago Press Journal of Clinical Infectious Diseases. The Infectious Diseases Society of America (IDSA) is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. ... The University of Chicago Press is the largest university press in the U.S. It is operated by the University of Chicago and publishes a wide variety of academic titles, including The Chicago Manual of Style, dozens of academic journals including Critical Inquiry, and a wide array of texts covering...


The new guidelines released by the IDSA are more restrictive in their treatment regimens than previously. The IDSA guidelines now require either an EM rash or positive laboratory tests for diagnosis. Seronegative Lyme disease is no longer acknowledged, except in early Lyme. The authors of the guidelines maintain that chronic Lyme disease does not result from persistent infection, and therefore treatment beyond 2-4 weeks is not recommended by the IDSA, even in late stage cases.


An opposing group of doctors making up the International Lyme and Associated Disease Society (ILADS) have purported the use of antibiotic treatment beyond four weeks for both early and late Lyme. ILADS supports studies that purport persistent or long term chronic infection with the infecting agent of Lyme, the borrelia spirochete. The ILADS treatment guidelines are available through National Guideline Clearinghouse. Species Borrelia anserina Borrelia burgdorferi Borrelia is a genus of bacteria of the spirochete class. ... Families Brachyspiraceae Leptospiraceae Spirochaetaceae The spirochaetes are a phylum of distinctive bacteria, which have long, helically coiled cells. ... National Guideline Clearinghouse National Guideline Clearinghouse (NGC) is a database of evidence-based clinical practice guidelines and related documents. ...


The discourse gap between the standards of care representing the disparate views of the IDSA and ILADS guidelines are juxtaposed in the table below.

ILADS (The International Lyme and Associated Diseases Society)[12]
ILADS Mission Statement[13]		 IDSA (The Infectious Diseases Society of America)[14]
IDSA Mission Statement[15]
Peer-reviewed treatment guidelines ILADS Guidelines[16]

Details of their methods as recorded by the National Guidelines Clearinghouse

 IDSA Guidelines[11]

Details of their methods as recorded by the National Guidelines Clearinghouse
EM rash Present less than 50% of the time. Studies that show otherwise are often excluded, as subjects must meet The CDC criteria which prioritize the rash over other disease manifestations. Among those who would be excluded from such studies are seronegative Lyme patients without a rash, seropositive patients without a rash who present with fever, flu-like symptoms, joint and muscle pain, paresthesia and/or encephalopathy, and late-stage patients whose diagnosis was delayed because no rash was present. "The great majority of Lyme patients" present with an EM rash, according to studies of patients with early Lyme disease diagnosed by CDC criteria.
Testing Not reliable, particularly for late cases; used to support a clinical diagnosis (see Testing section for discussion). Nearly always reliable after the first few weeks of infection.
Chronic Lyme disease Persistent Lyme infection exists due to various mechanisms of antibiotic resistance, particularly when diagnosis and treatment are delayed, as numerous studies have demonstrated. Lengthy treatment regimens are sometimes required. Persistent Lyme infection is not recognized. Some patients report continuing and/or relapsing non-specific symptoms following an episode of Lyme disease that has been treated with a standard course of antibiotics. Post-treatment symptoms are termed "Post-Lyme disease syndrome" and are often attributed to an unspecified autoimmune process and/or the development of fibromyalgia or chronic fatigue syndrome, psychiatric disorders such as somatization, or simply stress.
Long-term antibiotic treatment ILADS maintains that a 2-4 week course of antibiotics is not always curative, particularly when diagnosis is delayed and disease is at a later, disseminated stage. ILADS recommends long-term antibiotic therapy for these symptomatic patients, while acknowledging the lack of published data supporting either long-term or short-term treatment durations. While more research is needed, treatment should not be withheld from patients in the meantime. (See Evidence section for list of published clinical trials.) According to the IDSA, virtually all patients are cured of infection with a single course of 14-28 days of antibiotics, regardless of the stage of their illness. Rarely, a second course of treatment is recommended, but long-term antibiotic therapy is not recommended according to IDSA guidelines.
Primary concern regarding misdiagnosis The under-diagnosis of Lyme may lead to untreated chronic, persistent infection resulting in severe disability and possibly even death. The over-diagnosis of Lyme may lead to the unnecessary use of antibiotics resulting in side effects (most commonly nausea). Where intravenous therapy is used, there are more serious risks including central line infection, which has resulted in the death of one patient being treated for chronic Lyme disease.[17] There are also concerns about the cost of antibiotic treatment.
Risk-benefit analysis The potential harm in letting a persistent Lyme infection go untreated far outweighs the potential side-effects of long-term antibiotic use. If long-term oral antibiotic therapy is considered safe enough for acne patients, its use is certainly justified for chronic Lyme patients. Intravenous therapy is justified for serious, refractory cases or those with clear central nervous system involvement. Risks are minimized by skilled clinicians who take appropriate precautions. Since chronic Lyme infection is presumed not to exist, any potential adverse effects of long-term antibiotic therapy (both oral and intravenous) outweigh the (non-existent) benefits. According to the IDSA guidelines, long-term antibiotic therapy may be dangerous and lead to drug-resistant superbugs.

