Intended for healthcare professionals

Rapid response to:

Feature Covid

How “long covid” is shedding light on postviral syndromes

BMJ 2022; 378 doi: (Published 21 September 2022) Cite this as: BMJ 2022;378:o2188

Rapid Response:

Re: How “long covid” is shedding light on postviral syndromes

Dear Editor,

Chronic medical conditions like M.E., Fibromyalgia, Chronic Lyme Disease/PTLDS and long COVID all share similar symptoms as your article suggests, but the implication that Lyme disease fits into the same category from an etiological point-of-view, and is not a persistent infection, nor immunological in nature requires elucidation.

Although there has been a long ongoing debate on the nature of persistent symptoms in Lyme disease, recent published research from Johns Hopkins University, the University of New Haven and Stamford University have all implicated biofilm/'persister' forms of Borrelia as one of the reasons why symptoms persist in this chronically ill population. Clinical studies on dapsone combination therapy as well as disulfiram as ‘persister’ drug regimens have been shown to have benefit in relieving symptoms in the CLD/PTLDS population, and the published medical literature has found up to 16 reasons why symptoms may persist. A review of the literature reveals that long COVID and chronic Lyme disease share certain etiological overlaps based on published literature, including possible persistent infection, reactivation of infection (EBV, HHV6), autoimmunity and immune dysfunction, POTS/dysautonomia, and mitochondrial dysfunction.

In the United States, 87% of our health care costs and 70% of our deaths are due to chronic disease, and chronic infections and environmental toxins are not regularly considered in the work-up. In the case of COVID, disadvantaged populations exposed to high levels of pollution fared poorly during the pandemic due to higher levels of free radical/oxidative stress, and with chronic Lyme disease, environmental toxicity including heavy metals and mold toxins also may have a negative impact. Considering that 14.5% of the global population has now been diagnosed with Lyme disease, with climate change and environmental pollution a significant health risk, perhaps it is time to evaluate the 16 point MSIDS model as a potential diagnostic map to evaluate the high societal burden of chronic fatiguing, musculoskeletal illnesses with neuropsychiatric symptoms, which are responsible in large part for high levels of chronic disability and rising health care costs across the globe.

Dr Richard Horowitz
Medical director, Hudson Valley Healing Arts Center, Board certified internal medicine
Member NYS DOH Tick-borne Disease Working Group 2021-2022
Member HHS Tick-borne Disease Working Group 2017-2019
Co-chair HHS Other Tick-borne Diseases and Co-infections subcommittee 2017-2019
Member, HHS Babesia and Other Tick-borne Pathogens 2019-2020

Scientific References:
1. Horowitz, R.I., Murali, K., Gaur, G. et al. Effect of dapsone alone and in combination with intracellular antibiotics against the biofilm form of B. burgdorferi. BMC Res Notes 13, 455 (2020).
2. Horowitz, R.I.; Freeman, P.R. Efficacy of Double-Dose Dapsone Combination Therapy in the Treatment of Chronic Lyme Disease/Post-Treatment Lyme Disease Syndrome (PTLDS) and Associated Co-infections: A Report of Three Cases and Retrospective Chart Review. Antibiotics 2020, 9, 725.
3. Horowitz, R.I.; Freeman, P.R. Precision Medicine: retrospective chart review and data analysis of 200 patients on dapsone combination therapy for chronic Lyme disease/post-treatment Lyme disease syndrome: part 1. International Journal of General Medicine 2019:12 101–119.
4. Horowitz, R.I.; Freeman, P.R. Precision Medicine: The Role of the MSIDS Model in Defining, Diagnosing, and Treating Chronic Lyme Disease/Post Treatment Lyme Disease Syndrome and Other Chronic Illness: Part 2. Healthcare 2018, 6, 129.
5. Horowitz, R.I., The Global Rise of Chronic Diseases: Why Broaden the Paradigm to Include Tick-borne Illness and Environmental Toxin Exposure? Arch Med Case Rep. 2019, Volume 1, Issue 1.
6. Gao J, Gong Z, Montesano D, Glazer E, Liegner K. "Repurposing" Disulfiram in the Treatment of Lyme Disease and Babesiosis: Retrospective Review of First 3 Years' Experience in One Medical Practice. Antibiotics (Basel). 2020 Dec 4;9(12):868. doi: 10.3390/antibiotics9120868. PMID: 33291557; PMCID: PMC7761882.
7. Holman HR. The Relation of the Chronic Disease Epidemic to the Health Care Crisis. ACR Open Rheumatol. 2020 Mar;2(3):167-173. doi: 10.1002/acr2.11114. Epub 2020 Feb 19. PMID: 32073759; PMCID: PMC7077778.
8. D. Castanares-Zapatero, P. Chalon, L. Kohn, M. Dauvrin, J. Detollenaere, C. Maertens de Noordhout, C. Primus-de Jong, I. Cleemput & K. Van den Heede (2022) Pathophysiology and mechanism of long COVID: a comprehensive review, Annals of Medicine, 54:1, 1473-1487, DOI: 10.1080/07853890.2022.2076901
9. Li C, Managi S. Impacts of air pollution on COVID-19 case fatality rate: a global analysis. Environ Sci Pollut Res Int. 2022 Apr;29(18):27496-27509. doi: 10.1007/s11356-021-18442-x. Epub 2022 Jan 4. PMID: 34982383; PMCID: PMC8724597.
10. Dong Y, Zhou G, Cao W, Xu X, Zhang Y, Ji Z, Yang J, Chen J, Liu M, Fan Y, Kong J, Wen S, Li B, Yue P, Liu A, Bao F. Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ Glob Health. 2022 Jun;7(6):e007744. doi: 10.1136/bmjgh-2021-007744. PMID: 35697507; PMCID: PMC9185477.

Competing interests: No competing interests

21 September 2022
Richard Horowitz MD
Internal Medicine physician
New York State Tick-borne Disease Working Group
4232 Albany Post Road, Hyde Park, NY 12538