When to Suspect Lyme Disease

John D. Bleiweiss, M.D.

Traditionally, the public has been advised to suspect Lyme (LD) if a round or oval, expanding, red rash develops 3-32 days after a deer tick bite associated with or followed by a flu-like illness. This limited description will apply to only some cases. About 50% of patients do not recall one or more of tick bite, rash or flu-like illness. The rashes associated with LD can assume a variety of morphologies including vesicular, urticarial, eczematoid or atrophic (Acrodermatitis Chronicum Atrophicans). For many patients, neurologic, cardiac, arthritic, cognitive and/or psychological complications predominate. While deer ticks and LD have a well known affiliation, other potential vectors can carry the spirochete that causes LD (Borrelia burgdorferi; Bb). These include, the lone star tick, fleas, the biting flies (e.g. green-headed fly) (and mosquitoes?). A case of suspected transmission via blood transfusion has been reported by Dr. Burrascano.

The demonstration of Bb by PCR in two museum mouse specimens dating from 1894 (Massachusetts) and in ticks collected during WW II, provides a mechanism for potential life long exposure and disease which predates the formal 1975 discovery of LD. An occasional patient will date their symptoms which resolved on antibiotic therapy for LD to early childhood. Before the diagnosis was made, patients would dismiss those symptoms with the statement: "I've always had those problems". That resigned characterization implies that the longevity of the symptoms rules out a reversible cause. Subsequent resolution of the long standing symptoms on antibiotic therapy for LD belies that notion. Symptoms of LD can begin within days of inoculation with Bb or appear belatedly, but usually in the first to fourth month. Mice inoculated intraperitoneally had Bb demonstrated in the brain on biopsy 12 hours later with a peak at 48 hours (Stockholm Conference, 1990). Dr. Luft has published the detection of Bb by PCR (Polymerase Chain Reaction) in the CSF (Cerebrospinal fluid) of humans 2 weeks after the appearance of non-CNS related symptoms!

If dissemination can occur early, then staging the disease according to the temporal appearance of symptoms may be irrelevant. The absence of symptoms related to a particular organ system doesn't necessarily exclude the presence of Bb from that organ. Conversely, due to the possibility of symptoms being engendered by chemical mediators and autoimmune reactions by the host (against non-viable but immunoreactive DNA blebs), organ dysfunction and attendant symptoms can appear at sites removed from the actual spirochetes. The diagnostic and therapeutic problems that these phenomenon entail should be obvious.

Rapid dispersion of Bb could lead to the prompt appearance of complications; e.g., meningitis. There is no absolutely predictable clinical sequence for LD. The flu-like syndrome may be absent from the initial presentation and may endure once established without treatment. Cardiac and neurologic complications can be observed sometime within the first 3 months after microbiologically contracting the disease. Arthritis (i.e., joint inflammation; distinct from arthralgias; i.e., joint pain) can also accompany the initial clinical course, but more often develops later on between the second and sixth month from inoculation. The onset of complaints can not only be subtle and desultory, but delayed for a year or more. One of my patients denied all LD related symptoms until her husband died, whereupon, a plethora of complaints cascaded into her life beginning that very day. Another had an annual flare of LD as part of an anniversary reaction centered on the date of his mother's death.

Moreover, the early constellation of symptoms can have a paucity of findings with unidimensional presentations: the onset of solitary problems such as vertigo, or recurrent upper respiratory tract infections. Over time, as the untreated LD percolates, symptoms accrue to the burgeoning clinical picture until a multisystem presentation is created. Other patients can have their manifold symptoms complex develop in the manner of an avalanche. These patterns represent the extremes of a clinical continuum between which there are many variations on the theme ranging from mild to severe disease. Thus, The failure of a pathognomonic (unique and specific) presentation to consistently unfold causes sufficient clinical confusion, that a punctual diagnosis is problematic. Therefore, a high index of suspicion is placed at a premium. If a clinician can't reconcile preconceived notions about how LD should announce itself with a patient's history and physical findings, it is a disservice to the patient and an abdication of professional imperatives to presumptuously conclude that the symptoms are psychosomatic or that the patient is faking!

