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Rapid response to:

Feature

Lyme wars

BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39363.530961.AD (Published 01 November 2007) Cite this as: BMJ 2007;335:910

Rapid Response:

Re: "Lyme Wars"

Issues of diagnosis and management of Lyme disease in the USA,
highlighted in this article have also become contentious in Europe.
Unfortunately, the misdiagnosis of Lyme disease in patients who have other
serious, life-threatening or long-term conditions was not clearly
addressed in the report. Patients with multiple sclerosis, motor neurone
disease, scleroderma, polymyalgia rheumatica, systemic lupus
erythematosis, Addison’s disease and other conditions have been diagnosed
with “chronic Lyme disease” in the UK. Misdiagnoses led to delayed or
inappropriate management, and were potentially life-threatening in several
instances. Some of these patients were harmed by treatments that they had
received for Lyme disease through intravenous line-associated sepsis,
adverse reactions to antibiotics, hepatobiliary and renal damage and C
difficile colitis. Others also suffered financially because of high
treatment costs.

Some misdiagnoses were made by clinicians who followed the
nonspecific symptoms list and case descriptions in the International Lyme
and Associated Diseases Society’s guidelines (1), which apparently had not
undergone the peer review process of the journal in which they appeared as
a supplement (E. Manzotti, Futuremedicine.com, personal communication 9th
August 2006). Careful reading of the guidelines and their supporting
references show numerous inaccuracies, selective quotation and reliance on
early studies performed before modern diagnostic tests and treatments were
available. The guidelines do a disservice both to misdiagnosed patients
and to those with continuing symptoms following Lyme disease, who require
careful clinical and laboratory evaluation for evidence of active
infection and for other explanations for their symptoms, so that
appropriate management may be selected. (2)

It is incorrect that tests for antibodies to Borrelia burgdorferi are
unreliable, particularly in the long term. Patients with late Lyme
disease are rarely seronegative(3,4). Recently-infected patients may have
negative antibody tests, because the antibody response can take some weeks
to develop (3,4). It is unsurprising if patients diagnosed with “chronic
Lyme disease” using the nonspecific ILADS criteria are seronegative, or
that antibody test assessment panels using sera from such patients give
misleading data about test performance. Conversely, tests from some
commercial “Lyme-specialty” laboratories claiming a high degree of
sensitivity in “chronic Lyme disease” patients have very poor specificity.
Poorly validated tests used by some fringe practitioners were the focus of
a report for the Department of Health (5).

The two-tier approach to B burgdorferi antibody testing, recommended
by the US Public Health Service and European experts 12 years ago, remains
valid. Test methods have improved greatly in recent years, particularly
with the introduction of recombinant and synthetic peptide antigens from
different borrelial genospecies. The long term goal is to develop single
stage tests that increase sensitivity in early infection and maintain the
high sensitivity and specificity that the two-tier process currently
provides at later stages of infections. Considerable progress has been
made in applying proteomics and bioinformatics to Lyme disease diagnosis,
as demonstrated by presentations at the second Banbury Conference on the
Laboratory Diagnosis of Lyme Disease in September 2007. These new methods
require further development and validation but hold out great promise for
future diagnostic tests.

1. Cameron D , Gaito A, Harris N, Bach G, Bellovin S, Bock K et al.
Evidence-based guidelines for the management of Lyme disease. Exp Rev Anti
Infect Ther 2004;2(suppl1) S1-13.

2. Feder HM, Johnson BJB, O’Connell S, Shapiro ED, Steere AC, Wormser
GP. A critical appraisal of chronic Lyme disease. N Engl J Med
2007;357:1422-30.

3. Wilske B, Fingerle V, Schulte-Sprechtel S. Microbiological and
serological diagnosis of Lyme borreliosis. FEMS Immunol Med Microbiol
2007;49:13-21.

4. Aguero-Rosenfeld ME, Wang G, Schwartz I, Wormser GP. Diagnosis of
Lyme borreliosis. Clin Microbiol Rev 2005;18:464-509.

5. Duerden BI. Unorthodox and unvalidated laboratory tests in the
diagnosis of Lyme borreliosis and in relation to medically unexplained
symptoms. Department of Health, London, UK, 2006.
http://www.dh.gov.uk/assetRoot/04/13/89/17/04138917.pdf

Competing interests:
None declared

Competing interests: No competing interests

23 November 2007
Susan O'Connell
Consultant Microbiologist
Lyme Borreliosis Unit, HPA Microbiology Laboratory, Southampton General Hospital, Southampton SO16 6