Erythema migrans (EM), formerly called erythema chronicum migrans, refers to the rash often (though not always) seen in the early stage of Lyme disease. ... Seronegative is a general term that means absent from the blood. More specifically, it almost always is used to refer to antibodies being absent from the blood. ... Seropositivity is the presence of a certain antibody in a blood sample. ... Paresthesia or paraesthesia (in British English) is a sensation of tingling, pricking, or numbness of a persons skin with no apparent long-term physical effect, more generally known as the feeling of pins and needles or of a limb being asleep. // Transient paresthesia is the temporary sensation of tingling... Encephalopathy is a container term for various conditions affecting the brain. ... Autoimmunity is the failure of an organism to recognize its own constituent parts (down to the sub-molecular levels) as self, which results in an immune response against its own cells and tissues. ... Fibromyalgia (FM or FMS) is a chronic syndrome (constellation of signs and symptoms) characterized by diffuse or specific muscle, joint, or bone pain, fatigue, and a wide range of other symptoms. ... Chronic fatigue syndrome (CFS), also known as Myalgic Encephalomyelitis (ME), Post-Viral Fatigue Syndrome (PVFS), and various other names, is a syndrome (or group of syndromes) of unknown and possibly multiple etiologies, affecting the central nervous system (CNS) and possibly the immune system as well as other organs. ... Psychiatrist redirects here. ... Somatization disorder (or Briquets disorder) is a type of mental illness in which a patient manifests a psychiatric condition as a physical complaint. ... In medical terms, stress is a physical or psychological stimulus that can produce mental or physiological reactions that may lead to illness. ... See also preventable medical errors In the United States medical error is estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries each year. ... For the Beck song, see Nausea (song). ... Intravenous therapy or IV therapy is the administration of liquid substances directly into a vein. ... Risk-benefit analysis is the comparison of the risk of a situation to its related benefits. ...

Public Statements

"A small group of scientists...deny the existence of chronic Lyme disease," wrote ILADS president Raphael Stricker, M.D., referring in part to the IDSA. "Fearing 'over-diagnosis,' they publish guidelines endorsing an insensitive testing program that misses half the patients with the tick-borne illness. Fearing 'over-treatment,' they recommend antibiotic therapy barely adequate for acute infection and wholly inadequate for chronic Lyme disease. Although the Lyme denialists claim support from mainstream medical groups, the reality is that the handful of them have managed to dictate policy to larger health care organizations through a closed process that rejects dissenting views."[18]


The IDSA has attacked ILADS as a "special interest group... which represents a few physicians who advocate unconventional treatments based on testimonials rather than scientifically sound clinical trials... Nearly all people – more than 95 percent – who do get sick with Lyme disease and are treated with the recommended course of antibiotics get better and go on with their lives,” said Gary Wormser, M.D., lead author of IDSA’s 2006 guidelines on Lyme disease.


