lyme disease + case report + patient lg + nejm

What is the abstract of this article about Lyme disease?

This article has no abstract; the first 100 words appear below. Since its original description nearly 25 years ago, 1 Lyme disease has become recognized as an important infectious disease in the United States. The infection, which is caused by the tick-borne spirochete Borrelia burgdorferi, is now endemic in more than 15 states...

Is there long-term therapy for symptoms attributed to Lyme disease?

Randomized Trial of Longer-Term Therapy for Symptoms Attributed to Lyme Disease 1 Methods. The trial was approved by the medical ethics review committee Commissie Mensgebonden... 2 Results. Enrollment, Randomization, and Analysis. Approximately 1200 patients were screened. 3 Discussion. In this randomized, double-blind trial involving patients...

What is chronic Lyme disease a critical assessment?

A Critical Appraisal of “Chronic Lyme Disease”. “Chronic Lyme disease” is often used to explain persistent pain, fatigue, and neurocognitive symptoms in patients without any evidence of previous acute Lyme disease. Once this diagnosis is given, prolonged treatment with multiple antimicrobial agents may follow.

Is Borrelia burgdorferi found in the urine of patients with Lyme disease?

Borrelia burgdorferi DNA in the urine of treated patients with chronic Lyme disease symptoms: a PCR study of 97 cases. Infection 1996 ;24: 347 - 353 44. Rauter C, Mueller M, Diterich I, et al. Critical evaluation of urine-based PCR assay for diagnosis of Lyme borreliosis.

Who reports medical records for law firms for malpractice cases regarding Lyme disease?

Dr. Shapiro reports providing medical-record review for law firms for malpractice cases regarding Lyme disease. No other potential conflict of interest relevant to this article was reported.

What is Lyme disease?

Lyme disease, a zoonosis, is transmitted by certain ixodid ticks and is the most common reportable vectorborne disease in the United States, where it is caused only by the spirochete Borrelia burgdorferi sensu stricto (hereafter termed B. burgdorferi ). 1-3 In Europe and in Asia, B. afzelii, B. garinii, and other related species, in addition to B. burgdorferi, cause Lyme disease. 2 The most common sign of Lyme disease is erythema migrans ( Figure 1A ). 1-3 Erythema migrans usually begins as a small erythematous papule or macule that appears at the site of the tick bite 1 to 2 weeks later (range, 3 to 32 days) and subsequently enlarges. 4-7 The lesion may have centrally located vesicles or necrotic areas ( Figure 1B ). Erythema migrans may be asymptomatic, mildly pruritic, or, in rare cases, painful; if untreated, lesions may become 61 cm (2 ft) in diameter or larger and may last for 3 to 4 weeks before resolving. 4-7 Erythema migrans lesions may occur anywhere on the body surface, although common sites are the groin, axilla, waist, back, legs, and, in children, the head and neck. Although reputed to have a bull's-eye appearance, approximately two thirds of single erythema migrans lesions either are uniformly erythematous or have enhanced central erythema without clearing around it. 4-7 In some patients, erythema migrans is asymptomatic, but many patients have nonspecific symptoms, including fatigue, headache, arthralgia, myalgia, and, less often, fever. 4-7 An erythema migrans–like skin lesion can also be a sign of southern tick-associated rash illness, which is associated with the bite of the Lone Star tick, Amblyomma americanum. 8

How long does lyme disease last?

These are classified as post–Lyme disease symptoms if they persist for less than 6 months and as post–Lyme disease syndrome if they are disabling and persist for 6 months or longer. 40 The cause and frequency of this problem are unclear. 40,41 Such nonspecific symptoms are common in the general population without Lyme disease. The positive predictive value of serologic tests for Lyme disease in patients with only nonspecific symptoms is poor, 42 so misdiagnosis based on false positive serologic test results is common. 1,40-42 Moreover, extensive publicity as well as misinformation on the Internet about “chronic” Lyme disease, a condition for which there is no clear definition or scientific evidence of its existence, may increase anxiety on the part of patients about the consequences of the illness and may confound assessments of treatment outcomes. 41,43 In patients with two or more episodes of erythema migrans, often occurring years apart, it has been shown that the episodes were caused by different strains of bacteria, indicating reinfection rather persistence of infection with the original organism. 44,45 Several carefully conducted, placebo-controlled, randomized trials of prolonged antimicrobial treatment in patients with persistent subjective symptoms after treatment for Lyme disease have shown a minimal benefit or none and a substantial risk of adverse effects. 1,40,41,46,47 Consequently, prolonged antimicrobial treatment for subjective symptoms is not recommended in patients whose objective signs of Lyme disease have resolved in response to conventional therapy. Consideration of other causes of persistent symptoms is warranted. 40,41,48 In most of these patients, nonspecific symptoms resolve over time without additional antimicrobial treatment. 40,41