Antecedent or concomitant factors which can cause symptoms and physical changes de novo or aggravate contemporary problems are reliably solicited on close questioning of LD patients. Females experience an exacerbation of their LD symptoms before or during their menses, while pregnant and with oral contraceptive hormones. Many patients have symptoms intensify or reappear with physical and emotional stress, if sleep deprived, after exercise, in a hot bath, after alcohol consumption, with fasting (hypoglycemia) or dehydration. Humidity, low barometric pressure, cold or rainy weather can elicit arthralgias, fatigue, encephalopathy or headache. A cold draft of air can precipitate the appearance of pain in exposed skin and the underlying bone, or even VII cranial nerve (Bell's) palsy. Patients with poor control of symptoms abhor the extremes of ambient temperature. Typically, heat intolerance is revealed as irritability, headache, excessive perspiration or sleepiness. Photophobia can enhance the somnolent propensity that can occur while driving a car. Significant head trauma has incited severe symptoms that later resolved with antibiotic therapy for LD. A sudden acceleration of encephalopathy (see below), headache and dizziness, thought of as putative post-concussion syndrome, can be evoked by head trauma. Diagnostic inaccuracy will be minimized by not indolently attributing all problems following head trauma to the most obvious cause. I routinely advise my patients with LD to abstain from cigarettes, alcohol and steroids because therapeutic inadequacy or an avoidably prolonged convalescence is frequent (Dattwyler, RJ, Lancet 1:687, 1987 - on steroid use). Patients have described clinical deterioration when steroids were used fortuitously or intentionally when hypoadrenalism was absent. Another hazard attending palliative steroid use is that some symptoms will be concealed, rendering the clinical picture less interpretable. In a private communication, a physician related that one of his LD patients succumbed to fatal cardiomyopathy after receiving steroids. One helpful caveat is to avoid the use of electric blankets or sleeping in water beds with the electric current activated, otherwise you might wake up with one or more LD symptoms. Allergic and chemical hypersensitivities can enhance or cause symptoms to emerge temporarily.

Symptoms vary stereotypically during the day. Joint stiffness and "brain fog" are often reported on rising in the AM (but not solely in the AM). Fatigue can be unrelieved by sleep, or develop between noon and 4 PM, whereupon a short nap provides refreshment. "Madman Syndrome" (explosive irritability) may appear toward the end of stressful work period or late in the evening. A "mad face" can herald imminent detonation.

Prior to proper diagnosis, patients habitually report that they were assigned the following diagnoses most often: Chronic Fatigue Syndrome, Multiple Sclerosis, Fibromyalgia, Lupus, Candidiasis, Chronic mononucleosis, Hypoglycemia, and Stress-related illness. If these appear in a differential diagnosis, then LD should be considered.

On cursory inspection, many patients with LD appear deceptively well but in fact feel awful Don't be fooled! The mien of a Lyme patient ranges from phlegmatic, sullen, staring off into space, to one of agitated anxiety and hyperkineticism. Their oral and written recitations similarly vary from cryptic to being overinclusive and circumstantial. Geschwind's Syndrome embraces some varieties of LD encephalopathy precisely (Textbook of Internal Medicine, Ed: Kelly, 1989, p. 2509). Stuttering was reported by several patients to coincide with the onset of their LD and often proved reversible.

Patients most frequently report fatigue that varies from mild to debilitating. Usually there is a loss of interest and initiative so that lounging around becomes habitual. This derives not from laziness, but results from lassitude. Attempts to indulge avocational or vocational pursuits is frequently interdicted by either the languor of Lyme or by encephalopathy. There is a tendency to nap, sleep that is not rejuvenating, and hypersomnolence at inopportune moments; e.g., in the classroom or during a favorite pastime. Sleeping away entire days is not unknown.

Paradoxically, at usual bedtimes, patients often experience insomnia or frequent awakenings. Sleep does not always provide respite as ferocious or vivid nightmares can occur. Childhood night terrors can be due to LD or more mundane causes.

Intermittent fevers range from low grade to 104.5 degrees F. The typical context for high fevers is in the first week of antibiotic therapy especially if multiple agents and/or IV drugs are used. While fever is the hallmark of the classic Jarisch-Herxheimer (J-H) reaction, its appearance is inconstant. Compared with most causes of high fever, the patient can look and feel their best during or shortly after the fever with a relatively non-toxic demeanor. This can sometimes be diagnostically helpful. The differential diagnosis of febrile seizures in infants should include LD. Many LD patients have routinely subnormal body temperatures so that the appearance of a temperature of 98.6 degrees F may be compatible with a low grade fever analogous to diabetics.

Very often, the pinna and ear lobes are varying shades of red. Less commonly, a similar erythema can be observed on the hands or malar (upper cheeks) areas. A malar rash is not pathognomonic of Lupus, if in fact SLE is distinct from LD (Abstract 55A, V LD Symposium). Fifth Disease (slapped face) is suspected of being due to LD. Lymphocytoma of the ear lobes has been encountered more often in Europe. Cold hands and feet even in warm environments occurs and some patients have Raynaud's phenomenon. Potentially contributing to this vasoconstriction are excessive levels of vasoconstricting hormones, magnesium and potassium deficiency, limbic or hypothalamic dysfunction due to CNS infection, local inflammation of capillary sphincter or hypothyroidism. Eczema and psoriasis can appear in conjunction with LD. A female LD patient had generalized psoriasis covering 40% of her body. Antibiotics for LD gave total relief.

