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The News Times

Greater DAnbury News and Information

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Jun 04 2006 9:03 AM

Pesky Lyme disease hangs on

Medical professionals disagree on treatment

By

THE NEWS-TIMES

If you get bitten by a black-legged tick, what's your

next move?

If you start showing symptoms of Lyme disease, one

school of

treatment argues you should take at least two months

of antibiotics

for the simplest case and much more for complicated

ones.

You can also expect the tick to be carrying more than

the strain of

bacteria that causes the disease.

Dr. Horowitz of Hyde Park, N.Y.,

president-elect of the

International Lyme and Associated Diseases Society

(ILADS),

said " 99.9 percent of the patients I see with Lyme

disease are co-

infected. There are 10 other diseases we should be

looking for. "

Horowitz spoke last week at a forum held by the

Newtown Lyme Disease

Task Force.

The second school of thought would argue that the

longest you should

ever take antibiotics is 28 days - even if you've got

the painful

arthritis that's a symptom of Lyme.

It also questions whether there's a condition called

chronic Lyme

disease - a persistent infection that can last for

years - and

discounts the threat of omnipresent co-infection.

" The evidence does not support that - far from it, "

said Dr.

Wormser, chief of the infectious diseases division at

New York

Medical College in Valhalla, N.Y., and vice-chairman

of its

department of medicine.

The differences between the two approaches and the

implications for

the way patients are treated for Lyme disease are

profound. And this

comes at a time of increasing threat from the disease.

Lyme disease is at the epidemic stage in the state.

There were 1,810

cases reported to the state Department of Public

Health in 2005,

compared to 1,348 in 2004 - a 26 percent increase.

Connecticut has the highest per capita rate of Lyme

disease in the

country with about 136 cases per 100,000 people.

But by all accounts, the disease is underreported by a

factor of 10

or more.

" The Centers for Disease Control and Prevention

reported there were

19,804 cases (nationwide) of Lyme disease in 2004, "

said Pat ,

president of the Lyme Disease Association, a patient

advocacy group,

who also spoke at the Task Force meeting.

" That means there were about 200,000 cases, and that

doesn't count

the ones that don't fit the CDC requirements. "

Lyme disease is caused by a cork-screw-shaped

bacteria, Borrelia

burgdorferi. The black-legged tick - also known as the

deer tick -

ingests the bacteria when it feeds on deer,

white-footed mice and

small rodents, which act as sort of moveable

reservoirs of Borrelia.

When an infected tick bites a human, the human can get

infected as

well.

The initial symptoms of the disease can include a

bull's-eye rash,

fever, headache and sore joints - like a case of the

flu without a

cough. If the disease is diagnosed early, it can

usually be treated

successfully with a month of antibiotics.

" We've found there's a six-week window where treatment

is really

successful, " said Forschner, executive director

of the Lyme

Disease Foundation based in Tolland, Conn.

But only about half the people infected by a tick bite

get the

telltale rash. Some have no symptoms at all. Others

are treated with

antibiotics, but relapse. They can develop much more

severe symptoms,

including swollen joints.

But because the most common blood tests for Lyme

disease are highly

inaccurate, doctors who rely on them can easily

misdiagnose or

disregard the symptoms. The CDC says doctors should

not base a

diagnosis on those tests but on clinical observations.

" You only use the blood tests to support your

diagnosis, " said

Horowitz of ILADS, whose members are often doctors

whose practices

are devoted to treating the disease.

What's most controversial is the diagnosis of chronic

Lyme disease.

Doctors in the ILADS and patient advocates like

insist that

people can develop long-term, recurring Lyme

infections that can

manifest themselves in a host of symptoms - chronic

fatigue, sight

and hearing loss, memory loss, depression and

personality changes,

heart damage and arthritic pain that can flare up in

different

places.

" It's a multi-system bacterial infection, " Horowitz

said at the

Newtown Lyme Task Force meeting. " There are 300

different strains of

Borrelia burgdorferi internationally and 100 in the

United States.

The symptoms can come and go and they can migrate.

It's a gestalt of

symptoms. "

Doctors who are convinced chronic Lyme disease exists

treat those

patients with long-term courses of antibiotics, often

lasting months

or years. The ILADS criteria do not limit how long

patients should be

on antibiotics, leaving that up to the doctors'

discretion.

Horowitz said his rule of thumb is to continue

antibiotics until a

patient is symptom-free for two months.

Horowitz also said ticks carry several other

illnesses, including

anaplasmosis, the malaria-like babesiosis, and

bartonella, commonly

known as Cat Scratch fever. All of these come with

their own set of

symptoms, which must be treated as well. This means

patients must get

a mix of antibiotics.

" When I see a patient with chronic Lyme disease, I see

a patient with

chronic Lyme and co-infection, " he said.

But Wormser of New York Medical College follows the

guidelines of the

Infectious Diseases Society, or IDSA. He said there's

no evidence for

so much co-infection in Lyme patients. IDSA also says

there's no

scientific proof for a diagnosis of chronic Lyme

disease, and thus no

need whatsoever for long-term antibiotic therapy.

" Study after study has shown this, " he said. They've

tested patients

who claim they have chronic Lyme disease. Half never

had Lyme disease

to begin with.

" Another study at Yale showed that half the people

being treated for

chronic Lyme actually had other treatable diseases, "

Wormser said.

Wormser co-authored the IDSA Lyme disease guidelines.

The society

represents about 8,000 infectious disease specialists

in the United

States.

The society is now rewriting those guidelines. Wormser

said he does

not expect them to be substantially different than

they are now .

But proponents of more liberal use of antibiotics to

treat Lyme said

last week that they expect, if anything, the new IDSA

guidelines will

be even more conservative than they are now.

" It doesn't make any sense, " said Forschner of the

Lyme Disease

Foundation about any reduction in the IDSA guidelines,

which now

allow 14 to 28 days of antibiotic treatment. " What

difference does a

little bit more of antibiotics make? "

Forschner said the scientific literature does not

support long-term

antibiotic therapy for early Lyme disease, which some

doctors now

prescribe.

" I think the new IDSA guidelines are in reaction to

that. But why

swing the pendulum so far in the other direction? "

Forschner said.

There is one substantial change to the IDSA

guidelines, Wormser said.

It will advise doctors that, on a selective basis,

they can prescribe

a single large dose of antibiotics to a patient

immediately after a

black-legged tick bite, before the patient starts

exhibiting any

symptoms of the disease.

A 2001 study in the New England Journal of Medicine

showed that such

treatment, given within three days of a deer tick

bite, was 87

percent effective in stopping the disease in its

tracks.

of the Lyme Disease Association said what her

group would like

is for doctors to tell patients with Lyme disease that

there are two

established standards of care - the conservative one

endorsed by the

infectious diseases association, and the liberal one

written by the

International Lyme and Associated Diseases Society.

Then, at the very least, she said, patients would know

the

options. " We need to make sure the patients are aware

of this. "

praised a bill in the U.S. Congress sponsored by

Sen.

Dodd, D-Conn., and Sen. Rick Santorum,

R-Pa., that would

provide an additional $100 million in federal funding

for Lyme

research over the next five years.

said the federal government currently spends

about $32 million

a year for research on the disease and all its

manifestations.

" Another $20 million a year will be a significant

increase, " she

said.

The funding is also tied to specific goals, including

finding a

reliable blood test for Lyme infection.

" It took researchers five or six years to find a

reliable blood test

for AIDS, " she said. " We've know about Lyme disease

for 30 years and

we still don't have a reliable blood test. That's

outrageous. "

Contact

at bmiller@...

or at (203) 731-3345.

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