The CDC case definition

Confusion about the significance of the U.S. Centers for Disease Control Case Definition for Lyme disease lies at the heart of the controversy over diagnosis. The CDC has explicitly stated that the following definition is meant to be used for surveillance purposes, not diagnostic purposes.[19][20] The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, is recognized as the leading United States agency for protecting the public health and safety of people. ... The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, is recognized as the leading United States agency for protecting the public health and safety of people. ... The act of surveilling a clinical syndrome that have a significant impact on public health. ...

CDC Case Definition for Lyme disease
  1. Erythema migrans rash (at least 5 cm in diameter)
    - OR -
  2. Positive blood tests (ELISA followed by Western blot) AND one or more of the following manifestations:

A number of well-documented signs of chronic Lyme disease including encephalopathy[21][22][23] (manifested by memory loss, mood changes and sleep disturbance) are not part of the CDC case definition. Therefore clinicians using the CDC criteria for diagnostic purposes will misdiagnose patients who have the disease.[24] Additionally, reliance on the CDC case definition for clinical purposes would result in the misdiagnosis of those with false-negative test results, a widely reported phenomenon (see Lyme disease#Diagnosis). Erythema migrans (EM), formerly called erythema chronicum migrans, refers to the rash often (though not always) seen in the early stage of Lyme disease. ... Arthritis (from Greek arthro-, joint + -itis, inflammation; plural: arthritides) is a group of conditions where there is damage caused to the joints of the body. ... Bells palsy (facial palsy) is characterised by facial drooping on the affected half, due to malfunction of the facial nerve (VII cranial nerve), which controls the muscles of the face. ... Cranial nerves Cranial nerves are nerves that emerge directly from the brain in contrast to spinal nerves which emerge from segments of the spinal cord. ... Radicular Pain, or Radiculitis, is transferred pain radiated along the dermatome (sensory distribution) of a nerve due to pressure on the radicle (nerve root; so named for its resemblance to plant roots) at its connection to the spinal column. ... Meningitis is the inflammation of the protective membranes covering the central nervous system, known collectively as the meninges. ... Encephalitis is an acute inflammation of the brain, commonly caused by a viral infection. ... A heart block is a disease in the electrical system of the heart. ... Encephalopathy is a container term for various conditions affecting the brain. ... Memory loss can be caused by many things. ... A sleep disorder (somnipathy) is a disorder in the sleep patterns of a person or animal. ... See also preventable medical errors In the United States medical error is estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries each year. ... Type I errors (or α error, or false positive) and type II errors (β error, or a false negative) are two terms used to describe statistical errors. ... Lyme disease (Borreliosis) is a bacterial infection with a spirochete from the species complex Borrelia burgdorferi, which is most often acquired from the bite of an infected Ixodes, or black-legged, tick, also known as a deer tick. ...


Western Blot

There are two Western blot tests for borrelia species. IgG and IgM. A western blot with five vertical lanes, indicating proteins. ...

  • IgM is a sign of a current infection.
  • IgG is a sign of a current infection, or of a past exposure to or past infection by the organism.

There are nine known Borrelia burgdorferi genus specie specific kilodalton (KDA) Western Blot antibodies (bands): 18, 23, 30, 31, 34, 37, 39, 83, and 93. The atomic mass unit (amu), unified atomic mass unit (u), or dalton (Da), is a small unit of mass used to express atomic masses and molecular masses. ... Wikipedia does not yet have an article with this exact name. ...


CDC Western Blot IgG surveillance criteria includes 18, 23, 30, 37, 39, and 93 and excludes bands 31, 34, and 83, making positive diagnosis for borrelia more problematic.


