Getting Sour on Lyme: A Review of Lyme: The First Epidemic of Climate Change

I devour infectious disease books however the latest one has given me a bit of indigestion. I recently read Lyme: The First Epidemic of Climate Change by investigative reporter Mary Beth Pfeiffer. I came across this book after seeing it mentioned favorably in the premiere scientific journal, Nature. I don’t share their enthusiasm for the book.

For those who follow infectious disease news, the controversies and mythologies surrounding Lyme Disease are nothing new despite the fact that they seem to multiply, become more complex, and become more insoluble day-by-day.

Pfeiffer’s book is written from the viewpoint of someone who gives a lot of credence to alternative therapies for nebulous conditions that may or may not be related to Lyme infection. The best aspects of Pfeiffer’s book are its chronicling of the increasing geographic range of the Ixodes scapularis deer tick responsible for Lyme Disease transmission and explicitly linking it to suburban reforestation plans that put people into much greater contact with ticks.

She also deserves credit for cataloging the other important infections that can be spread by the deer tick such as Powassan virus, babesiosis, ehrlichiosis, and anaplasmosis — all of which are important for doctors to consider when evaluating someone with a potential tick-borne illness.

However there are several areas with which I strongly disagree with the book. Not surprisingly, much of my disagreement deals with her disparagement of the Infectious Diseases Society of America (IDSA) and major academic Lyme Disease researchers which she basically describes as a involved in a vast conspiracy to hide the truth about Lyme. This ire is focused almost entirely on the contentious subject of “chronic Lyme Disease” — an impossible to define concept that centers on the belief that ongoing damage-causing Lyme infection continues after sufficient antibiotic therapy and merits further antibiotics, hyperbaric oxygen, or other therapies.


In this brief review, it is impossible to rebut everything she asserts (with backing from certain physicians) but I would just point out that almost every patient I have seen who has this constellation of symptoms has no objective evidence of immune system response (i.e. C-reactive protein levels are completely normal) indicating that, even if remnants of the Lyme bacteria are present, there is no inflammation associated with and hence it does not make biological sense to attribute symptoms to something that the immune system itself is not attributing symptoms to. Furthermore, antibiotic therapy — which Pfeifer discounts the danger of — is not warranted.

One of my other problems with the book is how Pfeiffer conflates different diseases spread by ticks which could be confusing to the non-medical reader. While it is definitely the case that multiple infections with tick-borne pathogens can occur in the same person, it is not the usual case and lumping them all into the “Lyme” problem makes matters worse. For example, Borrelia miyamotoi does not cause Lyme Disease — it causes a distinct clinical syndrome — as does Babesia microti. The reader is left with dread feeling that every tick bite will unleash a Pandora’s Box of pathogens upon them and that of all infectious disease threats, this is the most pressing (while she discounts the arguably largest threat of antibiotic resistance fueled by antibiotic overuse).

I also have a lot of objections to what she writes about standard testing, its limitations, and the clinical diagnosis of Lyme by its characteristic rash.

I fear this book will make the field even more contentious and give patients, who desperately want answers for their symptoms, to continue down the wrong lane lined with those will not offer any evidence-based, scientific answers or therapies.

Could it Be "Lime's"? Lyme Disease & Some Thoughts on Diagnosis

One of the benefits (or drawbacks) of practicing medicine in Western Pennsylvania is that we're in the middle of an area in which Lyme Disease is highly prevalent. This prevalence has caused the general public to be very aware of Lyme Disease (or, as they call it, "Lime's Disease"--a phrase that instantly makes me cringe both for the mispronunciation and for the abyss I am about to descend). Such an awareness, in many ways, has mixed results. On the one hand, an informed patient is unequivocally better than one who is not: it can make diagnosis and treatment much easier as well as help with public health messaging regarding  precautions needed to take to avoid ticks. However, the general public is often unable to sift through all the misinformation about Lyme that exists and understand when it is truly a possibility and when it is arbitrary to suggest its involvement in an illness (let alone responsible for "chronic" symptoms).  I recently was asked to test for Lyme disease in a person with stroke symptoms.

Because Lyme disease has various stages and varied symptoms, many people have heard anecdotes about someone they know with mysterious symptoms that were eventually found to be due to Lyme disease. However, what must be kept in mind is that though there are rare cases of many conditions that have been shown to be the result of Lyme disease, they are a rarity and testing for Lyme disease in the absence of a real suspicion of a role for Lyme can lead one down the wrong path. It must be remembered that at least 10% of people with positive Lyme results have had asymptomatic infections and a positive antibody test will be meaningless if just tested as part of a "shotgun" approach to diagnosis.  

Chances are that any given person's stroke is caused, not by Lyme, but by atherosclerosis--indeed a major study on this topic said Lyme testing added "little value". The same is true is for the myriad other conditions that often get blamed on Lyme. This is not to say that Lyme isn't capable of being behind someone's nebulous symptoms, just that many people (physicians included) seize on Lyme when they're looking for a quick and easy answer.


Post-Lyme Syndrome: The Result of Altered Immunity, not Chronic Infection

One of the controversies in infectious diseases surrounds Lyme Disease. There is a large group of patients who, once adequately treated for the infection, continue to experience symptoms such as chronic pains, malaise, and related complaints. 

Although patients--and some clinicians--attribute this to ongoing replication of Borrelia burgdorferi, there is no evidence that a chronic form of infection amenable to antimicrobial therapy exists. A recent paper has shown that some Borrelia antigens may persist in a mouse model, but that does not mean long term antimicrobial therapy is warranted or beneficial in humans. The IDSA guidelines, which unfortunately continue to spark controversy, reflect this position.

Many infectious disease physicians believe that post-Lyme symptoms are the result of the specific immune constitution of individuals and, as such, prolonged antimicrobial therapy offers no benefit as clinical trials have shown.

A recent study, published in Clinical Infectious Diseases, attempted to assess if there are  immune differences in those that experience chronic Lyme symptoms. One of the fascinating results of this study was that, even prior to treatment, those that develop chronic Lyme symptoms have an altered polarity of their immune system when compared to those who suffer no chronic symptoms. Specifically, elevations of IL-23, a molecule which promotes the proliferation of Th 17 T cells, a specific class of immune cell linked to the development of autoimmune phenomena, were found to be associated with the development of chronic Lyme symptoms. One caveat: the study was conducted in Europe where B.afzelii is the culprit bacteria, which may limit its generalizability to the US setting.

The importance of this study is that it will, hopefully, dissuade those who demand chronic antimicrobial therapy from such requests while, at the same time, point the way towards fruitful areas of research that may yield effective treatment.