Borreliose-Gesellschaft e.V.


Issues in the diagnosis and treatment of Lyme disease
Sam Donta

Boston University Medical Center, 650 Albany Street, Boston & Fallmouth, MA 02541, Box 944, U.S.A.

Since the identification of the causative organism more than 30 years ago, there remain questions about the diagnosis and treatment of Lyme Disease. In this presentation, what is known about the disease will be reviewed, and approaches to the successful diagnosis and treatment of Lyme disease described. 

In considering the diagnosis of Lyme disease, one of the major problems is documenting the exis-tence and location of the bacteria. After the initial transfer of the bacteria from the Ixodes tick to the affected individual, the spirochetes spread locally at the site of the bite, but after an initial bacteremic phase that may last for up to 90 days, the organisms can no longer be reliable found in blood, urine, spinal fluid or other body fluids. The bacteria probably are present both in subcutaneous sites and intracellular loci, the latter being essential for persistence and survival of the organism, with the primary locus being the nervous system.  Currently, the use of circulating antibodies directed against specific antigens of the Lyme borrelia are the standard means to diagnose the disease, but specific antibodies do not provide an adequate means of assessing the presence or absence of the organism. What is needed is a more Lyme-specific antigen to provide a more definitive adjunct to the clinical diagnosis. 

As for the treatment of Lyme disease, the earliest phase is generally easily treated.  But it is the later and more chronic form of the disease that is plagued with lack of information, frequently leading to erroneous recommendations about the type and duration of treatments.  Based on currently available information, there is no way to determine whether the spirochetes are present or not present, and whether they are active or inactive.  Hence, often cited recommendations about the duration of treatment, e.g. four weeks is adequate treatment, have no factual basis to support that recommendation, often disregarding the clinical picture, and leading to the conclusion that there is another, perhaps psychosomatic reason, for the continuing symptoms. 
B. burgdorferi is sensitive to various antibiotics, including the penicillins, tetracyclines, and macrolides, but there are a number of mitigating factors that affect the clinical efficacy of these antibiotics, and these factors will be reviewed.  

At present, the diagnosis of Lyme disease is based primarily on the clinical picture. The pathophysiology of the disease remains to be determined, and the basis for the chronic illness needs additional research. Whether there is continuing infection, auto-immunity to residual or persisting antigens, and whether a toxin or other bacterial-associated product(s) are responsible for the symptoms and signs remains to be delineated. The successful treatment of Lyme disease appears to be dependent on the use of specific antibiotics over a sufficient period of time.  Further treatment trials would be helpful in finding the best regimens and duration periods.

Dr. Sam Donta is retired from a long career as an infectious disease specialist. He worked at the University of Iowa where he became a Professor of Medicine and Chief of Infectious Diseases be-fore moving to the University of Connecticut where he was Chief of Infectious Diseases for eleven years. Dr. Donta then moved to Boston University/Boston VA for ten years before his retirement. His basic interests have been in microbial toxins, but he has also been involved in a number of clinical trials. For the last twenty years, he has been interested in Lyme disease, and continues to practice and do research on the topic.  Dr. Donta received his B.S. from Allegheny College, his M.D. from Albert Einstein College of Medicine, did an internship/residency in Internal Medicine at University of Pittsburgh Hospitals.