Under the CDC criteria Western Blot IgG must have at least five of ten specific serologic bands to positive. 18, (22-25), 28, 30, 39, 41, 45, 58, 66 and 93. Western Blot IgM must have two of the three following bands to be considered positive (22-25), 39, and 41.[25]


Testing

The debate over Lyme disease testing remains a heated one, with concern over both false-positives and false-negatives (see Lyme disease#Diagnosis). Tests currently rely on indirect methods of detection (i.e. the body's immune system response), because it is very difficult to culture the bacteria directly from patients. Specific issues with regard to the testing controversy include the following: Type I errors (or α error, or false positive) and type II errors (β error, or a false negative) are two terms used to describe statistical errors. ... Type I errors (or α error, or false positive) and type II errors (β error, or a false negative) are two terms used to describe statistical errors. ... Lyme disease (Borreliosis) is a bacterial infection with a spirochete from the species complex Borrelia burgdorferi, which is most often acquired from the bite of an infected Ixodes, or black-legged, tick, also known as a deer tick. ... A scanning electron microscope image of a single neutrophil (yellow), engulfing anthrax bacteria (orange). ...

Critics argue that the CDC's 2-tiered testing protocol (ELISA test, followed by confirmatory Western blot test if positive or equivocal) misses many patients who are infected. This criticism is not without merit. Several studies have examined this question and found that as many as 50 percent of definite Lyme Disease as defined by the presence of Borrelial DNA or Borrelial culture were negative when tested against the CDC's recommendations. Such studies have included both early and late stage Lyme Disease patients. A study from the College of American Pathologists concluded that "these tests will not be useful as screening tests until their sensitivity is improved."[26] The sensitivity of a binary classification test or algorithm, such as a blood test to determine if a person has a certain disease, or an automated system to detect faulty products in a factory, is a parameter that expresses something about the tests performance. ... Elisa portrayed on the cover of her album Pearl Days. ... A western blot with five vertical lanes, indicating proteins. ... The sensitivity of a binary classification test or algorithm, such as a blood test to determine if a person has a certain disease, or an automated system to detect faulty products in a factory, is a parameter that expresses something about the tests performance. ...

  • Inadequate lab standardization.

Standardization of testing has been found to be inadequate, with a high degree of interlaboratory variability.[27][26][28]

Without a diagnostic gold standard to identify those with chronic Lyme disease, circular reasoning becomes a problem in studies that evaluate the sensitivity of serologic tests for this population. Bias is unavoidable if subjects are selected by CDC criteria, since late-stage patients must have tested positive previously in order to qualify for a study. In a study cited by the CDC to defend the tests' validity, the authors acknowledge this risk of selection bias.[29] In medicine, a gold standard test is the diagnostic test that is regarded as definitive in determining whether an individual has a disease process. ... See: Sensitivity (electronics) Sensitivity (human) Sensitivity (tests) For sensitivity in finance, see beta coefficient This is a disambiguation page — a navigational aid which lists other pages that might otherwise share the same title. ... Begging the question, in modern popular usage, is often used synonymously for raising the question. However the original meaning is quite different: it described a type of logical fallacy (also called petitio principii) in which the evidence given for a proposition as much needs to be proved as the proposition... The sensitivity of a binary classification test or algorithm, such as a blood test to determine if a person has a certain disease, or an automated system to detect faulty products in a factory, is a parameter that expresses something about the tests performance. ... Serology is literally the scientific study of the blood serum. ... Selection bias is the error of distorting a statistical analysis by pre- or post-selecting the samples. ...


False Negative Tests

False negative test results due to the following, particularly in late and chronic Lyme disease: Type I errors (or α error, or false positive) and type II errors (β error, or a false negative) are two terms used to describe statistical errors. ...

Intracellular sequestration, antigen variation, immune suppression, the formation of immune complexes, and predominance of cystic forms have all been cited as reasons for seronegativity in late and chronic Lyme disease (see Lyme disease microbiology#Mechanisms of persistence). A scanning electron microscope image of a single neutrophil (yellow), engulfing anthrax bacteria (orange). ... In cell biology, molecular biology and related fields, the word intracellular means inside the cell. It is used in contrast to extracellular (outside the cell). ... An antigen is a molecule that stimulates an immune response. ... A scanning electron microscope image of a single neutrophil (yellow), engulfing anthrax bacteria (orange). ... Immune Complex Diseases An immune complex is the combination of an epitope with an antibody directed against that epitope. ... A spheroplast is a gram-negative bacterium from which the cell wall has been almost completely removed as by the action of penicillin. ... Seronegative is a general term that means absent from the blood. More specifically, it almost always is used to refer to antibodies being absent from the blood. ... Borrelia burgdorferi the causative agent of lyme disease. ...

