Peter L. Salgo, MD: Let’s progress right on, then. What are the symptoms? If we’re going to make the diagnosis, whether it’s correct or not, we’re going to test for it. Clearly, something is going to trigger you to go looking for this. What are the symptoms associated with the initial acute Lyme disease?
Samuel Shor, MD, FACP: The initial acute presentation is a flu-like illness that occurs within 3 days to 3 weeks of the tick bite. That may or may not involve a rash. Most people think of a bullseye erythema-migrans rash but, in some studies, on average, 50% of people did not develop that rash.
Peter L. Salgo, MD: So, good luck using that as an absolute marker.
Samuel Shor, MD, FACP: Right, and the majority of people with bona fide Lyme disease don’t remember a tick bite, so it’s a challenge in that respect as well. There’s a seasonality to it, such that the time between April, May, and September is the peak of the tick nymph feeding, and that’s when it’s most common to develop this flu-like illness—sore throat, low-grade fever, and muscle aching. Without treatment, it will resolve on its own. The problem with that is that it can then result in more chronic manifestations that are well recognized.
Peter L. Salgo, MD: We’re going to go on to talk about that as well.
Leonard Sigal, MD: The term “chronic” is often used and, perhaps, sometimes misused. There are later manifestations of Lyme disease that are not necessarily chronic. There are chronic manifestations of illness that are a matter of debate, and I’m sure we’ll return to that in a moment.
Peter L. Salgo, MD: But is that syntax or is that medicine?
Leonard Sigal, MD: Well, “later” means it follows the tick bite, possibly when the erythema-migrans, if they’re infected, happens. So, the classic description of Lyme disease—and a lot of people have difficulties with this—is that there’s early disease and then there’s late disease. And the term “late” was what was originally used to describe cardiac disease, neurologic disease, and musculoskeletal manifestations, which don’t necessarily persist—which would be chronic. They occur later. So, I think there’s less of a value added to it.
Peter L. Salgo, MD: I think the syntax makes a difference, and I do want to get into it, because if what you mean by chronic is that there’s persistent infection, that needs to be treated. If it’s late, which are not necessarily active infections but some sort of immunologic response, that’s different as well.
Robert C. Bransfield, MD, DLFAPA: Well, there’s a distinction between chronic infection and chronic symptoms. And, in most diseases, chronicity usually means after 6 months—if something is there for 6 months. That’s the way a lot of diseases are categorized.
Peter L. Salgo, MD: And what are the psychological issues here?
Robert C. Bransfield, MD, DLFAPA: Well, the more common things, or the earlier symptoms, are an increase of milder cognitive impairments, slow processing, hypersensitivity to sound and light, and then, executive functioning problems. And then you can see depression, anxiety, and sleep disorders. You can see suicidal risk, and you can see much more extreme things. Now, you’re looking at things that evolve years after the infection. So, this is the later stage manifestation of the disease, and that’s usually in the people who I see, people who are 10 years out.
Samuel Shor, MD, FACP: I’d like to make a comment with respect to chronic active infection. I published a paper in 2011, whereby I believe I provided clinical evidence that was statistically significant. The majority of my patients—209 patients who had blood tests that were negative for Borrelia, but who presented with the international case definition of chronic fatigue syndrome and other markers that were suggestive of infection—were treated with antimicrobials, and 62% improved to a statistically significant degree to a P value of .0002.
Peter L. Salgo, MD: I want to get to that.