Chronic Lyme disease: psychogenic fantasy or somatic infection? (Correspondence).

Sigal and Hassett published an article about Lyme disease in the EHP Supplements (Sigal and Hassett 2002), suggesting that chronic Lyme disease is "psychogenic." I do not think that Sigal and Hassett, nonpsychiatrists, are qualified to speak about psychiatric matters. I, however, actually have had the disease, which they characterize as "medically unexplained," for over 25 years and have 15 years of experience as a patient advocate and educator. I beg to differ.

Many reports in the peer-reviewed medical literature substantiate the notion of persistent infection. Borrelia burgdorferi, the causative organism, has been cultured after "adequate" antibiotic therapy from the brain, eye, heart, spleen, spinal fluid, skin, lymph nodes, joints, and synovial fluid (Cimmino et al. 1989; Cimperman et al. 1996; Haupl et al. 1993; Liegner et al. 1992; Oksi et al. 1996; Patmas 1994; Peter et al. 1993; Pfister et al. 1991; Preac Mursic et al. 1993; Reimers et al. 1993; Schmidli et al. 1988). Table 1 provides information on some of the articles supporting persistent infection. A more complete listing of Lyme disease abstracts may be obtained from the Lyme Disease Network (2002).

I and the many other Lyme patients I know are neither "confused" nor "insecure." We did not seek a "societally and morally acceptable explanation" (Sigal and Hassett 2002) for our illness; we sought a scientific and medical explanation. We have been fortunate enough to find informed doctors to treat us with long-term antibiotics and to return to our normal activities. In my experience, patients with Lyme disease who are treated for psychogenic illnesses alone do not fare well.

Table 1. Available information of Lyme disease.

Reference                   Summary

Battafarano et al. 1993     "A patient had chronic septic Lyme
                            arthritis of the knee for 7 years,
                            despite multiple antibiotic trials and
                            multiple arthroscopic and open
                            synovectomies. Spirochetes were
                            documented in synovium and synovial
                            fluid."
Cimmino et al. 1989         "G-penicillin treatment was ineffect-
                            ive.... Borrelia-like spirochetes were
                            identified histologically in the
                            spleen."
Georgilis et al. 1992       "Fibroblasts protected B. burgdorferi
                            for at least 14 days of exposure to
                            ceftriaxone." Other cell types also
                            protected B. burgdorferi, contributing
                            to its long-term survival.
Haupl et al. 1993           The patient had relapsing Lyme
                            borreliosis with choroiditis,
                            arthritis, carditis, and tendinitis.
                            Repeated antibiotic treatment was
                            necessary to stop the progression of
                            disease but did not completely
                            eliminate B. burgdorferi from all
                            sites of infection. Viable B.
                            burgdorferi was cultured from a
                            ligament sample obtained surgically.
Liegner et al. 1992         Paired CSF and serum tests for anti-
                            bodies to B. burgdorferi and PCR for B.
                            burgdorferi-specific oligonucleotides
                            in CSF were negative. Eleven months
                            later, after treatment with cefotaxime
                            and minocycline, a T-cell stimulation
                            test with B. burgdorferi antigens was
                            strongly positive. A year later, paired
                            serum and CSF samples were strongly
                            positive for antibodies to B. burgdor-
                            feri and CSF was culture positive.
Liegner et al. 1993         Patient was ELISA-negative after
                            treatment, but blood was PCR-positive
                            and B. burgdorferi-compatible structure
                            was visualized in skin biopsy. Further
                            treatment resolved erythema migrans.
Montgomery et al. 1993      "The macrophage is a known reservoir
                            for a number of infectious agents, and
                            is therefore a likely candidate site
                            for persistence of Borrelia burgdor-
                            feri.... Although the large majority of
                            spirochetes within a given cell were
                            dead, we saw occasional live ones ...
                            and can reculture [them]."
Oksi et al. 1999            One patient had been treated for 47
                            weeks, including 7 weeks of intravenous
                            ceftriaxone; primary diagnosis was
                            confirmed by positive biopsy and the
                            relapse 44 weeks after treatment
                            confirmed by a positive plasma PCR.
                            One patient had relapse 130 weeks after
                            16 weeks of treatment. The patient was
                            seropositive initially but seronegative
                            at relapse. Relapse was confirmed by
                            positive PCR, and there was no history
                            of reinfection.
Preac Mursic et al. 1996    Persistence of B. burgdorferi s.I. and
                            clinical recurrences occur in patients
                            despite antibiotic treatment. Culture
                            confirmed relapses after 12-14 days of
                            treatment courses in five patients.
Straubinger et al. 1997     "Treatment with high doses of
                            amoxicillin or doxycycline for 30 days
                            diminished but failed to eliminate
                            persistent infection." Antibody titers
                            fell, but 6 months after antibiotic
                            treatment was discontinued, "antibody
                            levels began to rise again, presumably
                            in response to proliferation of the
                            surviving pool of spirochetes."

