Diagnostic challenges of early Lyme disease: Lessons from a community case series

Abstract

BackgroundLyme disease, the most common vector-borne infection in North America, is increasingly reported. When the characteristic rash, erythema migrans, is not recognized and treated, delayed manifestations of disseminated infection may occur. The accuracy of diagnosis and treatment of early Lyme disease in the community is unknown.MethodsA retrospective, consecutive case series of 165 patients presenting for possible early Lyme disease between August 1, 2002 and August 1, 2007 to a community-based Lyme referral practice in Maryland. All patients had acute symptoms of less than or equal to 12 weeks duration. Patients were categorized according to the Centers for Disease Control and Prevention criteria and data were collected on presenting history, physical findings, laboratory serology, prior diagnoses and prior treatments.ResultsThe majority (61%) of patients in this case series were diagnosed with early Lyme disease. Of those diagnosed with early Lyme disease, 13% did not present with erythema migrans; of those not presenting with a rash, 54% had been previously misdiagnosed. Among those with a rash, the diagnosis of erythema migrans was initially missed in 23% of patients whose rash was subsequently confirmed. Of all patients previously misdiagnosed, 41% had received initial antibiotics likely to be ineffective against Lyme disease.ConclusionFor community physicians practicing in high-risk geographic areas, the diagnosis of Lyme disease remains a challenge. Failure to recognize erythema migrans or alternatively, viral-like presentations without a rash, can lead to missed or delayed diagnosis of Lyme disease, ineffective antibiotic treatment, and the potential for late manifestations.

Development of a Multiantigen Panel for Improved Detection of Borrelia burgdorferi Infection in Early Lyme Disease

“…Alternatively, these patients were infected with B. burgdorferi and the laboratory detection of anti-B. burgdorferi antibodies was unsuccessful using the 10-antigen assay and the commercial EIA because titers fell below detection cutoffs, responses were targeted against antigens not included in the assays, or antibody responses were potentially precluded by early treatment with antibiotics (37,44).…”

Enfermedad de Lyme en pediatría: distintas caras, una misma enfermedad. Serie de casos

“…3,12,13 Sin embargo, puede ser necesaria la confirmación serológica en el diagnóstico diferencial de los eritemas anulares y en formas diseminadas. 11,14 Es excepcional que los estudios serológicos sean negativos en las formas tardías.…”

A Review of the Centers for Disease Control and Prevention’s Guidelines for the Clinical Laboratory Diagnosis of Lyme Disease

“…Patients can also be treated empirically, but it is important to keep in mind that antimicrobial therapy may decrease the immune response, leading to false negative serologic test results. 22,23 Additionally, if first-tier (or second-tier) testing is negative, the clinician may want to consider another diagnosis. 1 The 2-tiered testing algorithm has been validated in retrospective and prospective studies.…”