Post
by inmacdonald » Wed 28 Nov 2012 17:12
Dear Duncan,
Dr Allen Steere, [ not the historian by training as Dr Doris Kearns Goodwin is a true historian}
has recently in his Editorial in the New England Journal of Medicine Nov 15, 2012
discusses his conception of the natural history of Lyme disease for which no antibiotic therapy is administered. To quote from the NEJM Editorial,.."The infection usually began with an expanding skin lesion called erythema migrans, sometimes followed weeks later by Neurologic or cardiac involvement, and often followed later by arthritis. Attacks of arthritis commonly recurred over a period of several years, and occasionally erythema migrans reappeared faintly before episodes of arthritis. Thus, in untreated patients, relapse of the original infection was the rule."
He has a cohort of untreated patients from his years 1975-1982 from his Rheumatology practice
at Yale School of Medicine. These folks, culled from the "pre-spirochetal era" of Lyme disease {previously
nee "Lyme Arthritis" ] don't really qualify for "untreated patients, because Dr Steere prescribed
Corticosteroids alone to treat these people.
Steroid treatment alone for a bacterial illness is a therapeutic misadventure. We cannot elevate this treatment to malpractice because the spirochetal etiology of Lyme Disease was unknown in the Pre Spirochetal era prior to Dr Wily Burgdorfer's discovery.
Nonetheless, Dr Steere recounts that Lyme disease { for the group of patients who stayed with him and did not flee to Groton Connecticut where Antibiotics were prescribed without any peer reviewed proof that antibiotics were actually treating a known bacterial infection in th 1975-1982 years}:
Steere's faithful patients over time are reported by him {?? filtered data??] as gradually experiencing diminution of Arthritis { remember that he is a Rheumatologist,and not a Generalist}. The Arthritis
decline over a 6-8 year time scale would encourage the average reader to question the need to receive
antibiotic therapy at all. Neurologic sequelae are assiduously avoided in Dr. Steere's longitudinal history of Lyme Disease, and Neurologic sequelae deep to the meninges ( i.e. meningitis) have not and will not
appear in any of Dr Steere's Rheumatologic Lyme natural histories.
Post 1982, the issues of Medical Standard of Care, Medical Ethics, and Medical malpractice come into play.
Willfully withholding antibiotics for a known bacterial infection in the post 1982 era would of course be
un Ethical. We have no Evidence that Dr Steere declined to treat any of his Lyme patients with
antibiotics after 1982.
But then we must return to the Steere remarks about the Self limited clinical course of Lyme disease.
to be reconciled are two variables:
1. All Lyme Steere patients prior to 1982 received prescriptions for Steroids.
2. All patients diagnosed between 1972 to 1982 received prescriptions for 14 days of antibiotics after 1982.
How is it then possible for Dr Steere to write in his Nov 15,2012 NEJM editorial that the natural
history (untreated or 14 day treated) if Lyme patients under his care is a benign, gradually self healing history with no patients experiencing persistent Chronic Lyme Disease with viable Borrelia burgdorferi still circulating in their blood decades after the onset of their Lyme disease?
There is no data from a well medically supervised prospective or retrospective study to answer the
question of the natural history of untreated Lyme Borreliosis in the USA. European data offer the
examples of acrodermatitis chronica atrophicans and Mononeuritis multiplex (Bannwath's) as the residuae
of untreated Lyme borreliosis. Arthritis in European patients is under discussed, but perhaps not unknown.
Tardive manifestations of Lyme Disease are not on Dr. Allen Steere's Radar screen. Many patients over the years have left his practice, dissatisfied with their personal comes, or with his Classification of their illnesses as "antibiotic refractory arthritis" . What happened to Antibiotic refractory Central nervous system
Lyme Disease or antibiotic refractory Carditis/Cardiomyopathy, or antibiotic refractory blindness due to Lyme Temporal arteritis or antibiotic refractory Neuropsychiatric sequelae? Lyme is not A Rheumatologic Centered medical condition. The natural history of Lyme borreliosis involves All human organ systems.
Let the Word go Forth!
Best,
Alan