Pat Smith

Lyme disease has been recognized in the United States for more than 40 years, with about 400,000 new cases occurring in 2015, according to the Centers for Disease Control and Prevention (CDC). Nineteen tick-borne diseases now affect Americans, and one tick bite can cause more than one disease. A recent CDC study uncovered that ticks that cause Lyme disease are found in 50% of continental US counties.

 In addition, according to the results of a large Johns Hopkins University study, as many as 36% to 63% of patients with Lyme disease go on to develop chronic symptoms (posttreatment Lyme disease).

Major problems surrounding Lyme disease today include reliance upon dogma, promoting beliefs people are expected to accept without questioning or doubting, and the use of selective science by many in the medical community, the Lyme “experts,” who often blame the patient, the internet, and treating doctors with divergent opinions for their own lack of successful patient outcomes. They continue to approach Lyme with a “cookbook” approach. Patients are told the symptoms are “in their head,” that they need to stop reading the internet, or parents of patients are accused of Munchhausen by proxy syndrome (ie, making their children sick). These experts neither want to understand why their approach does not work, nor do they want to take the necessary time to understand the disease by researching and reading all the science, not just that which supports their unsuccessful treatment approach. Steeped in dogma, they ignore the fact that Lyme is meant to be a clinical diagnosis using testing as an adjunct.

Lyme clinical practice guidelines (CPGs) (eg, Infectious Diseases Society of America [IDSA] guidelines) often used by these physicians to treat Lyme are outdated and not posted on the National Guidelines Clearinghouse (NGC) These guidelines are most often used to deny treatment to patients with chronic disease, and so their current absence from the NGC is beneficial to patients who may need long-term antibiotic therapy and have been denied this through use of these guidelines. The only Lyme CPGs available on the NGC are those adhering to newly revised National Academy of Medicine, formerly Institute of Medicine, standards for guidelines− the International Lyme and Associated Diseases Society (ILADS) Lyme Guidelines,

 which address the usefulness of antibiotic prophylaxis for tick bites, the effectiveness of erythema migrans (EM) treatment, and antibiotics’ role in retreatment of persistent Lyme disease symptoms.

Many physicians solely rely on the two-tiered indirect Lyme tests recommended by the CDC and the outdated guidelines. These recommendations include a positive/equivocal enzyme-linked immunosorbent assay (ELISA) followed by western blot (WB), and the tests that are US Food and Drug Administration (FDA)-cleared (substantially equivalent to a predicate test),

 yet not necessarily approved. To date, the FDA has not been able to provide Lyme Disease Association, Inc., with any information on any FDA-approved test for Lyme, including the original predicate test.  According to research in 

 the two-tiered system, although very specific for Lyme disease (99%)—yielding few false-positives&mdash;has a uniformly low sensitivity (56%), missing 88 of 200 patients with Lyme. The current archaic Lyme tests remain unreliable decades later. By comparison, AIDS tests have a sensitivity of 99.5%, missing only one of 200 infected patients.

 Additionally, there is no test for active Lyme disease infection, and test interpretation, especially the use of specific bands in the WB (IgM 2/3; IgG 5/10), developed at the 1994 CDC/Association of State and Territorial Public Health Laboratory Directors Dearborn meeting,

 is problematic. Some doctors and researchers believe those bands were selected only to protect the then-in-development Lyme disease vaccine (subsequently licensed and withdrawn over 4 years). Furthermore, the Lyme ELISA used for screening may not react with serum antibodies if at least a month has not elapsed between the tick bite and the test. If antibodies do develop, research in the 

Journal of the American Medical Association

 has shown that the antigen and the antibody produced by the patient can form a complex. Current commercial tests can only test for a free antibody, not an antibody in a complex, so patients can remain undiagnosed despite having produced antibodies.

Perhaps most noteworthy is that FDA-cleared commercial serological tests are based on one strain of 

 bacteria in contrast, for example, to a 2-strain Lyme test developed by one independent Clinical Laboratory Improvement Amendments-approved lab.  The recent discovery by Mayo Clinic/CDC of the 

 species in the Midwest, which can also cause Lyme, and the acknowledgement that 

, a spirochete closely related to the relapsing fever bacteria and more distantly related to the Lyme bacteria, causes a Lyme-like disease in the United States, means 

 ticks transmit all three of those bacteria, further clouding the diagnostic picture.