  • Positive test criteria is based on early Lyme disease.

The CDC's criteria for a positive Western blot were developed based upon on a study of patients with early Lyme disease.[30] The serologic response of patients with late-stage Lyme disease was not analyzed and incorporated, despite that fact that such cases require a positive Western blot for diagnosis by CDC standards. A western blot with five vertical lanes, indicating proteins. ... Serology is literally the scientific study of the blood serum. ...

  • Specific markers for late-stage Lyme disease left out.

Several highly specific antibody bands for Lyme (31-kDa and 34-kDa, corresponding to outer surface proteins A and B) were not included in the CDC criteria for a positive Western blot because they only appear late in the disease. These bands which have not been included on the CDC Western Blot are so specific to Borrelia Burgdorferri that they are being used/studied for the development of a Lyme Disease vaccine.[31] As a result, the vast majority of laboratories do not report these bands, even if they are positive. This is one reason some clinicians use laboratories that specialize in tick-borne disease, as they usually report all antibody bands. Each antibody binds to a specific antigen; an interaction similar to a lock and key. ... A western blot with five vertical lanes, indicating proteins. ... Tick-borne diseases are diseases or illnesses transmitted by ticks. ...

  • Tests based on only one strain.

Current tests at most laboratories are based on only one strain of Borrelia burgdorferi (the B31 strain is used in the U.S.) despite the fact that there are over three hundred strains worldwide and over one hundred in North America[32] (see Lyme disease microbiology). Several studies have found that this practice can lead to false-negatives[33][34] - another reason some clinicians use tick-borne disease specialty labs, which utilize multiple strains of Borrelia burgdorferi in the preparation of test kits. In biology, Strain can be used two ways. ... Borrelia burgdorferi the causative agent of lyme disease. ... Type I errors (or α error, or false positive) and type II errors (β error, or a false negative) are two terms used to describe statistical errors. ... Tick-borne diseases are diseases or illnesses transmitted by ticks. ...


False Positive Tests

Many physicians with a conservative view of Lyme disease believe it is over-diagnosed and over-treated. One of the most widely cited studies from critics of Lyme Disease was written by Allan Steere. His study, published in JAMA concluded that 57% of patients diagnosed with Chronic Lyme in an endemic area did not actually have the disease.[35] Critics have responded with the following arguments:[36][37]

  • 45% of those considered "misdiagnosed" in the study received positive results from another laboratory, and negative results from the authors' laboratory. However there was no independent evaluation, and no reason to assume that the authors' laboratory was superior. In a separate study funded by the NIH, the laboratory used by Allan Steere was sent definite Lyme Disease serology in a blinded fashion in an attempt to discover the reliability of testing at major academic centers. The study concluded that the rate of true positives for this laboratory was significantly less than 100 percent[citation needed].
  • Rather than consider the possibility of persistent infection, the authors considered treatment failure to be evidence of misdiagnosis, i.e. patients could not possibly have Lyme if they were not cured by a standard course of antibiotics even though the authors had previously published that treatment failures were common. This assumption is supported by Borrelia burgdorferi not being resistant to the antibiotics used in its treatment. However, this assumption does not consider the possibility that symptoms may be due to abnormal host immunological response[43]. This type of response might be similar to the arthritides associated with gastrointestinal diseases.
  • The authors excluded patients from a diagnosis of Lyme disease if they had psychiatric symptoms, despite the fact that Lyme can cause such symptoms.[24][44][45]

Type I errors (or α error, or false positive) and type II errors (β error, or a false negative) are two terms used to describe statistical errors. ... Borrelia burgdorferi the causative agent of lyme disease. ...

