• Marzec NS, et al. “Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease — United States.”
MMWR Morb Mortal Wkly Rep. 2017;66:607-609,
Lyme disease results from infection with Borrelia
burgdorferi sensu lato, a spirochete transmitted in the
U.S. by the blacklegged ticks Ixodes scapularis (figure
1) and Ixodes pacificus. Lyme disease may be classified
into three stages: early localized, early disseminated
and late disease.
Early localized disease is characterized by erythema
migrans, a red, nonpruritic and usually painless macule or papule that expands over days to weeks into an
annular erythematous lesion, occasionally with central
clearing (figure 2). The median incubation period between tick bite and erythema migrans development is
11 days (range 1-32 days).
Early disseminated Lyme disease may present with
multiple erythema migrans lesions, carditis, ocular
and/or neurologic manifestations (meningitis, polyra-diculopathies, cranial nerve palsies). Fatigue, headache,
myalgias, arthralgias and low-grade fevers are common.
Patients not treated with an appropriate antimicrobial
agent in the early stages of infection may present with
an inflammatory, pauciarticular arthritis involving
large joints, commonly including knees. Rarely, patients may develop polyneuropathy, encephalopathy
Chronic Lyme disease has been used to describe a variety of symptoms, including fatigue, generalized pain,
muscle and joint aches, and various neurologic complaints. Diagnosis may be based on clinical judgment
alone or with support from standardized laboratory
testing. Information pertaining to diagnostic tests for
Lyme disease can be found in the AAP Red Book, http://
An array of oral and intravenous therapies, including
prolonged intravenous antibiotics, immunoglobulin
or hydrogen peroxide, have been advocated as treatment for chronic Lyme disease. Five patients who experienced severe therapy-related complications while
undergoing intravenous therapy for suspected chronic
Lyme disease are described below.
Case #1: A woman in her 30s with fatigue and joint
pain was diagnosed with chronic Lyme disease, babesi-
osis and Bartonella infection. Despite multiple courses
of oral antibiotics her symptoms worsened, so a periph-
erally inserted central catheter (PICC) was placed for
administration of ceftriaxone and cefotaxime. Three
weeks into treatment, she developed rash, fever, tachy-
cardia and hypotension. Despite broad-spectrum an-
tibiotics, vasopressors and mechanical ventilation, she
died from catheter-associated bacteremia.
Case #2: An adolescent female with fatigue, headaches, and muscle and joint aches was treated for three
months with oral antibiotics for chronic Lyme disease
but developed abnormal transaminase values. A PICC
was placed for intravenous antibiotic administration.
Her symptoms did not improve after an additional five
months of therapy. Intravenous therapy was discontinued, but her PICC was not removed. One week after
antibiotic discontinuation, she developed septic shock
with hypotension requiring vasopressor support. She
had Acinetobacter bacteremia, received broad-spectrum
antibiotics and was discharged after several weeks of
Case #3: A woman in her 40s developed an influenza-like illness. She was diagnosed with Lyme disease
one year later and received two courses of doxycycline.
Two years later, chronic Lyme disease was diagnosed
after she developed fatigue, decreased exercise tolerance
and cognitive difficulties. A tunneled intravenous catheter was placed, 10 months of IV antibiotics were given
and her intravenous catheter was replaced after a year.
Four weeks later, she developed dyspnea, malaise and
back pain requiring hospitalization and was diagnosed
with Pseudomonas aeruginosa bacteremia. She received
IV aztreonam for four weeks but was readmitted for
worsening back pain with biopsy-proven Pseudomonas
vertebral osteomyelitis and diskitis. She eventually re-
covered following appropriate antibiotic therapy.
Case #4: A woman in her 50s was diagnosed with
chronic inflammatory demyelinating polyneuropathy
after developing weakness, swelling and paresthesia.
Her symptoms progressed despite multiple therapies
over five years. Another physician diagnosed chronic
Lyme disease, Rocky Mountain spotted fever and babesiosis. She was treated for seven months with oral
and intravenous antimicrobial agents. She developed
severe abdominal cramping and diarrhea secondary
to Clostridium difficile infection requiring prolonged
treatment. Two years later, she died from complications
of amyotrophic lateral sclerosis.
Case #5: A woman in her 60s was diagnosed with
neuropathy secondary to chronic Lyme disease. She
developed fevers and neck pain after receiving IV immunoglobulin injections through a tunneled catheter
for more than 10 years. When methicillin-susceptible
Staphylococcus aureus bacteremia was identified, the
indwelling line was removed and she was treated with
IV antibiotics through a new PICC. She maintained
her PICC after antibiotic completion to continue IV
immunoglobulin therapy. She developed recurrent fevers after two months with catheter cultures revealing
coagulase-negative Staphylococcus, which was treated
with IV antibiotics and PICC removal. A new subcutaneous catheter was placed, but she developed back
pain and fever. She developed methicillin-susceptible
Staphylococcus aureus bacteremia and a paraspinal abscess that required surgical drainage.
Lessons learned about chronic Lyme disease.
• Chronic Lyme disease is a nonspecific diagnosis
without a consistent definition.
• Prolonged antimicrobial or immunoglobulin therapy lacks proof of effectiveness.
• Complications from prolonged therapies may
include C. difficile colitis, bacteremia, metastatic
infection, osteomyelitis, procedure-associated injuries, septic shock and death.
• Inappropriate antibiotic use may result in selection
of antibiotic-resistant bacteria.
• Focusing treatment on chronic Lyme disease can
lead to missed opportunities to diagnose and treat
the real underlying cause of a person’s symptoms.
Prolonged intravenous access for antimicrobial and
immunoglobulin therapy is not appropriate for chronic
Lyme disease and is not supported by appropriately
conducted scientific studies. Numerous complications
of prolonger therapy may occur as shown above.
Dr. Raabe is a post-grad-uate training fellow in
pediatric and internal
medicine infectious diseases at Emory University School of Medicine and
Children’s Healthcare of
Atlanta (CHOA). Dr. Pickering is adjunct professor
of pediatrics at Emory University School of Medicine
Dr. Raabe Dr. Pickering
Which of the following are true regarding chronic
a) A consistent definition does not exist.
b) Prolonged antimicrobial therapy can lead to significant
c) Intravenous treatment lacks data supporting effectiveness.
d) Bacterial resistance can occur following prolonged,
inappropriate antimicrobial use.
e) All of the above A n s w e r : e
Courtesy of the 2015 AAP Red Book
Figure 1: Ixodes scapularis, commonly referred to
as the deer tick or blacklegged tick, may transmit
Courtesy of the 2015 AAP Red Book
Figure 2: Classic targetoid appearance of erythema