Paul Auwaerter- Easy to Diagnose, Detect and Treat

20,000 people in the U.S. have Lyme disease

Date: 09/24/2008


Because of its signature bull’s-eye rash, the tick-borne illness is easy to detect and diagnose with blood tests and then treat with antibiotics.

But watch for long-term alternative treatments for so-called “chronic Lyme disease,” especially long-term antibiotics, says Paul Auwaerter, M.D., clinical director of Johns Hopkins infectious diseases. “For patients with persisting symptoms after initial treatment for Lyme disease,” he says, “long-term antibiotics were no better than placebo.”


In the Spotlight on Lyme

As debate swirls, Paul Auwaerter argues against overprescribing antibiotics.

Steve Desiderio, the protein prober.
Illustration by Vladimir Rajevac

Fiery advocacy groups. Sprawling conspiracy theories. Over a thousand emotional videos on YouTube, nearly all challenging the official guidelines laid down two years ago for the treatment of Lyme disease.

The conflict? The guidelines from the 8,000-member-strong Infectious Diseases Society of America (IDSA) say Lyme disease is relatively easy to detect and treat, and that antibiotics should generally be used for no longer than one month. Not so, the opponents say, insisting there’s an emerging phenomenon they call “Chronic Lyme Disease” that causes fatigue, muscle pain, poor sleep, and memory problems requiring much longer courses of drugs that could take years.

Enter Paul Auwaerter, clinical director of infectious diseases here, who has taken to the dais at national meetings for two years in a row for live debates about Lyme. With the tick-borne illness currently afflicting nearly 20,000 people in the U.S.—and with many more claiming to have it despite the absence of its defining pathogen—we asked Auwaerter to explain the issues surrounding the controversy.

How do you currently define the Lyme condition?

The operative bug is a spirochete called Borrelia burgdorferi. It’s typically introduced by a tick’s bite, and most commonly produces the well-known rash that in some has a bull’s-eye appearance. The rash, called erythema migrans, is often accompanied by fever, malaise, headache, and musculoskeletal pains. If untreated, the infection may go on to cause heart block, chronic arthritis, and occasionally neurological complications.

How do you confirm a diagnosis?

The rash remains the best marker for Lyme disease and standard Lyme blood tests are frequently negative in this stage of the infection. Physicians must therefore suspect Lyme disease and consider the diagnosis based on the rash. If there is uncertainty, checking a Lyme blood test four to six weeks after the rash is a good idea. For problems occurring weeks or months after the initial infection, we depend on serological tests that analyze blood samples looking for evidence that the patient’s immune system has reacted to Borrelia burgdorferi. These tests work well to diagnose Lyme disease in most patients. Those who advocate for “Chronic Lyme Disease” often use “specialty Lyme research laboratories” that diagnose the infection using unvalidated methods. This is confusing for patients.

How do you treat the Lyme?

Antibiotics such as doxycycline and amoxicillin have proven very effective. Depending on the stage, treatment can be as little as 10 days, but may extend to three weeks. For arthritis cases not responding to oral antibiotics—or for certain Lyme-related neurological problems—a course of IV antibiotics could be recommended for two or four weeks.

Why is there a debate?

Up to a quarter or more of patients experience some fatigue or muscle aches even after antibiotic therapy for the first few months after treatment. Over time, most return to normal. For unknown reasons, perhaps 5 percent continue to suffer problems long after the infection has cleared—typically things like “brain fog,” fatigue, poor sleep, and muscle and joint pains. The trouble is that these are common complaints throughout the general population. So far, no good studies help separate pre-existing conditions such as depression, fibromyalgia, or chronic fatigue syndrome from those actually brought about by the Lyme infection. Although I believe some patients continue to have problems, the key thing I tell them is that the spirochete bacteria can no longer be found despite rigorous testing. Alternative practitioners believe that B. burgdorferi evade detection through a stealth mechanism. They treat this so-called Chronic Lyme Disease with very long courses of antibiotics. They have no controlled studies that show patients durably benefit. In fact, the opposite is true. For patients with persisting symptoms after initial treatment for Lyme disease, long-term antibiotics were no better than placebo.

Does this alternative therapy cause any harm?

Yes. Excessive courses of antibiotics may contribute to drug-resistant superbugs. They tax other organ systems and may cause complications, especially intravenous antibiotic therapies. This alternative approach also consumes many resources throughout the entire health system. Other problems include some practitioners who use very unconventional strategies (chelation therapy for heavy metals, hyperbaric oxygen therapy, colloidal silver) for these “chronic Lyme” patients. These odd ideas are being used to offer hope, I believe, but it is likely a false and unproven hope.

So what can physicians here do?

Some academics and clinicians have gotten gun-shy around this whole issue. If we decline to evaluate something that others call “chronic Lyme disease,” I feel that we are not being responsive to these patients. I find it rewarding to see these patients and try to explain the differing opinions as well as outline why treatments may or may not work. I do believe that there might be something we can call “post-treatment Lyme disease syndrome”—instead of “Chronic Lyme Disease,” which suggests an active infection—but it doesn’t respond to antibiotics. What we need is more work on this problem. RF