Testing positive after treatment

Because the tests measure antibodies to Borrelia burgdorferi and not the organism itself, it is theoretically possible to test positive even if the organism has been eradicated. All agree that no treatment is required in asymptomatic patients regardless of test results; however, controversy arises when a patient continues to have symptoms after a course of treatment. In this scenario, those who hold a conservative view believe the infection must have been eradicated by the treatment, and the positive test no longer indicates active infection but rather a persisting antibody response, regardless of the clinical picture. Those with a broader view of Lyme believe the evidence and clinical picture in this case most likely point to a persisting infection requiring further antibiotic treatment. Wikipedia does not yet have an article with this exact name. ... Lyme disease (Borreliosis) is a bacterial infection with a spirochete from the species complex Borrelia burgdorferi, which is most often acquired from the bite of an infected Ixodes, or black-legged, tick, also known as a deer tick. ...


Long-term antibiotic therapy

There is little concrete evidence either for or against the use of antibiotics for chronic Lyme disease, because only three such double-blind, placebo-controlled clinical trials have been funded to date by the U.S. National Institutes of Health, with conflicting results. More randomized studies with long-term follow-up are warranted to determine the most successful regimens and adequate durations of antibiotic treatments for disseminated Lyme borreliosis. The double blind is ray charles is ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesis ray charlesof the scientific method, used to prevent research... “Placebo effect” redirects here. ... In medicine, a clinical trial (synonyms: clinical studies, research protocols, medical research) is the application of the scientific method to human health. ... The National Institutes of Health (NIH) is the primary agency of the United States government responsible for medical research. ...


Evidence from controlled studies

Klempner et al. (2001)

The study intervention was one month of intravenous ceftriaxone, followed by two months of oral doxycycline or an identical sequence of IV and oral placebo, given to chronic Lyme patients with one or more of the following symptoms: musculoskeletal pain, cognitive impairment, radicular pain, paresthesias or dysesthesias. Two separate analyses were perfomed, one for Lyme antibody seronegative patients (n=51) and one for Lyme antibody seropositive patients (n=78).[46] Ceftriaxone (trade name Rocephin®) is a third-generation cephalosporin antibiotic. ... Doxycycline (INN) (IPA: ) is a member of the tetracycline antibiotics group and is commonly used to treat a variety of infections. ... “Placebo effect” redirects here. ... Radicular Pain is pain experienced along the dermatome (or sensory distribution) of a nerve due to pressure on the nerve root. ... Paresthesia or paraesthesia (in British English) is a sensation of tingling, pricking, or numbness of a persons skin with no apparent long-term physical effect, more generally known as the feeling of pins and needles or of a limb being asleep. // Transient paresthesia is the temporary sensation of tingling... Neuropathy is usually short for peripheral neuropathy, meaning a disease of the peripheral nervous system. ...

  • No significant benefit was seen in either physical or mental health-related quality of life in either patient group, as assesed with a standardized clinical questionnaire.
  • Physicians writing for the ILADS[5] as well as others[47][48] cited several percieved methodological flaws in the study, including concerns about patient selection criteria, randomization, drug dosing, treatment duration, method of symptom evaluation and analysis, and the accuracy of ancillary diagnostic testing, all of which were suggested to have affected the study's validity and generalizability to other patient populations and long-term antibiotic treatment strategies.

Krupp et al. (2003)

The study intervention was four weeks of intravenous ceftriaxone or placebo, given to previously antibiotic-treated Lyme disease patients with "persistent severe fatigue".[49] Ceftriaxone (trade name Rocephin®) is a third-generation cephalosporin antibiotic. ... “Placebo effect” redirects here. ...

  • Significant improvements were seen in symptoms of fatigue. The treatment effect remained even after adjusting for age, pain, history of psychiatric disorder and depressive symptoms.
  • No improvement was seen in cognitive symptoms. The authors caution, "although the patients with Lyme disease showed cognitive slowing compared to healthy controls, these deficits were relatively mild, which may have contributed to the lack of a treatment effect on cognition."
  • A 7% incidence of severe adverse events (requiring hospitalization) was seen between the two groups, with three episodes of IV sepsis (in the IV placebo group) and one episode of anaphylaxis (in the ceftriaxone group).
  • The authors concuded that this data suggsts that "repeated courses of antibiotic treatment are not indicated for persistent symptoms following Lyme disease including those related to fatigue and cognitive dysfunction, particularly in light of the frequency of serious adverse events."

