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Autoimmune Arthritides, Rheumatoid Arthritis, etc. Following Lyme Disease

Posted: Mon 30 Jan 2017 0:08
by dlf
Considering that many mainstream IDSA physicians have been telling patients for years that Lyme is mostly an easily treated disease with relatively benign sequelae which are mostly comparable to the "aches and pains of everyday life", this study would seem to be an admission of sorts. Of course, they are not even remotely suggesting that the ongoing arthritic problems might still be Lyme. :bonk:

To my mind, there seems to be a lot of questionable assumptions and conclusions with this one.

http://onlinelibrary.wiley.com/doi/10.1 ... 39866/full

Arthritis Rheumatol. 2016 Sep 16. doi: 10.1002/art.39866. [Epub ahead of print]

Autoimmune Arthritides, Rheumatoid Arthritis, Psoriatic Arthritis, or Peripheral Spondyloarthropathy, Following Lyme Disease.

Arvikar SL1, Crowley JT2, Sulka KB2, Steere AC2.
Abstract

OBJECTIVE:
To describe systemic autoimmune joint diseases following Lyme disease and to compare their clinical features with Lyme arthritis.

METHODS:
Records of all adult patients referred to our Lyme arthritis clinic over a 13-year period in whom we diagnosed a systemic autoimmune joint disease following Lyme disease were reviewed. For comparison, records of patients enrolled in our Lyme arthritis (LA) cohort over the most recent 2-year period were analyzed. IgG antibodies to Borrelia burgdorferi and to 3 Lyme disease-associated autoantigens were measured.

RESULTS:
We identified 30 patients who developed a new-onset systemic autoimmune joint disorder a median of 4 months after Lyme disease, usually erythema migrans (EM). Fifteen had rheumatoid arthritis (RA), 13 had psoriatic arthritis (PsA), and 2 had peripheral spondyloarthropathy (SpA). The 30 patients typically had polyarthritis; and those with PsA/SpA often had previous psoriasis, axial involvement, or enthesitis. In the comparison group of 43 LA patients, monoarticular knee arthritis, without prior EM, was the usual clinical picture. Most systemic autoimmune patients had positive tests for B. burgdorferi IgG antibodies by ELISA, but they had significantly lower titers and lower frequencies of Lyme-associated autoantibodies than LA patients. Prior to our evaluation, the patients often received additional antibiotics for presumed Lyme arthritis without benefit. We prescribed anti-inflammatory therapies, most commonly disease modifying anti-rheumatic drugs (DMARDs), resulting in improvement.

CONCLUSION:
Systemic autoimmune joint diseases, RA, PsA/SpA, may follow Lyme disease. Development of polyarthritis after antibiotic-treated erythema migrans, previous psoriasis, or low-titer B. burgdorferi antibodies are clues to the correct diagnosis.


<Snip>
Clinical characteristics of the patients
During the 13-year period in which we have practiced at MGH, 30 patients were referred to us for evaluation of presumed LA, in whom we had diagnosed a systemic autoimmune joint disorder. Of the 30 patients (each of whom had new-onset illness) 15 had RA, 13 had PsA, and 2 had peripheral SpA. The median duration from the onset of Lyme disease to the start of joint symptoms was 4 months (range 2 weeks to 2 years) (Figure 1), which is similar to the timeframe in which LA may occur after EM [4].

The number of LA patients whom we have evaluated has steadily increased over the past 13 years (Figure 2). Moreover, during the most recent 3-year period, the proportion of patients in whom we diagnosed a systemic autoimmune joint disease following Lyme disease increased more than during any other period. Of the 30 patients reported here with RA, PsA, or SpA following Lyme disease, 18 (60%) were seen during the past 3 years. Overall, during this most recent period, approximately one-third of the patients referred had LA that was responsive to antibiotic therapy, another one-third had antibiotic-refractory LA, and the remaining one-third had another autoimmune arthritic disorder following Lyme disease.
Of course they don't mention that after years and years of mostly unsuccessfully trying to find autoantibodies in Lyme patients, it was only in 2013 that "A novel human autoantigen, endothelial cell growth factor, is a target of T and B cell responses in patients with Lyme disease.", was published:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535550/

So, it is pretty much no wonder that 60% of these patients were diagnosed within the past three years. It is rather disturbing to think that as soon as 2 weeks after the onset of Lyme they are telling patients that if they have developed polyarthritis instead of monoarthitis, systemic symptoms and low antibody titres, that what they have is no longer Lyme.


