Lyme Disease Practice and Research

• Page 1
• Page 2
• Page 3
• Page 4
• Page 5
• Page 6
• Page 7
• Page 8
• Page 9

The included 100 adolescents and adults who were treated in a community-based setting from July 1997 to January 2000. This is the largest case-controlled study to examine subjects confirmed by the CDC’s recommended two-tier diagnostic criteria. Subjects who failed initial treatment comprised the case group and subjects who were successfully treated, the control group.

Fifteen of 24 cases (63%) failing treatment received delayed treatment. Treatment delay was more common among cases (58%) than controls (24%, P = 0.002). The delay was also significantly longer for cases than controls (518 ± 851 and 92 ± 362 days, P = 0.001).

The majority (60%) of cases (cases 1, 3–5, 7, 11–15) with delayed treatment conformed to CDC epidemiological standards, presenting with a rash, Bell’s palsy, or arthritis. Five of the cases meeting CDC epidemiological standards had been diagnosed with meniscus tear, oedema, ‘water on the knee’, pericarditis, asthmatic bronchitis, and cellulitis. Four of these cases were told by their doctors they did not have Lyme disease. Two of the five presented with a classic erythema migrans rash. The third had an atypical rash but other symptoms typical of Lyme and a positive Lyme test; the fourth had Bell’s palsy. Another case meeting CDC epidemiological standards, with Bell’s palsy followed by typical symptoms, did not seek medical care. The remaining third of our cases had characteristic clinical presentations confirmed by two-tier serologic criteria did not meet CDC epidemiological case definition. Steroids were prescribed in four of these cases.

Treatment delay was strongly associated with treatment failure for patients with Lyme disease. The average 1.8 years treatment delay were consistent with previous reports of treatment delays spanning 6 weeks to 3 years. Two-thirds of the delays occurred even though patients conformed to the well-defined CDC case definition. An additional third presented with well-described clinical presentations of Lyme disease, including fatigue, memory and concentration problems, irritability and headaches.

The poor outcome after treatment delay supports the hypothesis that treatment delay is a major risk factor for developing chronic Lyme disease. Delayed treatment was identified in 58% of the cases with treatment failure. Failure was more than twice as likely to occur with delayed treatment than with timely treatment (P < 0.002).

The lower failure of 24% in those who received timely treatment underscored the importance of immediate and accurate diagnosis. The study was not intended to determine if a treatment failure resulted from persistent infection or immune mediation. Additional trials were recommended to understand the mechanism for treatment failure. Clinicians were urged to avoid treatment delay to avoid unnecessary suffering and expense. Education programs are recommended to help clinicians recognize and treat Lyme disease at onset.