Supervillain or Drama Queen? Differentiation of Reinfection from Relapse in Recurrent Lyme Disease

Published - Written by John Staples

Like a cinematic supervillain, Borellia burdorferi is sometimes portrayed as a big, bad boogeyman that’s vexingly difficult to kill. Proponents maintain that an episode of Lyme disease requires prolonged antibiotic treatment that lasts for months. Nonsense, says the Infectious Disease Society of America (IDSA): A standard course of treatment is adequate, and more elaborate or prolonged antibiotic prescriptions simply exposes patients to unnecessary treatment-related risks.

While the on-line debate about the management of Lyme disease is remarkably vitriolic, B. burgdoferi is no stranger to controversy. Practitioners offering unconventional approaches to Lyme disease are routinely reprimanded for being charlatans and quacks, while conspiracy theorists accuse the medical profession of corruption and cover-up. All of this acrimony has prompted numerous physician disciplinary hearings, countless magazine articles, an antitrust investigation of the IDSA, a feature-length film, and fodder for the recently-concluded American presidential campaign. Even if B. burgdorferi isn’t a supervillain, it certainly qualifies as a drama queen.

In this week’s NEJM, Dr. Robert B. Nadelman (New York Medical College, NY) and colleagues report on a clever study that tries to address the controversy surrounding treatment duration. They identified 17 patients with at least two bouts of culture-positive erythema migrans (EM) despite standard antibiotic treatment following each episode. The investigators then compared the B. burgdorferi genotype from each episode to determine if antibiotic failure and relapse was responsible for the recurrent EM.

How often was there evidence that it was the same bug coming back to haunt the patient again? The B. burgdorferi genotypes isolated from first and second bouts of EM were distinctly different for all of the 22 pairs of episodes examined. The investigators conclude that recurrent EM is almost certainly the result of a new tick bite and re-infection with B. burgdorferi and very unlikely to be the result of antibiotic failure leading to relapse of the previous infection.

In an accompanying editorial, Dr. Allen Steere (Massachusetts General Hospital, MA) notes the broader context in which the issue of relapse versus re-infection is set: Persistent B. burgdorferi infection has been hypothesized as a cause for medically unexplained symptoms that persist or arise soon after completion of a recommended antibiotic regimen. Considering this study and others, however, Dr. Steere concludes “the weight of the evidence is strongly against persistent infection as the explanation for persistent symptoms in antibiotic-treated patients with Lyme disease.”

This conclusion may not convince the patient advocates and unconventional practitioners on the other side of the debate. Like a supervillain, medical controversy can be surprisingly difficult to put to rest. Recurrence? Sequel? Whatever you call it, this is one argument that is certain to be in the limelight for years to come.