Is Lyme Disease Overlooked in Infectious Disease Consultations?

In their article “Functional signs in patients consulting for presumed Lyme borreliosis,” Voitey et al. [1] examined patients referred to infectious disease specialists for suspected Lyme disease.

Patients referred for infectious disease consultations often present with complex symptoms. When diagnostic criteria rely heavily on laboratory testing, some cases of Lyme disease may be overlooked.

Among the 48 patients diagnosed with Lyme disease, the most common Lyme disease symptoms were arthralgia (23%), neuropathic pain (23%), and asthenia (17%). Asthenia is characterized by abnormal physical weakness or lack of energy.

Their findings raise an important question: Is Lyme disease being overlooked during infectious disease consultations?

“Unlike published data, arthralgia and myalgia were more frequent in our study: 30% and 6% of cases respectively,” writes Voitey.

Another eight patients were diagnosed with probable Lyme disease, reflecting the complexity of the diagnostic process.

• Five patients had meningoradiculitis (suggestive clinical signs and symptoms, positive serology, but lumbar puncture was not performed and symptoms improved after treatment).
• One patient had myositis (persistent localized muscle pain with positive Lyme serology and resolution after antibiotic therapy).
• Two patients had sensory polyneuropathy (axonal involvement confirmed by electromyogram, positive Lyme serology, no CSF pleocytosis, but a positive index for intrathecal antibody synthesis in CSF).

Lyme Disease Diagnosis in Infectious Disease Consultations

The infectious disease specialists concluded that the remaining 196 individuals had another condition.

“A differential diagnosis was made at the end of the consultation for 196 (64%) patients, mainly rheumatologic diseases (25.5%), psychiatric disorders (25%), neurological disorders (11%), infectious diseases (9.6%), and dermatological disorders (9.6%),” writes Voitey.

[bctt tweet=”Infectious disease doctors concluded 36% of patients referred for Lyme consultation did not have Lyme disease. Or did they?” username=”DrDanielCameron”]

However, the authors were unable to make a diagnosis for the remaining 111 individuals.

“No diagnosis was found or suggested at the end of the infectious disease consultation for 36% of patients.”

Interestingly, these individuals—who were not diagnosed with Lyme disease—were more symptomatic than those who were diagnosed.

The non-Lyme group exhibited asthenia (59%), myalgia (32%), and generalized pain (31%).

Lyme disease diagnosis can also be complicated by Lyme disease coinfections, which may produce overlapping symptoms and make clinical evaluation more difficult.

The authors did not question the EUCALB Lyme disease criteria [2], which rely heavily on positive serologic tests or confirmation by spinal tap.

Strict diagnostic criteria may miss patients who have clinical symptoms of Lyme disease but lack confirmatory laboratory testing.

These criteria also do not include several manifestations commonly seen in clinical practice, including neuropsychiatric Lyme disease and post-treatment Lyme disease syndrome.

Nor did the authors question the reliability of the alternative diagnoses assigned to many patients.

“No systematic multidisciplinary meeting was held, and patients were referred to a specialist based on the initial clinical presentation and on the infectious disease specialist’s advice,” writes Voitey.

These findings raise concerns that Lyme disease may sometimes be underdiagnosed during infectious disease consultations, particularly when symptoms are complex or laboratory tests are inconclusive.

The difficulty diagnosing patients with complex symptoms highlights why Lyme disease tests the limits of medicine, particularly when laboratory tests are inconclusive and clinical judgment becomes essential.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

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