Tuesday, June 3, 2008

I have heard that there are three stages of Lyme disease. What are they?

The first stage of Lyme refers to the classic rash called Erthema Chronic Migrans. A red spot or bump is seen at the site of the tick bite. It gradually increases in size. It is supposed to have a circular or spreading annular appearance. Over time the edges of the rash are bright red and there is central clearing causing what is known as the classic bulls eye rash. The CDC says the rash should be greater than 5 centimeters in diameter to qualify. Let's talk about this point. The CDC admits that this is part of what is called a surveillance definition. They want to make sure all cases are 100% certain to be Lyme disease. The 5cm size is not required for diagnosis, which is different from fulfilling a surveillance case definition, designed for epidemiological research purposes. The IDSA claims that this finding is reliable. That it is seen in 80% of the cases. The ILADS model feels that the characteristic rash is rare. It is not known how frequently it is seen, but it is probably present in less than 30% of cases. The rash may also take many atypical forms. Even when it is present, it is missed by many physicians who are unaware of the various forms the rash may take. Patients who present with stage one can usually be cured easily. Doxycycline or Amoxicillin are the best choices. A course of three to six weeks is generally adequate, although I believe treatment should be continued if the rash is still present. Patients with stage one disease have no other Lyme symptoms. When other symptoms are present it suggests the possibility that the patient was previous infected with Lyme and the new exposure is causing an exacerbation of the illness.

Stage two disease may occur weeks to months after exposure. It is related to spread of the germ to other organs outside the skin. It is still a relatively acute illness at this time. The skin may show similar rashes in areas unrelated to the bite. Patients may have headache, stiff neck, fever, chills, muscle and joint pains, malaise and fatigue. Other symptoms may include eye pain, iritis, swollen glands, sore throat and cough. This constellation of symptoms may be seen as the "summer flu." Patients in this stage may have involvement of the nervous system. Meningitis, usually misdiagnosed as viral meningitis, encephalopathy with confusion, Bell's palsy, and many other neurological syndromes can be present. Patients may develop cardiac abnormalities including problems with electrical conduction in the heart sometimes requiring an emergency pacemaker as well as pericarditis (fluid constriction the heart) and damage to the heart muscle itself.

Stage three is due to longstanding latent infection. It is associated with arthritis and severe neurological problems. These patients are known to have peripheral neuropathy, encephalopathy with cognitive impairments, upper motor neuron disease similar to that seen in MS, with MRI and or SPECT scan changes.

In my experience these differentiations are somewhat arbitrary and not necessarily helpful. Most of the patients I see have some form of stage three disease which I call chronic Lyme disease. The is great deal of overlap between stage two and three. This staging is not very helpful in gauging the duration or kinds of antibiotic therapy that I recommend. I tend to classify Lyme as early and late. Many in ILADS believe that once the infection has been present for some times, especially greater than one year, it tends to become entrenched and more difficult to eradicate. There is a larger number of spirochetes present. And there may be immunosuppressive changes which the infectious has produced making treatment and cure more problematic. Patients frequently ask me how long they have had the infection. This is usually impossible to tell. When the brain issues are advanced the infection has probably been present for years. Certain antibody bands for the Western Blot test, such as the 31 band also indicate long term established infection. Each case is different. Irrespective of how long the infection may have been presents each person handles the infection differently. Some people are fairly easy to cure and others are very difficult.

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