Alterations of cutaneous sensation are very common. Most often there is numbness and tingling (paraesthesias)of the central face, fingertips, scalp and in the extremities. Muscle twitching usually occurs in the eyelids and extremities. Tremors, myoclonic jerking of entire extremities or truncal shudders can suggest pseudoseizures but is attributed to neuritis. Patients also report electric shocks, dysesthesias (abnormal sensory responses to stimuli), painful or itchy skin and flushing. An inordinate amount of exertional or non-exertional sweating may be described in the absence of hyperthyroidism. One of my patients experience anhydrosis (inability to sweat) for 27 years until antibiotics were given for LD.

Dizziness, imbalance and clumsiness can become very frustrating as patients drop objects or knock them over, trip a lot, turn into the wall when rounding corners, and develop sloppy and slower handwriting.

Many use the phrase "a vibration in my head". Others remark that they feel "toxic". Along with the "brain fog", these colloquialisms connote LD until proven otherwise.

Eventually the majority, but not all, complain of one or more of "foggy brain", forgetfulness, anxiety, mood swings, loss of initiative, depression, impairment of concentration, inattention, easy confusion or disorientation when attempting intellectual tasks. Paper shuffling can be the end result when patients attempt to organize or assimilate even limited amounts of information. These problems, and the others described below, constitute the salient features of Lyme encephalopathy.

Short term memory impairment causes patients to forget what they were going to say, why they entered a room, where objects were placed, the previous sentence or plot content, calendar dates, their schedules, names and faces of familiar people, even family members. Cognitive neglect caused one patient to wander around the room looking for the room looking for the pencil clenched between his teeth. A mother left her infant and baby carriage in my office parking lot and went home. Others forgot how to spell even simple words, how to read or must re-read with varying degrees of comprehension. One patient drove to Philadelphia instead of the desired Princeton destination because the initial letters were identical and confused him. After shopping for groceries, another patient placed her shoes in the refrigerator and stored the food in the clothes closet. Lyme patients can lose their way home or on the way to work, bypassing otherwise familiar exits or plain forgetting where they are in time and space or how they got there. This is known as topographical disorientation or environmental agnosia. Elementary math problems may prove insurmountable. numerical errors are common. Sequential task performance is compromised in Lyme. Lyme patients have a penchant for saying, "Wait a minute", 2-3 times rapidly when the only demand on them is to record a phone number, which also speaks of perseveration.

Inattention frequently characterizes the way patients relate to the world. Some patients participate passively, unable to initiate or engage in the usual forms of social and intellectual exchange. Verbal and written forms of expression have a typical Lyme flavor. The content demonstrates disorganization, an inability to follow a train of thought and there is a proclivity to ramble on and on in great detail which propels further confusion amongst the forest of details. Ubiquitous among the myriad cognitive flaws are the frequent errors of word selection or pronunciation and the consistent word and number reversals.

Concentration on a task can be problematic because attention span is abbreviated. As increasing amounts of information have to be processed, the Lyme patient becomes proportionally lost, disoriented, frustrated, fatigued and finally must desist from further intellectual activity. The desire to initiate projects and social interaction is often blunted if not absent altogether. Thus a deterioration in academic and vocational performance is a frequent manifestation of LD in children and adults..

Miklossy (NeuroReport 4:841-848, 1993) reported the detection of Bb spirochetes on dark-field microscopic examination of post-mortem brain biopsy specimens FROM PATIENTS WITH ALZHEIMER'S DISEASE! CSF and blood cultures grew out Bb from those cases. In my view, a child assigned a diagnosis of Attention Deficit Hyperactivity Syndrome (ADH) or PNI (Perceptual Neurologic Impairment) should be evaluated for LD. A 16 year old boy whose Tourette's Syndrome began at age 5, had Osp A antigen detected in his CSF. LD treatment resolved the Tourette manifestations. Another patient of mine with ADH had a positive IgM Lyme antibody in the serum. The manifestations of ADH were eradicated while on antibiotics. Distinguishing causality from mere exacerbation of ADH or Tourette by Lyme is moot, and therefore, I suggest an evaluation LD for these patients. Parenthetically, the boy with Tourette also had cognitive impairment, familial nephritis with early renal insufficiency and OCD (Obsessive Compulsive Disorder). These clinical features all remitted with antibiotics! A real estate agent's prominent encephalopathy resolved with LD treatment whereupon his commercial output jumped to a record zenith and became the recipient of numerous corporate awards. The benefits of arresting LD are self evident to him.

