Delaware County Medicine & Health Winter 2017 - 22
FEATURE
The CDC recognizes that the surveillance criteria
should not be used to exclude the clinical diagnosis of
Lyme disease: the narrow surveillance criteria are not
comprehensive enough to encompass all manifestations
of this illness. Unfortunately, this surveillance case
definition has caused some confusion and controversy
among physicians and patients regarding who should
be diagnosed with and treated for Lyme disease.
Physicians who rely too heavily on the narrow CDC
surveillance clinical criteria might fail to correctly diagnose
Lyme-infected patients who present with less typical
manifestations. In this situation the treatment may be delayed
or absent altogether, resulting in unnecessary pain and
disability. If detected and treated shortly after initial infection,
Lyme disease is often cured with a brief course of antibiotics;
however, delay in initiating antibiotic treatment is problematic.
When treatment is delayed, the symptoms that develop may
be less responsive to standard courses of treatment. Some
patients present with arthritis or a neuropsychiatric illness as
a complication of a previously undiagnosed Lyme infection.
Broader Symptom Spectrum for Lyme Diagnosis
With an awareness that the narrow CDC criteria are
appropriate for national surveillance but not appropriate as
the sole basis for clinical decision-making in individual cases,
some physicians use a broader, more inclusive set of clinical
criteria for the diagnosis of Lyme disease. This group of
doctors, after conducting a careful history of tick exposure
from Lyme endemic areas, examining blood test results, and
ruling out other possible causes of the patient's symptoms,
may diagnose the patient as having "probable Lyme disease."
Probable Lyme disease indicates that the physician's diagnosis
is tentative but there is sufficient evidence to support the
possibility of Lyme disease as the cause for the patient's
multiple symptoms. In this case, the physician explains that
the diagnosis is not definitive and reviews the potential
benefits and risks of treatment with the patient. These
physicians recognize that Lyme disease can present in a
variety of ways and will treat patients whose symptoms
may not fit the narrower CDC surveillance guidelines.
While recognizing that there are significant risks associated
with antibiotic treatment, particularly when administered
intravenously, these physicians would argue that the threat
of serious physical, cognitive, and functional problems
associated with long-term untreated Lyme infection
outweighs the risks of antibiotic therapy. However, by
taking this broader more inclusive approach to diagnosis
and treatment, it is likely that these physicians will also
treat some patients with antibiotics who do not have Lyme
disease. When a patient diagnosed with "probable Lyme
disease" fails to improve after antibiotic treatment, the
diagnosis should be reconsidered. An unwavering focus by
20 DELAWARE COUNTY MEDICINE & HEALTH
winter 2017
the physician (or patient) on Lyme disease as the diagnostic
explanation for ongoing symptoms - even in the absence
of improvement with antibiotics - can be harmful as other
causes of the patient's ongoing symptoms may be ignored.
Over-diagnosis vs Under-diagnosis
Is Lyme disease under-diagnosed or over-diagnosed?
Both are occurring. When doctors fail to apply good
clinical judgment in the interpretation of highly suggestive
serologic tests (e.g., 4 bands on the IgG Western blot) in a
patient with high probability of Lyme disease - or - when
they fail to consider the possibility of new onset Lyme
disease in a patient from a Lyme endemic area who presents
with prolonged flu-like symptoms during spring or early
summer months without having noticed a tick bite or rash,
it is likely that this doctor would risk not treating someone
who may well have Lyme disease. Some patients may not
develop multiple CDC-specific bands until months after
the infection, and in rare cases, not at all (the bacteria may
evade the immune system, or the antibodies may be bound
in immune complexes). Conversely, when doctors fail to
apply good clinical judgment in the interpretation of weakly
positive serologic tests in a patient with a set of symptoms
not linked to Lyme (e.g., gastric distress, rhinitis) or with
suggestive but extremely common symptoms with a broad
differential diagnosis that has not been fully evaluated or
treated (e.g., fatigue, depression, memory problems), then
this would likely be a situation of mis-diagnosis of Lyme
disease. Over-diagnosis might also be seen if a patient is
given a diagnosis of Lyme disease who has had no known
tick bites or EM rash and no known exposure to Lyme
endemic area but presents with typical Lyme symptoms
that occur in other diseases (e.g., arthralgias, numbness/
tingling, diffuse pain) or with weakly positive tests (e.g., a
single positive IgM Western blot or ELISA). Misdiagnosis
is a problem - whether it is over-diagnosis or underdiagnosis - as in each case the consequences can be serious.
It is important to keep in mind that Lyme antibody
tests obtained within the first few weeks after the bite
are often negative, because it may take several weeks
before the antibodies become detectable on blood
tests. Subsequent articles will address diagnostic and
treatment challenges, post-treatment Lyme symptoms,
aka "Chronic Lyme Disease", and co-infections.
-------------------------------------------------------------------------By Marina Makous, MD, Assistant Professor of Family Medicine
at Columbia University Department of Psychiatry. Dr. Makous
completed a 2-year Fellowship at the Department of Psychiatry/
Neuro-Inflammatory Diseases/Lyme Research and Evaluation
Center. She is seeing patients at her office in Exton, PA. This
article is adapted from the upcoming book by Dr. Fallon with
Dr. Makous, published by Columbia University Press.
Table of Contents for the Digital Edition of Delaware County Medicine & Health Winter 2017
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