The word fatigue is used in everyday living to describe a range of afflictions, varying from a general state of lethargy to a specific work induced burning sensation within muscle. ... Cognitive The scientific study of how people obtain, retrieve, store and manipulate information. ...

Fallon et al. (not yet published)

This trial involved ten weeks of intravenous ceftriaxone or placebo given to chronic Lyme patients with ongoing memory impairment. Advanced neuroimaging techniques were used to study the patients' response to treatment. Preliminary results were orally presented on October 22, 2004 at the Columbia University / Lyme Disease Association Conference in Rye, NY.[50] According to an LDA press release, the antibiotic group showed "significant improvement in neurocognitive function," as well as in "other symptoms".[51] Definitive results of this study have not yet been published in a peer-reviewed medical journal as of May 2007. Ceftriaxone (trade name Rocephin®) is a third-generation cephalosporin antibiotic. ... “Placebo effect” redirects here. ...


Evidence from uncontrolled studies

While the results of placebo-controlled studies are mixed, several uncontrolled studies suggest that longer durations of antibiotic treatment may be beneficial for chronic Lyme disease.[52][53][54][55][56][57] “Placebo effect” redirects here. ...


Implications for treatment

The widely publicized results of the Klempner study have led some to proclaim that long-term antibiotics are unhelpful for patients with chronic Lyme disease, warning patients and clinicians that the evidence does not support their use. Others see this as an abuse of the concept of evidence-based medicine. They argue that treatment failure in one questionably designed clinical trial does not justify such warnings in light of other evidence, and that withholding antibiotic treatment is unethical in the face of patient suffering. More randomized studies are needed to elucidate proper use and duration of antibiotics in treatment protocol. Evidence-based medicine (EBM) is an attempt to more uniformly apply the standards of evidence gained from the scientific method, to certain aspects of medical practice. ...


Chronic Lyme Disease and Post Lyme Syndrome

Much of the questioning behind continuing antibiotic therapy for patients with ongoing symptoms is whether chronically ill Lyme patients have an autoimmune reaction in the patient via immunologic mechanisms triggered by the initial borrelia infection, or have an ongoing (chronic) borrelia infection. There is viable evidence for both theories. The persistance of borrelia infection in the central nervous system following some treatment regiments has been discussed in the literature since the 1970's.[58] Autoimmune diseases arise from an overactive immune response of the body against substances and tissues normally present in the body. ...


The new IDSA guidelines reject the term "chronic Lyme disease" in favor of "post-Lyme syndrome" because they argue the infection does not persist after treatment, although the same authors have used the term "chronic Lyme disease" in previously published work.


Patients with "post-Lyme syndrome" may or may not have serologic evidence of continuing spirochete infection. Previous antibiotic treatment may reduce or completely clear the borrelia infection in these patients but the inflammatory response persists. Inadequate serology testing does not help define if infection has been cleared or not. A patient may continue with symptoms after antibiotic treatment but have a negative serology, or they may be asymptomatic but have a positive serology. Further antibiotic treatments are not ameliorating of symptoms in these patients.[59][60]


There is currently no consensus on whether ongoing symptoms result from the various hypotheses put forth by the IDSA in their discussion of "post-Lyme syndrome" including autoimmune hypersensitivity, or cell-mediated proinflammatory process,[61] or if they sometimes result from persistent infection. IDSA argues that there is no convincing evidence of persistent infection. ILADS and others argue that the IDSA ignored evidence that Lyme infection sometimes persists despite a standard course of antibiotics. Hypersensitivity refers to undesirable (damaging, discomfort-producing and sometimes fatal) reactions produced by the normal immune system. ... Cell-mediated immunity is an immune response that does not involve antibodies but rather involves the activation of macrophages and NK-cells, the production of antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen. ... Borrelia burgdorferi the causative agent of lyme disease. ...


