Lyme Disease: Accurate Diagnosis is Essential

Summary
In North America, the number one disease transmitted via an organism is Lyme disease, which affects multiple body systems. If not diagnosed early, the infection spreads from the location of the tick bite on the skin to other parts of the body and becomes harder to treat. This study examined the diagnostic tests, diagnosis, treatment and their accuracy in 165 cases. Some patients either lacked the expected rash, or had a deceptively mild rash, resulting in a wrong diagnosis. The study shows that early diagnosis of Lyme disease is tricky, and the symptoms are often mistaken for viral infection, resulting in an erroneous and delayed treatment strategy.

Introduction
Lyme disease is caused by a spiral bacterium ‘Borrelia burgdorferi sensu stricto,’ and spreads via a tick bite. Positive indicators for the disease are a rash and blood test results, although a percentage of patients does not test positive for either, or both in the early stages. Delay in diagnosis results in the infection spreading to the heart, joints, nervous system and other areas from the skin through the blood. The Centers for Disease Control and Prevention (CDC) has standardized the criteria for diagnosing Lyme disease, but they depend on correct identification of the rash, which is challenging. Wrong treatment can affect recovery.

Methods
* Records of 165 patients who came to an internist trained to detect Lyme disease in Baltimore, between 2002 and 2007, were analyzed.
* A standardized form was used to document the medical history, physical examination, neurological involvement, blood biochemistry and previous and recommended medicinal treatments of each patient.
* The information was grouped into ”confirmed,” ”probable” or ”alternative acute illness” according to the presence or absence of rash, blood test results, symptoms like meningitis, palpitations, or non-specific viral-disease-like symptoms.

Results
* The review found that 101 of 165 patients were detected with ”confirmed” or ”probable” Lyme disease, and 64 had other acute illnesses. Eighty-eight of 101 had the rash. The remaining 13 tested positive on blood tests, and neural and heart-related symptoms.
* Of the 88, seven were not diagnosed with the rash at first, and in 13 cases, the rash was wrongly identified. Fourteen of these 20 showed positive blood test results.
* Of the 13 with no rash, seven were misdiagnosed, and 11 were given the wrong antibiotic treatment.

Shortcomings / Next steps
Tools commonly used during research (DNA amplification, cell cultures) are not used by clinicians in the field. This hampers correct analysis in ”probable” or ”suspected” cases. The patient population was exclusively from Maryland. Other areas may vary in the understanding of Lyme disease affecting the number of patients referred and co-infections. More accurate detection techniques need to be developed.

Conclusion
Attention needs to be focused on three points: accurate rash identification, identification of Lyme disease cases with viral-like symptoms and no rash, and correct choice of drug treatment in areas at high-risk for Lyme disease. Antibiotics that work against Lyme as well as other diseases should be prescribed. Physicians working in high-risk areas for Lyme disease need to be highly experienced to arrive at an accurate diagnosis. In spite of experience, there is a high chance of missing some cases. Lyme disease expresses itself through a variety of symptoms, increasing the chances of wrong diagnosis and treatment that can be harmful later on. Criteria for clinical diagnosis need to include research tools and techniques that are absent in high-risk medical centers today.

For More Information:
Diagnostic Challenges of Early Lyme Disease: Lessons from a Community Case Series
Publication Journal: BMC Infectious Diseases, June 2009
By John Aucott; Candis Morrison; Johns Hopkins School of Medicine, Baltimore, Maryland and Lyme Disease Research Foundation of Maryland, Lutherville, Maryland
*FYI Living Lab Reports Are Summaries of the Original Research.

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