Can Lyme Disease Be More Severe in Immunocompromised Patients? Lessons From a Rituximab Study
Lyme disease in patients with weakened immunity
Rituximab and increased risk of dissemination
Implications for diagnosis and treatment
Can Lyme disease be more severe in immunocompromised patients? A small study found that patients receiving Rituximab had higher rates of disseminated Lyme disease and Borrelia detected in the bloodstream compared with immunocompetent individuals.
A small study examined the risk of developing disseminated Lyme disease in people with weakened immune systems. Researchers enrolled seven patients with erythema migrans (EM) who were diagnosed with Lyme disease while receiving Rituximab therapy.
All seven patients initially presented with erythema migrans, the most common early manifestation of Lyme disease.
Why immune suppression may matter in Lyme disease
Rituximab is a medication used to treat conditions such as rheumatoid arthritis, non-Hodgkin lymphoma, chronic lymphocytic leukemia, and granulomatosis with polyangiitis. Because it affects B cells, it can alter the body’s immune response to infections.
Four of the seven patients were also receiving additional immunosuppressive medications, including corticosteroids, methotrexate, and bortezomib.
“Rituximab is the anti-CD20 monoclonal antibody that influences B cells and consequently impairs secretion of antibodies, antigen presentation, and secretion of cytokines,” write Maraspin and colleagues.
What is disseminated Lyme disease?
Disseminated Lyme disease occurs when Borrelia burgdorferi spreads beyond the initial tick bite site. Patients may develop multiple erythema migrans lesions, neurologic symptoms, Lyme carditis, Lyme arthritis, or evidence of infection in the bloodstream.
In this study, patients receiving Rituximab had higher rates of disseminated Lyme disease than immunocompetent patients treated at the same institution.
Signs of disseminated Lyme disease
According to the authors, 43% of the patients treated with Rituximab showed signs of disseminated Lyme disease compared with only 8% of immunocompetent individuals.
The isolation rates of Borrelia from the bloodstream before antibiotic treatment were also unusually high (40%) compared with immunocompetent patients (<2%).
Patients receiving Rituximab were therefore more likely to have evidence of bloodstream infection before treatment.
“Impaired immunity might be an explanation for the complicated course of LB (signs of disseminated LB or unfavorable outcome after antibiotic treatment) present in 57% of our patients, but rarely seen in immunocompetent adult patients with EM,” the authors write.
Three patients with multiple erythema migrans lesions were treated with intravenous antibiotics. The remaining patients received oral antibiotic therapy.
Treatment response and retreatment
One patient, a 65-year-old woman, failed initial treatment.
“Her skin lesion persisted for >2 months after the start of treatment with doxycycline,” explain Maraspin and colleagues. “However, it disappeared after retreatment with amoxicillin and the subsequent clinical course was uneventful.”
At one-year follow-up, none of the patients had objective signs of Lyme disease. However, the authors did not report whether symptoms such as fatigue, pain, or cognitive difficulties persisted.
Because this study included only seven patients, larger studies are needed to confirm these findings.
Previous reports of treatment failure
Another study by Maraspin and colleagues reported that 25% of Lyme disease patients receiving immunosuppressive drugs such as adalimumab, infliximab, etanercept, or golimumab experienced treatment failure. Three of the four patients required retreatment.
Patients with weakened immune systems were also more likely to develop signs of disseminated Lyme disease when compared with immunocompetent individuals.
Frequently Asked Questions
Can Lyme disease be more severe in immunocompromised patients?
This small study found higher rates of disseminated Lyme disease among patients receiving Rituximab compared with immunocompetent individuals.
Can Lyme disease make you immunocompromised?
Lyme disease itself is not generally considered an immunocompromising condition. However, altered immune responses have been described in some patients.
Does Rituximab increase the risk of disseminated Lyme disease?
Patients treated with Rituximab in this study had higher rates of disseminated Lyme disease and bloodstream infection than immunocompetent patients.
Can people taking Rituximab get Lyme disease?
Yes. Patients receiving Rituximab can develop Lyme disease and may be at greater risk for disseminated infection because of altered immune function.
Can Lyme disease treatment fail in immunocompromised patients?
Treatment failures occurred in some patients receiving immunosuppressive therapies, although most improved after additional treatment.
Clinical Takeaway
This small study suggests that patients receiving Rituximab may have a greater risk of disseminated Lyme disease and treatment complications than immunocompetent individuals.
Clinicians should consider Lyme disease promptly in immunocompromised patients who develop erythema migrans or other signs of tick-borne illness.
It remains unclear whether immunocompromised patients are also at greater risk for persistent fatigue, pain, cognitive symptoms, or other long-term manifestations following Lyme disease.
The relationship between immune suppression and Lyme disease severity remains an important area for future research.
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Persistent Lyme disease symptoms
Coinfections and Lyme disease
Can Lyme disease trigger an autoimmune disease?
References
- Maraspin V, et al. Erythema Migrans: Course and Outcome in Patients Treated With Rituximab. Open Forum Infect Dis. 2019;6(7):ofz292.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
I had undiagnosed Lyme in mid 80′ -`1994 ,5,96
never positive so not treated for years. Dr.s in England wrote all the info, which i followed , first a positive IGG and IGM ( was told by Yale ” what do they know in England, you have fibromyalgia ,” eventually a very positive spinal tap before the first spinal surgery in 1994.
Obviously much more occurred and was observed which I will skip.
other than severe rheumatoid arthritis and erosive and sjogrens syndrome etc
i felt the lyme was more or less gone and the autoimmune situation was actually probably helping with that. Recently i was put on sulfasalazine first and then cimzia
right away after first injection i knew somethng was not right, by the second the arthritis exploded in the only 2 uninvolved joints left , my hips, both knees, Left already replaced, became white hot, swollen etc , left ring finger went ballistic and throbbed unlike other long ago attacks on my hands that had already crippled and deformed them etc. ETC.
I had a new arthritis dr, whom i had never seen, no tests were ever done , and when i finally 5 months later saw the new dr and told her what was happening and what i thought had happened she had me tested and said i was fine. i said exactly what this article says and she was rather unpleasant! After reading this article thank you!
I will never take another drug for this and hope my immune system will kick in and help . I now live in Florida ( having moved from Westport CT) I am writing a synopsis of my experience through all these years for John Hopkins which I hope will help others, including 1 heart attack and 3 TIAs that occurred while it was active.
I am an 80 year old female. Rower , athlete , now having incredible difficulty walking, and unable to row for the last 1 1/2 yr after c2- t2 cervical surgery which caused more problems along with this new explosion. thank you it felt great to read this article and to vent that i was right1
marisol laux
You are not alone