Is antibody testing helpful for lyme disease?

Antibody testing is generally not helpful in patients with this condition. Treatment with doxycycline, amoxicillin, or cefuroxime is effective for early Lyme disease. Funding and Disclosures. Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

When were patients recruited for lyme disease?

Patients were recruited from October 2010 through June 2013. Eligibility was assessed according to previously described inclusion and exclusion criteria (Table S1 in the Supplementary Appendix, available at NEJM.org). 11 In short, patients with persistent symptoms attributed to Lyme disease (musculoskeletal pain, arthritis, arthralgia, neuralgia, sensory disturbances, dysesthesia, neuropsychological disorders, or cognitive disorders, with or without persistent fatigue) were eligible if these symptoms either were temporally related to an erythema migrans rash or an otherwise proven case of symptomatic Lyme disease or were accompanied by B. burgdorferi IgG or IgM antibodies, as confirmed by means of immunoblot assay.

How long should you take antibiotics for lyme disease?

Previous randomized, clinical trials have not shown convincingly that prolonged antibiotic treatment has beneficial effects in patients with persistent symptoms attributed to Lyme disease. 4-6 Nonetheless, the debate about this issue has continued. 7 Although most guidelines do not recommend antimicrobial therapy for longer than 2 to 4 weeks, 8,9 other guidelines recommend prolonged antibiotic therapy. 10 We performed a randomized, double-blind, clinical trial (Persistent Lyme Empiric Antibiotic Study Europe [PLEASE]) that included three study groups to compare shorter-term treatment (ceftriaxone followed by placebo [placebo group]) with longer-term treatment (ceftriaxone followed by doxycycline [doxycycline group] or ceftriaxone followed by the combination of clarithromycin and hydroxychloroquine [clarithromycin–hydroxychloroquine group]).

How long does ceftriaxone last?

All the patients received treatment with 2000 mg of open-label intravenous ceftriaxone daily for 14 days. Patients were admitted at the study site for ceftriaxone administration during days 1 and 2; subsequent doses were given intravenously by specialized home-care nurses. After the 2-week course of ceftriaxone treatment was completed, the patients received a 12-week oral course of doxycycline (100 mg of doxycycline twice daily combined with a placebo twice daily), clarithromycin–hydroxychloroquine (500 mg of clarithromycin twice daily combined with 200 mg of hydroxychloroquine twice daily), or placebo (two different placebo capsules twice daily), as randomly assigned in a blinded manner. The study drugs and placebo were prepared as capsules with an identical appearance. Active drugs were purchased as standard tablets through the hospital pharmacy department and were placed inside size 000 capsules; placebos were prepared by filling color-matched size 000 capsules with inactive microcrystalline cellulose. Adherence was verified by means of pill counts, patient diaries, and the Medication Event Monitoring System (AARDEX Group), in which microprocessors in the cap of a medication bottle electronically record each time a bottle is opened. 13 The use of specific concomitant medications was prohibited during the entire study period, as described previously. 11

What is the term for a rash caused by Borrelia burgdorferi sensu lato complex?

Patients with Lyme disease, which is caused by the Borrelia burgdorferi sensu lato complex (including B. afzelii and B. garinii in Europe), often report persistent symptoms. 1 These symptoms are also referred to as the post–Lyme disease syndrome or chronic Lyme disease and may occur after resolution of an erythema migrans rash or after other — possibly unnoticed — manifestations of early Lyme disease, regardless of whether a patient received initial appropriate antibiotic treatment. Patients present mainly with pain, fatigue, and neurologic or cognitive disturbances. 2,3

How many adverse events were reported in the 2 week open label phase of ceftriaxone?

