Outside of the vaccine debate, few medical topics can get people riled up like Lyme disease. In fact, the term “Lyme wars” is often used to describe the debate about the diagnosis and treatment of this tick-borne disease. The bad news is that this debate probably isn’t going away anytime soon. The good news is that The American Academy of Neurology, Infectious Diseases Society of America, and American College of Rheumatology have introduced new draft guidelines in an effort to reduce some of this conflict and make treatment decisions easier for those on the front lines.
Prevention of Lyme Disease
Beginning with prevention, the new guidelines address how to handle a “high-risk” tick bite, which must:
- Be from an Ixodes tick
- Occur in a highly endemic area
- Come from an engorged tick attached for 36 hours or more.
If these three requirements are met, a single dose of oral doxycycline should be administered within the first 72 hours after tick removal. If the bite does not satisfy the requirements of a high-risk bite, the guidelines recommend against prophylactic antibiotics.
Diagnosis of Lyme Disease
Because so many of the neurological symptoms associated with Lyme disease are non-specific, diagnosis of Lyme can be quite complicated. According to the draft guidelines, certain conditions are more suggestive of Lyme, and when combined with a reasonable exposure to high-risk ticks warrant Lyme testing. These include:
- Mononeuropathy multiplex, and
- Acute cranial nerve neuropathies.
However, Lyme testing is not recommended for other neurological or psychiatric conditions, including developmental, behavioral or psychiatric disorders in children.
Treatment of Lyme Disease and Post-Lyme Disease Syndrome
Appropriate treatment of erythema migrans is one of the less controversial aspects of the Lyme wars, and the guidelines recommend a ten-day course of doxycycline, or a 14-day course of amoxicillin, cefuroxime, or phenoxymethylpenicillin when the characteristic rash appears.
Post-Lyme disease syndrome is where the Lyme Wars truly rage on, and the draft guidelines do address this concern.They do not recommend additional antibiotics when symptoms persist or nonspecific symptoms arise after appropriate treatment for Lyme disease. Particularly when there is no evidence of reinfection or treatment failure, additional antibiotic treatment does not appear to provide benefit. Further, the guidelines offer direction for evaluating patients in this circumstance, as other issues may be responsible for the symptoms.
Moving Forward: Lyme Disease Research Needs
The Lyme wars won’t be coming to an end because of the new draft guidelines. The guidelines call for further research into “poorly understood symptom complexes that lack a unifying medical diagnosis.” Until we have high-quality research into these issues that are commonly lumped into the “chronic Lyme disease” category, the war will rage on.
In the meantime, the 2019 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease are available for in-depth review. Public commentary is open until August 10, 2019. Since neurologists are on the front lines of the “Lyme wars” their input is critical.