Doctors described a 23-year-old woman with severe chronic pain for nine years due to PTLDS in the journal Saudi J Anaesthsia. “Her functionality was severely affected; she was bedbound for approximately 5 years and required a wheelchair.” writes Lim from the Department of Anesthesia and Perioperative Care, University of California, San Francisco. 1 Her medical history also included fibromyalgia, hypothyroidism, anxiety/depression, and insomnia.
Her skin, spine, bones and joints pain was severe and difficult to treat. “She had severe pain episodes requiring emergency department visits and admissions with notably poor response to opioids but relieved with ketamine.” writes Lim. Her pain medications had included an extensive list of pain therapy modalities and medications, a history of sustained use of opioid medication, methadone, and buprenorphine 2 mg tablet for breakthrough pain approximately once every 3–4 weeks.
Her pain medication list was extensive as she was preparing for dental extraction. She was able to taper the methadone prior to surgery. Her symptomatic management also included clonazepam (0.5 mg nightly), and quetiapine (200 mg nightly).
She was evaluated by preanesthesia clinic for perioperative multimodal pain management therapy.
Not surprisingly, there was a considerable amount of pain despite uneventful extraction of four molars. “The patient received fentanyl 250 mcg intravenous (IV), ketamine 100 mg IV, acetaminophen 1000 mg IV, and ketorolac 30 mg IV for pain control.” writes Lim. “At the end of surgery, local anesthetic was administered in all four quadrants by the surgeon for postoperative pain relief.”
The pain was severe and uncontrolled in the recovery room. “The patient received an additional fentanyl 250 mcg IV, hydromorphone 1.2 mg IV, lorazepam 2 mg IV, gabapentin 600 mg p.o., and ketamine 50 mg p.o.” writes Lim. “Her pain was still severe and uncontrolled; therefore, a ketamine infusion was started at 5 mcg/kg/min.”
The escalation of pain and hypoxia required transfer to the Intensive Care Unit (ICU). “A multimodal pain regimen was used for 2 days and included: ketamine infusion; acetaminophen 1 g IV four times a day; ketorolac 15 mg IV four times a day; sublingual buprenorphine 2 mg once a day; oxycodone 10–20 mg p.o. as needed; and hydromorphone 0.4–1.2 mg IV as needed.”
She remained on pain meds on discharge. was discharged home on day 3. “Discharge pain medications included ibuprofen 800 mg three times a day, oxycodone-acetaminophen (5/325) two tablets four times a day, ketamine 20 mg four times a day, gabapentin 600 mg three times a day, clonazepam 0.5 mg nightly, sublingual buprenorphine 2 mg once a day, and hydromorphone 4 mg every 4 h as needed.” writes Lim. “The patient was expected to taper off medications for acute pain over a period of several days as acute pain from her dental procedure was expected to resolve over that period of time.”
Doctors have confirmed that PTLDS is a serious condition last can last for year. The woman described met the definition of PTLDS described by Lim.2 “The definition of PTLDS by the Infectious Disease Society of America in 2006 includes (1) documented episode of early or late Lyme disease with posttreatment resolution of the symptoms, (2) subsequent onset of symptoms of fatigue, widespread musculoskeletal pain with or without cognitive difficulties, (3) symptoms lasting for at least 6 months, and (4) symptoms severe enough to reduce the functional ability of the patient.
There are doctor that have concluded that the cause of chronic pain of PTLDS. Is inflammatory, musculoskeletal, neuropathic, and/or mixed.” The persistent symptoms may be due to central sensitization, which is known as central sensitivity syndrome (CSS).” writes Lim. “
There are doctors who are concerned that a persistent infection might underlie the PTLDS.3 There is no test to confirm that post-treatment means the infection has resolved. The trials that suggested that antibiotics are not effective for persistent infection are flawed. There are growing concerns that Lyme and tick borne illnesses are more complex than originally thought.
It would be reasonable to revisit the woman’s PTLDS clinical history to determine she was adequately treated for her infection. There are patients who have been diagnosed with PTLDS after only 3 weeks of doxycycline.
Lim S, Kinjo S. Exacerbation of chronic pain after dental extractions in a patient with post-treatment Lyme disease syndrome. Saudi J Anaesth. 2018;12(1):112-114.
Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-1134.
Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther. 2014:1-33.