During the 2-week open-label ceftriaxone phase, 131 patients (46.8%) reported at least one adverse event. Most of these adverse events were judged to be drug-related, and rash and diarrhea were the most common events. No catheter-associated infections were reported. In 6 patients, an allergic adverse event led to the discontinuation of ceftriaxone. Five serious adverse events were reported, four of which were allergic reactions related to ceftriaxone use.

What are the secondary outcomes of the RAND SF-36?

Main secondary outcomes were physical and mental aspects of health-related quality of life, as assessed with the use of the RAND SF-36, 11 and fatigue, as assessed with the use of the fatigue-severity scale of the Checklist Individual Strength, on which scores range from 8 to 56, with higher scores indicating more fatigue 15 ( Table 1 ).

Does Lyme disease have a longer term effect?

In patients with persistent symptoms attributed to Lyme disease, longer-term antibiotic treatment did not have additional beneficial effects on health-related quality of life beyond those with shorter-term treatment.

How many states have Lyme disease?

The infection, which is caused by the tick-borne spirochete Borrelia burgdorferi, is now endemic in more than 15 states and has been responsible for focal outbreaks in some eastern coastal areas.

Where is Lyme borreliosis endemic?

Lyme borreliosis is also endemic in Europe and Asia, where certain aspects of the disease (erythema migrans, meningopolyneuritis, and acrodermatitis chronica atrophicans) were described in the early and mid-20th century.

Is Lyme disease a disease?

Since its original description nearly 25 years ago, 1 Lyme disease has become recognized as an important infectious disease in the United States. The infection, which is caused by the tick-borne spirochete Borrelia burgdorferi, is now endemic in more than 15 states and has been responsible for focal outbreaks in some eastern coastal areas. Lyme borreliosis is also endemic in Europe and Asia, where certain aspects of the disease (erythema migrans, meningopolyneuritis, and acrodermatitis chronica atrophicans) were described in the early and mid-20th century. These syndromes were linked conclusively in 1982 and 1983 with the recovery of a previously unrecognized spirochete . . .

Chronic Lyme Disease

The diagnosis of chronic Lyme disease and its treatment differ substantively from the diagnosis and treatment of recognized infectious diseases.

Treatment of Post–Lyme Disease Symptoms

Controlled treatment trials have been conducted only for patients with category 4 disease.

Persistent B. burgdorferi Infection and Post–Lyme Disease Symptoms

A report by Phillips and colleagues 39 is often cited to provide support for the hypothesis of persistent B. burgdorferi infection. They indicated that they detected B. burgdorferi in blood specimens from 43 of 47 patients who had received or were receiving prolonged antibiotic therapy for chronic Lyme disease (91%).

Advice to Clinicians

How should clinicians handle the referral of symptomatic patients who are purported to have chronic Lyme disease? The scientific evidence against the concept of chronic Lyme disease should be discussed and the patient should be advised about the risks of unnecessary antibiotic therapy.

Chronic Lyme Disease in the Public Domain

Physicians and laypeople who believe in the existence of chronic Lyme disease have formed societies, created charitable foundations, started numerous support groups (even in locations in which B. burgdorferi infection is not endemic), and developed their own management guidelines.

Conclusions

Chronic Lyme disease is the latest in a series of syndromes that have been postulated in an attempt to attribute medically unexplained symptoms to particular infections.

Author Affiliations

From the Departments of Family Medicine and Pediatrics, Connecticut Children's Medical Center, Hartford, and University of Connecticut Health Center, Farmington (H.M.F.); Microbiology Laboratory, Division of Vector-Borne Infectious Diseases, Centers for Diseases Control and Prevention, Fort Collins, CO (B.J.B.J.); Lyme Borreliosis Unit, Health Protection Agency Microbiology Laboratory, Southampton General Hospital, Southampton, United Kingdom (S.O.); Departments of Pediatrics and Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT (E.D.S.); Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C.S.); and the Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla (G.P.W.).