Probable late lyme disease: a variant manifestation of untreated Borrelia burgdorferi infection

Abstract

Background: Lyme disease, a bacterial infection with the tick-borne spirochete Borrelia burgdorferi, can cause early and late manifestations. The category of probable Lyme disease was recently added to the CDC surveillance case definition to describe patients with serologic evidence of exposure and physician-diagnosed disease in the absence of objective signs. We present a retrospective case series of 13 untreated patients with persistent symptoms of greater than 12 weeks duration who meet these criteria and suggest a label of 'probable late Lyme disease' for this presentation.

Methods: The sample for this analysis draws from a retrospective chart review of consecutive, adult patients presenting between August 2002 and August 2007 to the author (JA), an infectious disease specialist. Patients were included in the analysis if their current illness had lasted greater than or equal to 12 weeks duration at the time of evaluation.

Results: Probable late Lyme patients with positive IgG serology but no history of previous physician-documented Lyme disease or appropriate Lyme treatment were found to represent 6% of our heterogeneous sample presenting with ≥ 12 weeks of symptom duration. Patients experienced a range of symptoms including fatigue, widespread pain, and cognitive complaints. Approximately one-third of this subset reported a patient-observed rash at illness onset, with a similar proportion having been exposed to non-recommended antibiotics or glucocorticosteroid treatment for their initial disease. A clinically significant response to antibiotics treatment was noted in the majority of patients with probable late Lyme disease, although post-treatment symptom recurrence was common.

Conclusions: We suggest that patients with probable late Lyme disease share features with both confirmed late Lyme disease and post-treatment Lyme disease syndrome. Physicians should consider the recent inclusion of probable Lyme disease in the CDC Lyme disease surveillance criteria when evaluating patients, especially in patients with a history suggestive of misdiagnosed or inadequately treated early Lyme disease. Further studies are warranted to delineate later manifestations of Lyme disease and to quantify treatment benefit in this population.

Figure 1

Categorization of patients presenting for evaluation of Lyme disease with symptoms ≥ 12 weeks duration (n = 235).

Figure 2

Untreated skin lesion in patient number 1. Because of the small size, lack of enlargement and lack of symptoms the lesion was not felt to be consistent with erythema migrans. The patient noted onset of symptoms 10 weeks later with olecranon bursitis.

Figure 3

Percent male in each disease group (n = 235).

Figure 4

Box plots of the number of reactive IgG bands on commercially available serologic tests for antibodies toBorrelia burgdorferiby disease group (n = 235).