The distinction has treatment implications: the IDSA recommends no specific treatment for "post-Lyme syndrome," and never recommends long-term antibiotic therapy, while ILADS and others recommend longer courses of antibiotics for "chronic Lyme disease" if it is believed that the patient has an ongoing infection. The term "chronic Lyme disease" definitively suggests persistent infection by viable bacteria, when an autoimmune reaction to the initial infection may be the cause of continuing symptoms. This has yet to be unequivocally defined, and may be a case by case scenario.


Further investigation to the nature of borrelia burgdoferi senso latu is warranted, both in the laboratory and in the clinical setting, for optimal treatment in patients with continuing symptoms of borrelia infection who may be antibiotic refractory in the late course of disease. Since the optimal choice of antibiotic(s) and treatment duration is unknown and may vary by strain, additional research is needed before strict treatment recommendations can be issued. In biology, Strain can be used two ways. ...


Both ILADS and ISDA guidelines are meant to guide the physician and neither are the final word on treatment for Lyme disease. Ultimately physicians should make their choices based upon the available science and best interest of their patients taking into account benefits and risks of any treatment.


Recent Developments

Since October 2006, the Lyme controversy has become more polarized with the release of updated diagnosis and treatment guidelines from the Infectious Diseases Society of America (IDSA).[62] The new IDSA recommendations are even more restrictive than previous ISDA guidelines, requiring either an EM rash or positive laboratory tests for diagnosis. Seronegative Lyme disease is no longer acknowledged, except in early Lyme. The authors of the guidelines maintain that chronic Lyme disease does not result from persistent infection, and therefore treatment beyond 2-4 weeks is not recommended by the IDSA, even in late stage cases. October 2006 is the tenth month of that year and has yet to occur. ... The Infectious Diseases Society of America (IDSA) is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. ...


The 2006 IDSA guidelines[11] have come under fire from a variety of corners. The International Lyme and Associated Diseases Society (ILADS), a professional medical society, formally requested retraction of the IDSA guidelines,[63] arguing that the authors ignored all published data that conflicted with their opinions, and refused input from physicians and patients with differing views. The all-volunteer Lyme Disease Association, which is the largest Lyme advocacy group in the U.S., expressed concerns that the guidelines do not allow for physicians' clinical discretion, and that with more cases going undiagnosed and untreated by the stricter guidelines, more patients than ever will develop disabling, late-stage Lyme disease.[64]


Connecticut State Attorney General Richard Blumenthal initiated a formal investigation into the development of the IDSA guidelines in November 2006. The Attorney General's office is considering whether the IDSA violated antitrust laws through exclusionary conduct and monopolization in the development of the guidelines. "These guidelines were set by a panel that essentially locked out competing points of view," Blumenthal said. "Presumably, the IDSA is a non-profit making organization, but such organizations can still be used for anti-competitive purposes."[65] It has been suggested that this article be split into multiple articles. ... In most common law jurisdictions, the Attorney General is the main legal adviser to the government, and in some jurisdictions may in addition have executive responsibility for law enforcement or responsibility for public prosecutions. ... Richard Blumenthal, Connecticut Attorney General was awarded the Raymond E. Baldwin Award for Public Service by the Quinnipiac University School of Law in 2002 Richard Blumenthal is the 23rd elected Attorney General of Connecticut. ... 67 die and about 300,000 people are affected by floods in Ethiopias Somali Region of Ogaden after the Shabelle River bursts its banks. ... This article is about anti-competitive business behavior. ...


See Also

Borrelia burgdorferi the causative agent of lyme disease. ... There are very few or no other articles that link to this one. ... Families Brachyspiraceae Leptospiraceae Spirochaetaceae The spirochaetes are a phylum of distinctive bacteria, which have long, helically coiled cells. ... Species Borrelia anserina Borrelia burgdorferi Borrelia is a genus of bacteria of the spirochete class. ...

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