Borrelioositestit eivät ole luotettavia sillä varhaisvaiheessa vasta-aineita ei ole ehtinyt muodostua ja myöhäisvaiheessa esim. elimistön immuunivaste on heikentynyt siinä määrin että se ei kykene muodostamaan vasta-aineita. Siksi diagnoosiin päätyminen edellyttää useissa tapauksissa potilashistorian tarkkaa selvittämistä ja useiden osatekijöiden huomiontia.
Psykologi Sheila Statlenderin kolme lasta sairastuivat borrelioosiin ja kaikki saivat useita virheellisiä diagnooseja. Hän kertoo esimerkin potilaasta joka sai opiskeluaikoinaan punkinpureman. Nainen oli aikoinaan menestyvä opiskelija, mutta pureman jälkeen hän alkoi äkillisesti saada tarkaavaisuus + kognitiivisia häiriöitä. Hänellä diagnosoitiin masennus ja ahdistus. Nyt hän on 45-vuotias."
The New England Psychologist
Lyme disease symptoms present challenges
The threat of Lyme disease is particularly relevant in New England. Leo J. Shea, Ph.D. is chairman emeritus of the National Research Fund for Tick-Borne Diseases, Inc. He is a clinical assistant professor at New York University Medical Center and has a private practice in Quincy, Mass. (photo by Tom Croke)
By Ami Albernaz
Mood disturbances, difficulty concentrating, impaired cognitive processing - all are symptoms that can be linked to an array of diagnoses. Yet some psychologists argue that one possible culprit is often overlooked, setting unknown numbers of people on ineffectual courses of treatment. The culprit: Lyme disease.
Just as physicians might mistake Lyme disease for multiple sclerosis, Lou Gehrig's disease or chronic fatigue syndrome, psychologists might misdiagnose it as attention deficit disorder, Tourette's syndrome or chronic fatigue syndrome, says Leo J. Shea, Ph.D., chairman emeritus of the National Research Fund for Tick-Borne Diseases, Inc.
The threat of Lyme disease is particularly relevant in New England, most which is deemed high or moderate risk by the Centers for Disease Control and Prevention. Though Lyme disease can be effectively treated with antibiotics, it can cause chronic joint ache and neurological problems if undiagnosed.
Identifying Lyme disease is tricky because "no one has been able to come up with a gold standard for diagnosis or for treatment," says Shea, who is also a clinical assistant professor of rehabilitation medicine at New York University Medical Center and maintains a private practice in Quincy, Mass. While tests for antibodies to the spirochete bacteria that cause the illness do exist, they are not foolproof. A person who has recently been bitten by a tick may not produce antibodies for a few weeks, resulting in a false negative. People with compromised immune systems may not produce antibodies at all. Additionally, the symptoms of Lyme disease, such as memory impairment, subtle deficits in visual processing and fatigue, can be non-specific.
Practitioners suspecting Lyme disease often are left to piece together a diagnosis based on the patient's history. "What we would look for is whether there was a clear point in time at which things changed," Shea says. If this is the case, he might recommend a test for Lyme disease; if the patient is lucky, the test will come back positive and it will be early enough for antibiotics to treat it. Without a diagnosis - even if Lyme disease is suspected - physicians may be hesitant to prescribe long courses of antibiotics for reasons including potential drug resistance.
For patients in this category, understanding what is wrong with them is an exercise in frustration. Sheila Statlender, Ph.D., a clinical psychologist practicing in Newton and Cambridge, Mass., says she gets as many as three or four calls per week from people concerned that they or a child might have the illness. She sees both children and adults, and currently her practice includes a number of bright, high-functioning teenagers who suddenly began experiencing cognitive difficulties.
She notes one patient who is now 45 and had been a top student in high school before she began struggling, rather suddenly, with attention and cognition problems. She was treated for depression and anxiety, but now traces the problems back to a high school camping trip during which she was bitten by a tick. For Statlender, helping people who have Lyme disease stems from hard-earned personal experience. All three of her children have had the illness and all received a series of misdiagnoses after they fell ill. The three exhibited different symptoms including slowed processing speed and impaired concentration, gastrointestinal problems, joint and muscle pain and extreme fatigue. Though they are now better, "it's a work in progress," Statlender says.
Neuropsychological testing can inform the sorts of interventions and accommodations that could be helpful for patients struggling with Lyme disease, she says. Children and teens experiencing new or intensified academic challenges might benefit from educational accommodations, while adults find that they may experience new difficulties at work and at home performing tasks that they previously were able to do well.
"It's not unusual to hear some of them express the fear that they are developing early Alzheimer's," Statlender says. "It is important to include both timed and untimed [cognitive] testing to get an accurate idea of their current potential. What's needed is better awareness of the neuropsychological symptoms which can be associated with Lyme disease, along with appropriate support and flexibility."
Patrick McAuliffe, Ph.D., who helped facilitate a support group for teens with Lyme disease in Wilton, Conn., agrees. McAuliffe, who is now an adjunct assistant professor of psychology at Teachers College at Columbia University, says that not only is there controversy over the exact cause of the cognitive and behavioral disturbances sometimes associated with Lyme, but there's also "a lack of good, solid research on what helps kids [with cognitive problems that might be linked to Lyme disease] in school.