There has been considerable research over the past several years supporting the existence of chronic Lyme, including the discovery at Northeastern University that persister cells are formed by 

 These cells go dormant when treated with antibiotics, but can grow again after treatment stops. Persisters are found in other diseases as well. Work at Johns Hopkins has also been done on persisters: research in 

 “…identified 165 agents approved for use in other disease conditions that had more activity than doxycycline and amoxicillin against 

 persisters. The top 27 drug candidates from the 165 hits were confirmed to have higher persister activity than the current frontline antibiotics.” Additionally, work on biofilms in Lyme, by researchers from the University of New Haven, and published in 

European Journal of Microbiology & Immunology

 demonstrated for the first time “…the presence of 

 biofilm in human infected skin tissue.”

The results of several animal studies have shown that the Lyme spirochete survives antibiotic treatment for Lyme disease, including a University of California mouse study,

 and a National Institutes of Health human xenodiagnosis study.

As new research continues to unlock persistence mechanisms used by 

, the medical community needs to avail itself of those scientific findings by attending continuing medical education conferences and grand rounds and partaking in preceptorships that foster divergent views. The medical community needs to support further research on why some individuals remain sick. It is imperative that healthcare professionals learn how to change that outcome rather than relying on outdated methodologies that have not benefited patient health.

Patricia Smith (Pat), President of the Lyme Disease Association, Inc., graduated from Monmouth University. She has been involved with Lyme disease issues for 33 years and is a Member of the Columbia Lyme & Tick-Borne Diseases Research Center Advisory Committee, the Congressionally Directed Medical Research Programmatic Panel on Tick-Borne Diseases, and the Environmental Protection Agency Pesticide Environmental Stewardship Program. She has twice testified before US House Subcommittees on Lyme and is former Chair of the NJ Governor’s Lyme Disease Advisory Council. She has published on and been interviewed for broadcast, electronic, and print media on Lyme and tick-borne diseases.

Eisen RJ, Eisen L, Beard, CB. County-scale distribution of Ixodes scapularis and Ixodes pacificus (Acari: Ixodidae) in the continental United States. 

Adrion ER, Aucott J, Lemke KW, Weiner JP. Health care costs, utilization and patterns of care following Lyme disease. 

. 2015;10(2):e0116767. doi:10.1371/journal.pone.0116767. 

Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. 

FDA moves to regulate all Lyme tests. Lyme Disease Association website. www.lymediseaseassociation.org/govt/govt-agencies-a-policy/hhs-food-drug-administration-fda/1344-fda-moves-to-regulate-all-lyme-tests-sp-1259648730. Published Jan 12, 2015. Accessed May 2017. 

Stricker RB, Johnson L. Lyme wars: let’s tackle the testing. 

Lyme Disease Association. Conflicts of interest in Lyme disease: laboratory testing, vaccination, and treatment guidelines. LDA website. www.lymediseaseassociation.org/images/pdf/ConflictReport.pdf. Published 2001. Accessed May 2017. 

Schutzer SE, Coyle PK, Reid P, Holland B. Borrelia burgdorferi—specific immune complexes in acute Lyme disease. 

Sharma B, Brown AV, Matluck NE, Hu LT, Lewis K. Borrelia burgdorferi, the causative agent of Lyme disease, forms drug-tolerant persister cells. 

Feng J,Wang T, Shi, W, et al. Identification of novel activity against Borrelia burgdorferi persisters using an FDA approved drug library. 

Sapi E, Balasubramanian K, Poruri A, Maghsoudlou JS, et al. Evidence of in vivo existence of Borrelia biofilm in Borrelial lymphocytomas. 

Hodzic E, Feng S, Holden K, Freet KJ, Barthold SW. Persistence of Borrelia burgdorferi following antibiotic treatment in mice. 

Embers ME, Barthold SW, Borda JT, et al. Correction: persistence of Borrelia burgdorferi in rhesus macaques following antibiotic treatment of disseminated infection. 

Straubinger RK, Straubinger AF, Summers BA, Jacobson RH. Status of Borrelia burgdorferi infection after antibiotic treatment and the effects of corticosteroids: an experimental study. 

Marques A, Telford SR 3rd, Turk SP, et al. Xenodiagnosis to detect Borrelia burgdorferi infection: a first-in-human study. 

Articles

Lyme Disease Association President, Pat Smith, takes on the major problems surrounding Lyme disease today.