Personality changes are nearly universal in Lyme encephalopathy with emotional and expressive incontinence being typical. Usually there is a baseline irritability which fluctuates. Patients with LD encephalopathy react to even mild degrees of stress with frustration, anger or crying spells out of proportion to the situation. Emotions can reach escape velocity and rages can become volcanic with a momentum beyond volitional control. Unpleasantness is inevitable due to volatile tempers, super critical dispositions, and impatience with themselves or others. Lyme patients can be easily irritated by anyone just walking into the same room even though eye contact is never made or words exchanged. Low threshold exasperation in unexpected circumstances is not uncommon. Thus a parent responds to an infant's needs with anger and frustration. Perpetrators of "shaken baby syndrome" recapitulate an emotional response indistinguishable from that of a Lyme patient whose encephalopathy is out of control.

Many express morbid fears of occult illness, impending death and can be generally pessimistic or maudlin. Some develop intricate paranoid theories regarding imagined conspiracies against them. Lyme patients often evince a tendency for being overly sentimental. Hyperbolic thought finds expression in obstinacy, self-righteousness, being contentious, speaking in categoricals, and inappropriate and atypical vulgarity. Internalized anxiety results in the perception of being hurried even without a deadline or the inability to remain calm when there is no reason for not feeling calm. Panic attacks are the extreme of this anxious state and should arouse a suspicion of LD. I suspect that in addition to CNS infection of the limbic system, these phenomenon could also be the result of elevated adrenaline levels, Mg++ deficiency or hypoglycemia. A rare LD patient will admit to agoraphobia or claustrophobia.

Depression alternating with anxiety is very common in LD. Psychiatrists should routinely evaluate a depressed patient for LD before/when initiating psychotropic medication. A patient with LD may have a plausible reason to be depressed, but their emotional response can not only be incongruous with their usual coping style but also the depression can be ablated or ameliorated with control of the LD infection. Lyme encephalopathy typically vitiates an otherwise mature and functional emotional repertoire.

With a loss of voluntary and subconscious editorial control of emotions and expression in word or behavior, a patient with encephalopathy gives the general impression of being erratic, inappropriate, if not dysfunctional. Less frequently, mania, obsessive-compulsiveness, schizoaffective disorders and homicidal/suicidal ideation is encountered and has been reported. Fatal attractions are consistent with the LD style.

Adolescent hormonal surges and the emotional turmoil wrought by LD at once camouflage and exacerbate each other mutually. Thus, children tend to be unruly, hard to please and prone to atypical emotional reactions. A child who is misbehaving in class should not be dismissed as a "bad kid". Lyme can catalyze inappropriate behavior and commentary. Many patients retrospectively realize that they were out of control but in the event were unable to intercept their behavior. Misattribution as to the origin of behavioral perturbations is the rule. The development of aberrant personality traits can be gradual or even situational, further obscuring the medical etiology. An acute break from normal behavior can serve to highlight the abnormalities and suggest the need for evaluation. thus, dysfunctional behavior and intellectual incapacitation are bitterly recalled by LD patients when they finally realize how their interpersonal relationships, school and vocational conduct were negatively impacted.

Clinically, there is considerable overlap between LD and Chronic Fatigue Syndrome (CFS). In their masterful review of the pathophysiology of CFS, Drs. Rosenbaum and Susser (Solving the Puzzle of CFS, 1992) describe SPECT scan findings of brain perfusion (blood) in CFS patients. Hypoperfusion of the left temporal, right parietal and left frontal lobes were consistently seen. These regions control the very areas of functioning which are abnormal in both LD and CFS, namely verbal capacity, memory, emotions and higher order information processing. Dr. Jay Goldstein has proposed the term "limbic encephalopathy" to describe the disorders of memory, appetite, temperature and appetite regulation, libido and hormonal homeostasis seen in CFS. He advances the concept of an "agent X" which incites CFS and causes dysregulation of the immune system and the limbic components of the CNS. I feel "agent X" is Bb. I am encouraged in this view by anecdotal experience whereby CFS responded to antibiotics given either fortuitously or by way of Lyme treatment, due to positive serologies (antibody tests) for LD in some CFS patients and the development of a J-H reaction in CFS patients who take antibiotics. Crimson crescents, portrayed as diagnostic for CFS, I have detected in LD where the diagnosis was secure.

Limbic encephalopathy elegantly embraces the preceding observations in Lyme encephalopathy. It is a potential mechanism to explain my suggestion that LD can be responsible for anorexia nervosa/bulimia. Anorexia was documented in earlier studies on LD. Uncinate fits and are characterized by hypersexuality, rage states and vulgarity, are compatible with LD. Indeed, disinhibition, the release of the usual brakes on behavior, would be part of limbic dysfunction.

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