British Medical Journal - Editorial - admonitions about denialist views concerning Lyme Borreliosis

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British Medical Journal - Editorial - admonitions about denialist views concerning Lyme Borreliosis

Postby inmacdonald » Fri 4 Dec 2015 22:33

British Medical Journal
year 2015
volume 351
page H 6520
Lyme disease: time for a new approach?
Many more questions than answers

Liesbeth Borgermans professor 1, Christian Perronne professor 2, Ran Balicer professor 3, Ozren
Polasek professor 4 5, Valerie Obsomer ecological and environmental risk expert 6
1Department of Family Medicine and Chronic Care, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium; 2 Infectious
Diseases Unit, Hôpitaux Universitaires Paris-Ile de France-Ouest, Saint Quentin en Yvelines, France; 3Epidemiology Department, Faculty of Health
Sciences, Ben-Gurion University of the Negev, Israel; 4Department of Public Health and Croatian Centre for Global Health, University of Split, Croatia
; 5Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK; 6 Agriculture, Environment,
Natural Resources and Environmental Risk Management, Public Service of Wallonia, Namur, Belgium
Lyme disease is the most common vector borne disease in North
America and Europe, with 300 000 new cases in the United
States1 and an estimated 100 000 new cases in Europe each
year.2 These numbers are likely to be underestimates because
case reporting is inconsistent3 and many infections go
undiagnosed.4 Climate change may have contributed to a rapid
increase in tick borne diseases, with migratory birds
disseminating infected ticks.5
Our common understanding of Lyme disease is that a tick bite
is followed by the development of a classic rash pattern
(erythema migrans). When treated early with a relatively short
course of antibiotics, most patients have good outcomes.6 But
the standard two tier testing for Lyme disease is inaccurate in
the early stages, and many patients and doctors fail to recognise
the rash.7 Patients who present with the later stages of the disease
can also be easily dismissed because the two tier testing lacks
sensitivity and cannot distinguish between current and past
infection. At the same time, the evidence remains limited on
the reasons for treatment failure and unresolved systemic
symptoms in patients with or without serological evidence of
the disease. Most patients will present to family physicians,
who often have few subsequent resources when the initial
treatment proves unsuccessful.
Recently, the medical community has been collectively forced
out of its comfort zone on Lyme disease by increasing evidence
of the complexity of this multisystem disease.8 To further
complicate matters, some patients develop long term symptoms.
The complexities are essentially related to either a lack of
understanding of the disease or conflicting evidence. Many
questions await full answers (box).9 Evidence that answers these
questions, and especially that highlights the inter-relatedness
of the different components, could underpin the necessary
rethinking around this condition.
Recent evidence shedding light on how spirochaetes of the
Borrelia genus evade host immune defences and survive
antibiotic challenge10-15 threaten current beliefs about the
persistence of infection, one of the largest points of contention
in the medical community. The possibility of persistent infection
has important implications for diagnosis, treatment, and
doctor-patient interactions.16
We need more national and international debates on Lyme
disease, complemented by a solid research agenda and a focus
on cutting edge biological technologies. The use of diverse
public health strategies to increase awareness of the risks of
Lyme disease and a focus on preventive measures are also
important. Family physicians can act as important partners
alongside infectious disease specialists and others to drive this
debate forward. Discussions should include national medical
societies, doctors, patient advocacy groups, international health
institutions, insurance companies, lawyers, governments, the
private health medical sector, and scientific journals. It needs
representatives of many different viewpoints who are prepared
to remain open minded.
Previous examples in medical history, such as the delayed
recognition of the role of Helicobacter pylori in gastric disease,
have shown the consequences of ignoring findings that
contradict our current beliefs about a disease. In an era where
patient centred care is considered the cornerstone of high quality
and integrated medicine, we cannot allow ourselves to repeat
past mistakes at our patients’ expense. The suffering of many
affected patients17 obliges us to learn more about this disease,
and fast.
We have read and understood BMJ policy on declaration of interests
and declare that we have no competing interests.
Provenance and peer review: Not commissioned; externally peer
1 Kuehn BM. CDC estimates 300 000 US cases of Lyme disease annually. JAMA
Correspondence to: L Borgermans

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Re: British Medical Journal - Editorial - admonitions about denialist views concerning Lyme Borreliosis

Postby hv808ct » Sat 5 Dec 2015 3:43

Sounds very much like what they published last year:

International Journal of Family Medicine
Volume 2014 (2014), Article ID 138016, 10 pages
Review Article
Relevance of Chronic Lyme Disease to Family Medicine as a Complex Multidimensional Chronic Disease Construct: A Systematic Review.
Liesbeth Borgermans, Geert Goderis, Jan Vandevoorde, and Dirk Devroey

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Re: British Medical Journal - Editorial - admonitions about denialist views concerning Lyme Borreliosis

Postby duncan » Sun 6 Dec 2015 13:29

It bears repeating.

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Re: British Medical Journal - Editorial - admonitions about denialist views concerning Lyme Borreliosis

Postby lou » Thu 17 Dec 2015 16:51

Be nice if Lancet would publish something like this. So far, their track record is poor.

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Re: British Medical Journal - Editorial - admonitions about denialist views concerning Lyme Borreliosis

Postby RitaA » Thu 31 Dec 2015 8:14


Lyme disease: time for a new approach?

BMJ 2015; 351 doi: (Published 03 December 2015)
Cite this as: BMJ 2015;351:h6520

22 December 2015
Matthew S Dryden
Consultant in infection and microbiology

Hampshire Hospitals NHS Foundation Trust & RIPL, PHE, Porton
Royal Hampshire County Hospital, Winchester, SP11 6NU

Re: Lyme disease: time for a new approach?

The editorial by Borgemans et al is timely and calls for greater open mindedness rather than slavish following of dogma. Dogma leads to extreme views and intransigence in all walks of life and Lyme disease is no exception.

Following up patients with Lyme disease in Hampshire for 20 years has revealed two distinct groups (ref1): those with objective clinical signs and positive serology by the two tiered test system and those with symptoms but no objective signs and negative or equivocal serology. Most of the former recover with short course antibiotics. Managing the latter group is much more challenging because there are many uncertainties: do they have Lyme disease; if they do, is the infection active; if it is not active, what is the pathology - immune system activation, another infection, a toxin, a psychosomatic disorder. It can be anyone of these and possibly all of them together. Giving the patient a diagnosis is impossible because there is no clear case definition in this group to differentiate chronic Lyme from post infectious symptoms, fibromyalgia or chronic fatigue syndrome.To complicate matters recent publicity has encouraged many patients with neurodegenerative disorders to question their diagnosis which often fails to define an aetiology and explore the possibility that they in fact might have Lyme disease.

Much research is needed on this group, as outlined in the editorial, but most urgently there needs to be research on diagnosis to establish whether persisting infection is present in some of the patients with persisting chronic symptoms. This will allow the development of more appropriate treatments for this group. It will also save the anguish and confusion that many patients experience when forced to spend money on tests which have not been clinically validated.

1. Dryden M, Saeed K, Ogborn S, Swales P. Lyme borreliosis in southern United Kingdom and a case for a new syndrome, chronic arthropod-borne neuropathy. Epidemiol. Infect., 2014. 9:1-12 . doi:10.1017/S0950268814001071

Competing interests: No competing interests

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