<Snip>
Treatment and outcomes
In the systemic autoimmune disease group, we advised treatment with antiinflammatory agents according to the standard of care. These treatments included steroids (3%), nonsteroidal antiinflammatory drugs (20%), DMARDs (57%) (most commonly methotrexate, but also tumor necrosis factor [TNF] inhibitors), or combinations of these agents. Arthritis was well controlled with this treatment strategy in all cases, and none of the patients had reactivation of infection. However, 6 patients (20%) were reluctant to accept the diagnosis of a systemic autoimmune disease and sought further treatment for Lyme disease elsewhere, with additional courses of antibiotic therapy.

Of the 43 LA patients, arthritis resolved within 1 month of completion of oral antibiotic treatment in 11 (26%), and in 8 patients (19%) whose arthritis did not respond to oral doxycycline, resolution occurred within 1 month of completing IV antibiotic treatment. However, 24 patients (56%) had persistent proliferative synovitis despite treatment with oral and IV antibiotics. Of these 24 patients, 23 (96%) were treated with DMARDs, including hydroxychloroquine, methotrexate, or TNF inhibitors. Similar to the systemic autoimmune disease group, these 24 patients had marked improvement within months, and to date, none has had recurrence of Lyme disease or required synovectomy.

Of the 43 LA patients, arthritis resolved within 1 month of completion of oral antibiotic treatment in 11 (26%), and in 8 patients (19%) whose arthritis did not respond to oral doxycycline, resolution occurred within 1 month of completing IV antibiotic treatment. However, 24 patients (56%) had persistent proliferative synovitis despite treatment with oral and IV antibiotics. Of these 24 patients, 23 (96%) were treated with DMARDs, including hydroxychloroquine, methotrexate, or TNF inhibitors. Similar to the systemic autoimmune disease group, these 24 patients had marked improvement within months, and to date, none has had recurrence of Lyme disease or required synovectomy.
I imagine many of us reading the following quote would also be reluctant to accept this opinion as a firm and real diagnosis, "However, 6 patients (20%) were reluctant to accept the diagnosis of a systemic autoimmune disease and sought further treatment for Lyme disease elsewhere, with additional courses of antibiotic therapy."; but bear the quote in mind for later.

<Snip>
Regardless of whether the occurrence of systemic autoimmune joint disease following infection is coincidental, induced nonspecifically by adjuvant effects of infection, or related to specific Lyme disease–associated autoimmune responses, an important point for clinicians is that postinfectious joint disorders that occur after recommended antibiotic treatment for Lyme disease should be treated with DMARDs (rather than with additional antibiotic). Some of our patients were reluctant to accept the non–Lyme disease diagnosis and pursued further antibiotic treatment elsewhere. One patient who developed RF- and ACPA-positive RA initially had complete remission of RA with methotrexate treatment, but stopped this medication and sought further treatment for Lyme disease elsewhere with prolonged courses of multiple antibiotics. Three years later, he returned in a wheelchair and had developed radiographically evident erosions, and deformities and contractures in multiple joints. Given a choice between LA and a chronic illness that may require lifelong immunosuppressive therapy, it is not surprising that patients would find LA a more attractive diagnosis. However, there is increasing evidence that earlier aggressive treatment of inflammatory arthritis is associated with improved radiographic outcomes and chances of sustained remission [49, 50]. Delaying appropriate DMARD treatment of autoimmune joint disorders, by pursuing further therapy with antibiotic agents, may lead to poorer clinical outcomes.
Ok, so remember that quote........I want to know what happened with the other 5 patients who sought further treatment for their Lyme disease!

I would also like to know what exactly they consider to be "marked improvement" within months.

Maybe this is one of those clinical scenarios where DMARDs (i.e. hydroxychloroquine) would benefit patients when taken concomitantly while on antibiotics. ;) ;)