Abbreviations: CSF, cerebrospinal fluid; PCR, polymerase chain
reaction.

Phyllis Mervine
Lyme Disease Resource Center
Ukiah, California
E-mail: [e-mail]

REFERENCES

Battafarano DF, Combs JA, Enzenauer RJ, Fitzpatrick JE. 1993. Chronic septic arthritis caused by Borrelia burgdorferi. Clin Orthop 297:238-241.

Cimmino MA, Azzolini A, Tobia F, Pesce CM. 1989. Spirochetes in the spleen of a patient with chronic Lyme disease. Am J Clin Pathol 91(1):95-97.

Cimperman J, Strle F, Maraspin V, Lotric S, Ruzic Sabljic E, et al. 1996. Repeated isolation of Borrelia burgdorfefi from cerebrospinal fluid of two patients treated for Lyme neuroborreliosis. Presented at the Seventh International Conference on Lyme Borreliosis, 16-19 June 1996, San Francisco, CA.

Georgilis K, Peacocke M, Klempner MS. 1992. Fibroblasts protect the Lyme disease spirochete, Borrelia burgdorferi from ceftriaxone in vitro. J Infect Dis 166:440-444.

Haupl T, Hahn G, Rittig M, Krause A, Schoerner C, Schonnherr U, et al. 1993. Persistence of Borrelia burgdorferi in ligamentous tissue from a patient with chronic Lyme borreliosis. Arthritis Rheum 36:1621-1626.

Liegner KB, Rosenkilde CE, Campbell GL, Guam TJ, Dennis DT. 1992. Culture-confirmed treatment failure of cefotaxime and minocycline in a case of Lyme meningoencephalomyelitis. Presented at the Fifth International Conference on Lyme Borreliosis, 30 May-2 June 1992, Arlington, VA.

Liegner KB, Shapiro JR, Ramsay D, Halperin A J, Hogrefe W, Kong L. 1993. Recurrent erythema migrans despite extended antibiotic treatment with minocycline in a patient with persisting Borrelia burgdorferi infection. J Am Acad Dermatol 28:312-314.

Lyme Disease Network. 2002. Available: http://www.lymenet.org/ [accessed 2 January 2003].

Montgomery RR, Nathanson MH, Malawista SE. 1993. The fate of Borrelia burgdorferi, the agent for Lyme disease, in mouse macrophages: destruction, survival, recovery. J Immunol 150(3):909-915.

Oksi J, Kalimo H, Marttila R J, Marjamaki M, Sonninen P, Nikoskelainen J, et al. 1996. Inflammatory brain changes in Lyme borreliosis. A report on three patients and review of literature. Brain 119(Pt 6):2143-2154.

Oksi J, Marjamaki M, Nikoskelainen J, Viljanen MK. 1999. Borrelia burgdorferi detected by culture and PCR in clinical relapse of disseminated Lyme borreliosis. Ann Med 31 (3):225-232.

Patmas MA. Persistence of Borrelia burgdorferi despite antibiotic treatment. 1994. J Spiro Tick Diseases 1:101.

Peter O, Bretz AG, Zenhausern R, Roten H, Roulet E. 1993. Isolation of Borrelia burgdorferi in the cerebrospinal fluid of 3 children with neurological involvement. Schweiz Med Wochenschr 123(1-2):14-19.

Pfister HW, Preac Mursic V, Wilske B, Schielke E, Sorgel F, Einhaupl KM. 1991. Randomized comparison of ceftriaxone and cefotaxime in Lyme neuroborreliosis. J Infect Dis 163(2):311-318.

Preac Mursic V, Marget W, Busch U, Pleterski Rigler D, Hagl S. 1996. Kill kinetics of Borrelia burgdorferi and bacterial findings in relation to the treatment of Lyme borreliosis. Infection 24(1):9-16.

Preac Mursic V, Pfister HW, Spiegel H, Burk R, Wilske B, Reinhardt S, et al. 1993. First isolation of Borrelia burgdorferi from an iris biopsy. J Clin Neuroophthalmol 13(3):155-161.

Reimers CD, de Koning J, Neubert U, Preac Mursic V, Koster JG, Muller Felber W, et al. 1993. Borrelia burgdorferi myositis: report of eight patients. J Neurol 240(5):278-283.

Schmidli J, Hunziker T, Moesli P, Schaad UB. 1988. Cultivation of Borrelia burgdorferi from joint fluid three months after treatment of facial palsy due to Lyme borreliosis [Letter] J Infect Dis 158(4):905-906.

Sigal LH, Hassett AL. 2002. Contributions of societal and geographical environments to "chronic Lyme disease": the psychopathogenesis and aporology of a new "medically unexplained symptoms" syndrome. Environ Health Perspect 110(suppl 4):607-611.

Straubinger RK, Summers BA, Chang YF, Appel MJ. 1997. Persistence of Borrelia burgdorferi in experimentally infected dogs after antibiotic treatment. J Clin Microbiol 35(1):111-116.