"You can look at IQ and achievement, though oftentimes that's not broad enough when more subtle deficits might be driving the problems," he says. "The better that the schools can test the entire range of functioning, the better the interventions can be. There's a lot of individual variability."
Meanwhile, efforts toward a more definitive Lyme disease test continue. The National Research Fund for Tick-borne Diseases has raised more than $1 million toward this end, which Shea says has been made possible by the group's membership comprising doctors and researchers with diverging views on Lyme disease.
"We just want the best possible research and the way to get that is by having a range of ideas represented," Shea says, adding that he is hopeful that someday, people will not have to suffer the consequences of not having the illness detected early on.
Low White Blood Cell Count Distinguishes Lyme Arthritis From Septic Arthritis
Crina Frincu-Mallos, PhD
Review data November 13, 2009 (Washington, DC) ? The odds that a child living in a Lyme-endemic area of the United States who presents with a joint effusion will be diagnosed as having Lyme arthritis is 29%. The odds are even higher (44%) if the affected joint is the knee. The leukocyte count is useful in distinguishing between septic and Lyme arthritis, researchers announced here.
?There was an increase in the number of cases in the United States by 101% over the past 15 years, possibly due to increased recognition of Lyme disease,? said Aristides I. Cruz Jr., MD, resident in the Department of Orthopedics and Rehabilitation at Yale University in New Haven, Connecticut. During his presentation, he noted that 93% of all Lyme disease cases arise from 10 states, most in the Northeast United States.
?Children are more likely to present with arthritis as initial manifestation of Lyme disease,? Dr. Cruz told the audience.
?Children with Lyme arthritis presenting with a limp and a swollen joint will typically have a lower peripheral white blood cell count,? Dr. Cruz added. "They are less likely to have complete non?weight-bearing on the affected limb, less likely to have a fever, and [arthritis symptoms are] more likely to involve the knee joint compared with children with septic arthritis.? The findings were reported here at the American Academy of Pediatrics 2009 National Conference & Exhibition.
Basic Diagnostic Tools Help Distinguish Lyme From Septic Arthritis
?In the Northeast, we see a lot of Lyme disease,? said Yi-Meng Yen, MD, PhD, instructor in orthopaedic surgery, Harvard Medical School, Children?s Hospital Boston in Massachusetts. ?It is hard to distinguish whether [it] is Lyme disease or whether [it] is septic arthritis,? Dr. Yen agreed.
?Septic arthritis mandates that we take the patient to the operating room and do a surgery, whereas Lyme arthritis theoretically can be treated with antibiotics,? he told Medscape Pediatrics in an interview. For instance, he said, ?Our institution has been looking at MRIs [magnetic resonance images] as a way to reliably distinguish between the two, because it takes several days sometimes for the lab tests to come back to definitely tell you whether you have Lyme disease or not. So, in those few days, if you have septic arthritis, that?s a bad thing.?
?To reliably, quickly diagnose what the patient has can help us determine the treatment quickly,? added Dr. Yen, who was not involved in this study.
?If you are clinically susceptible for septic arthritis, it pays to go to the operating room,? Dr. Cruz said in answer to a question from the audience. ?In the past, almost all these patients automatically went to the operating room.?
However, if the clinical presentation is consistent with Lyme arthritis, treatment with antibiotics should suffice, he added. ?The point of this study was to come up with some clinically useful criteria to arm ourselves with more tools to diagnose the disease.?
Dr. Cruz and his team sought to evaluate clinical parameters that could eventually be used to differentiate Lyme arthritis from septic arthritis in children and help with diagnosis and subsequent treatment.
In this retrospective analysis, the investigators reviewed data from children who underwent lower-extremity joint aspiration at Yale University Medical Center, a tertiary care children?s hospital in a Lyme disease endemic area.
Between August 2002 and August 2008, more than 200 children underwent a total of 212 aspirations for a joint effusion. Cell count, culture, hematologic inflammatory markers, and subsequent surgical intervention were available for 170 of the 212 aspirates.
Dr. Cruz's team compared findings from 50 children with serologically confirmed Lyme disease with data from 21 patients with culture-positive septic arthritis.
They found statistically significant differences between the 2 cohorts. For instance, the peripheral white blood cell count was 9.5 x 1000/μL (range, 3.0 ? 14.9 x 1000/μL) in the aspirates from children with Lyme disease vs 12.5 (range, 5.5 ? 30.1) in children with septic arthritis (P = .002).
Other parameters, such as joint fluid cell count, erythrocyte sedimentation rate, and C-reactive protein levels, were not significantly different between the 2 groups and could not be used to differentiate between septic and Lyme arthritis.
Interestingly, said Dr. Cruz, of all the children presenting with a joint effusion at their hospital, 29% were likely to be diagnosed as having Lyme arthritis overall compared with 44% if the aspirate was a knee aspirate.
?Is it worthwhile to develop something that?s very reliable? Absolutely!? said Dr. Yen. ?Especially in the Northeast centers. It is a growing healthcare problem and a lot more study should be put into it.?
Dr. Cruz and Dr. Yen have disclosed no relevant financial relationships.
American Academy of Pediatrics (AAP) 2009 National Conference & Exhibition (NCE): Abstract 5806. Presented October 17, 2009.
Authors and Disclosures
Crina Frincu-Mallos, PhD
Crina Frincu-Mallos is a freelance writer for Medscape Medical News.