To the Editor:
Alternative considerations are presented for the article “Common Misconceptions About Lyme Disease.”
1
Are serology tests for Lyme disease reliable? Enzyme-linked immunosorbent assays may provide false-negative results not only because of the time delay for the patient's immune system to produce the antibodies but also because the various enzyme-linked immunosorbent assays are intrinsically unreliable.2
The Western blot is more specific and reliable; however, many laboratories omit bands 31 (outer surface protein A) and 34 (outer surface protein B).
3
These 2 bands are specific for the Lyme spirochete. They were included in the Lyme disease vaccine when it was available. Their omission may result in a false-negative Western blot test result.Is there a rationale for longer treatment course? The most important factor determining the distinction between acute or chronic Lyme disease is the interval between the inoculation and the beginning of effective treatment.
Prompt initiation of antibiotic therapy in the proper dose and duration will cure acute Lyme disease and prevent the development of chronic Lyme disease. Delayed or inadequate treatment for persons with Lyme disease is not infrequent. The reasons for the delay vary; often the person cannot recall any tick bite or the characteristic erythema migrans may be minimal and totally ignored. The initial systemic symptoms may be attributed to a viral illness. In such circumstances, treatment may be delayed until other manifestations of the Lyme disease become apparent. This delay is critical in determining the ultimate duration of the Lyme disease in each patient!
Laboratory experiments to simulate delayed or inadequate treatment for Lyme disease have been published.
4
The consequences of delayed treatment confirm the persistence of viable Borrelia bergdorferi organisms after subsequent adequate antibiotic treatment. The evidence for their persistence is confirmed by culture, polymerase chain reaction, and xenodiagnoses. The surviving Borrelia bergdorferi organisms become more difficult to eradicate because they become cystic in their configuration and less penetrable by antibiotics.5
References
- Common misconceptions about Lyme disease.Am J Med. 2013; 126: 264.e1-264.e7
- Large differences between test strategies for the detection of anti-Borrelia antibodies are revealed by comparing eight ELISAs and five immunoblots.Eur J Clin Microbiol Infect Dis. 2011; 30: 1027-1032
- Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease.MMWR Morb Mortal Wkly Rep. 1995; 44: 590-591
- Persistence of Borrelia burgdorferi following antibiotic treatment in mice.Antimicrob Agents Chemother. 2008; 52: 1728-1736
- Persisting atypical and cystic forms of Borrelia burgdorferi and local inflammation in Lyme neuroborreliosis.J Neuroinflammation. 2008; 5: 40
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Conflict of Interest: None.
Authorship: The author is solely responsible for the content of this manuscript.
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© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
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- Common Misconceptions About Lyme DiseaseThe American Journal of MedicineVol. 126Issue 3
- PreviewLyme disease, infection with Borrelia burgdorferi, is a focally endemic tick-transmitted zoonosis. During the 3 decades since the responsible spirochete was identified, a series of misconceptions and misunderstandings have become widely prevalent, leading to frequent misdiagnosis and inappropriate treatment. Persistent misconceptions concern the reliability of available diagnostic tools, the signs and symptoms of nervous system involvement, the appropriate choice and duration of antimicrobial therapy, the curability of the infection, and the cause of symptoms that may persist in some patients after treatment.
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- The ReplyThe American Journal of MedicineVol. 126Issue 8
- PreviewMiller's letter1 further illustrates the misconceptions about Lyme disease. The assertion that Lyme “ELISA [enzyme-linked immunosorbent assay] tests are intrinsically unreliable” is inaccurate. In the majority of patients with very early Borrelia burgdorferi infection, typically an erythema migrans, antibody is undetectable; such patients should be treated without testing. Serologic testing also may be negative in occasional patients with other early manifestations, such as facial nerve palsy. Here a convalescent titer will almost always be positive, just as in other diseases.
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