Letters to Editors

The Nurse Practitioner Journal

Re: Nurse Practitioner July 2010

July 2010 - Volume 35 - Issue 7 - p 44–50

doi: 10.1097/01.NPR.0000383661.45156.09

Feature: INFECTIOUS DISEASE

Lyme disease: A diagnostic dilemma

Savely, Virginia DNP, MEd, MSN, RN, FNP-C

July 2010 - Volume 35 - Issue 7 - p 44–50

doi: 10.1097/01.NPR.0000383661.45156.09

Feature: INFECTIOUS DISEASE

Lyme disease: fewer dilemmas with better data

The recent article by V. Savely presents a confusing and outdated view of Lyme disease (1). Many of her statements are based on dated references, opinions from the speculative journal, Medical Hypotheses, and commentaries and letters to the editor instead of original research articles. Assertions about the reliability of diagnostic assays and the association of Lyme disease with other chronic illnesses also are not supported by current clinical practice or scientific data.

Lyme disease is a common tick-borne infection largely confined to several states on the East Coast, the Midwest, and California (2). That clinical cases are reported in other states suggests people travel to Lyme endemic states, and that other tick species in other states may transmit other Lyme-like illnesses (3). Savely claims a Lyme “infection can remain active indefinitely,” and “remain latent…indefinitely,” but there is no bacteriological evidence of such phenomena (4). Descriptions of the Jarisch-Herxheimer reaction, seen in a minority of Lyme disease cases, are similarly unsubstantiated (5).

Savely’s claim that ELISA diagnosis is only 40-50% sensitive is based on a twenty-year-old article written four years before the Dearborn conference standardized Lyme diagnostics (6). Recent studies found “the sensitivity of 2-tier testing (ELISA and Western blot) for patients with disseminated or persistent Lyme disease was 100%, and the specificity was 99%” (7). Moreover, the FDA has approved 70 serologic assays, while warning about other “inadequately validated” diagnostics (8). Among the unconventional diagnostic methods mentioned by Savely, CD57 cell counts have been discredited (9) and data about C4a complement levels have not been replicated.

Savely’s laundry list of possible Lyme disease symptoms (e.g., tooth pain, hair loss, clumsiness) suggests Lyme disease should be suspected in every patient. Yet, symptoms associated with the three stages of Lyme disease generally are limited and well described (10). Attempts to link Lyme disease with other diseases (e.g., autism, ALS, lupus, Alzheimer’s) are based more on Internet gossip and quackery than evidence-based medicine (1). Readers are encouraged to visit the American Lyme Disease Foundation website for expert-written articles and references debunking such misinformation (www.aldf.com/Misinformation_about_Lyme_Disease.shtml).

Savely claims that there are two standards of care for Lyme disease patients. One is the national, 8,000-member Infectious Diseases Society of America whose treatment guidelines were recently re-reviewed and validated (11). The other is a small group of private practice physicians—many with no training in infectious diseases—whose guidelines were never peer-reviewed (12). Savely is a member of this latter organization, the International Lyme and Associated Diseases Society (ILADS). Standards of care are important, and the use of the ILADS standards apparently compelled Savely to abandon her practice in Texas (13). Now in California, she practices with Raphael Stricker, M.D., a former ILADS president who once was barred from receiving federal funds after he falsified research data (14). Both Stricker and Savely serve as advisors to the California Lyme Disease Association and the New Morgellons Order where they advocate the use of long-term antibiotics for two syndromes of uncertain etiology: chronic Lyme disease (4) and Morgellons (i.e., delusional parasitosis).

Over the last thirty years, Lyme disease has become a contentious issue of public health, public policy, and public hysteria. Good basic and clinical research have helped to guide the first two public issues, but misinformation, rumors, marketing, and money have driven the last issue (15). Clearly, more research is needed, along with better communication about the true nature of Lyme disease.

References

  1. Savely V. Lyme disease: A diagnostic dilemma. Nurse Practitioner, 2010;35(7):44-50.
  2. CDC. Surveillance for Lyme disease—United States, 1992-2006. MMWR, 2010;57(SS10):1-9.
  3. Taft SC, Miller MK, Wright SM. Distribution of borreliae among ticks collected from eastern states. Vector Borne Zoonotic Dis. 2005 Winter;5(4):383-9.
  4. Feder HM, et al. A critical appraisal of "chronic Lyme disease". N Engl J Med. 2007 Oct 4;357(14):1422-30.
  5. Pound MW, May DB. Proposed mechanisms and preventative options of Jarisch-Herxheimer reactions. J Clin Pharm Ther 2005;30:291-5.
  6. CDC. Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. MMWR 1995;44:590--1.
  7. Steere AC, McHugh G, Damle N, and Sikand VK. Prospective study of serologic tests for Lyme disease. Clin. Inf. Dis. 2008;47:188-95.
  8. CDC. Notice to readers: caution regarding testing for Lyme disease. MMWR 2005;54:125.
  9. Marques A, Brown MR, Fleisher TA. Natural killer cell counts are not different between patients with post-Lyme disease syndrome and controls. Clin Vaccine Immunol. 2009 Aug;16(8):1249-50.
  10. Wormser GP, et al. The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin. Inf. Dis. 2006;43:1089–1134.
  11. Lantos MP. Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America. Clinical Infectious Diseases 2010;51:1–5.
  12. O’Connell S. Rapid Response to “Lyme wars.” BMJ http://www.bmj.com/cgi/eletters/335/7626/910#181023; and personal communication from Editorial Director, Future Drugs 9th Aug 2006. Assessed June 22, 2010.
  13. Roser MA. Nurse practitioner said no Austin doctor willing to practice with her. Austin-American Statesman, March 30, 2006. Available at: http://www.standupforlyme.org/getinformed/statesman_20060330.html. Assessed June 22, 2010.
  14. Final Findings of Scientific Misconduct, NIH Guide. Volume 22, Number 23, June 25, 1993. Available at: http://grants.nih.gov/grants/guide/notice-files/not93-177.html. Assessed June 22, 2010.
  15. Whelan D. Lyme Inc. Ticks aren't the only parasites living off patients in borreliosis-prone areas. Forbes. March 12, 2007. Available at: http://members.forbes.com/forbes/2007/0312/096.html. Assessed June 22, 2010.

Words: 560

Edward McSweegan, Ph.D. is a microbiologist and a former Lyme disease program manager at the National Institutes of Health.