Dr. Daniel Cameron: Inside Lyme Podcast

Lyme Podcast: 75-year-old Chinese man with a negative Lyme disease test

A 75-year-old Chinese man with a negative Lyme disease test.

I will be discussing a 75-year-old Chinese man with a negative Lyme disease test. How often have doctors dismissed Lyme disease if the screening tests are negative?

Lamichhane and colleagues first discussed this case in the journal Case Reports in Infectious Diseases  in 2018.

A 75-year-old Chinese man was evaluated in an emergency room for an unsteady gait. He had a history of hypertension, hyperlipidemia, coronary artery disease, diabetes mellitus, benign prostatic hyperplasia, and osteoarthritis wrote the authors.

His examination was normal. His blood tests showed mild anemia and had a low platelet count. He was sent home.

He was hospitalized four days later with a maximum fever of 105 degrees Fahrenheit and an unsteady gait. He found it difficult to maintain his balance. He suffered from “rigors, chills, diaphoresis, diffuse myalgias, generalized weakness, malaise, confusion, and decreased appetite.” wrote the authors.

A negative Lyme disease test

The most significant findings were continued mild anemia, a decrease in his white blood cells, and a marked reduction in his platelet count. The doctors considered Lyme disease. He initially had a negative Lyme disease test. The doctors apparently did not request a western blot test after the initial negative Lyme disease test.

The doctors suspected a bacterial infection. They prescribed ceftriaxone, ampicillin, and vancomycin.

How often have doctors dismissed Lyme disease if the screening tests are negative? I address this question in an Inside Lyme podcast. Click To Tweet

By the next day, the man’s condition worsened. His heart rate climbed to over 200. His blood pressure dropped. He developed encephalopathy. Encephalopathy refers to brain disease, damage, or malfunction. The symptoms can range from memory loss or subtle personality changes to acute confusion and dementia.

His doctors then ordered more than the screening Lyme disease test. His blood tests were now positive for Lyme disease and Babesia. He was positive for Lyme disease by a Lyme IgG and IgM ELISA test and Lyme IgM Western blot. He was also positive by Babesia microti IgG and IgM antibody tests.

A spinal tap is ordered

His doctors arranged for a spinal tap despite the absence of evidence of meningitis. His spinal tap was positive for Lyme disease by IgM and IgG western blot bands. Three of 3 of his IgM western blot were positive. Nine of 10 IgG western blot bands were positive for Lyme disease. Doctors only need 2 of 3 IgM and 5 of 10 IgG western blots to be positive according to the CDC criteria.

Spinal taps have not been all that helpful in some studies. Less than one in ten patients with chronic neurologic Lyme disease tested had an abnormal spinal tap in a 1990 study by Logigian and colleagues.

The man was diagnosed with Lyme neuroborreliosis. He was prescribed doxycycline for 21 days.

He was not treated for Babesia. He would have had to have been treated with medication like the combination of atovaquone and azithromycin.

Within 48 hours, his cognitive function and gait returned to normal, according to the authors.

The authors summarized the difficulties making a diagnosis of Lyme neuroborreliosis. The authors write, “Here we have presented a patient who had no characteristic clinical signs of LD, whose main symptoms were a high fever, encephalopathy, diffuse myalgia, and tachycardia.” A broad range of other tests were normal.

“The single diagnostic modality yielding concrete results was the patient’s CSF Lyme serology.” write the authors.

What can we learn from this cases?

  1. Lyme disease can lead to an abnormal gait and encephalopathy.
  2. The doctors diagnosed Lyme disease despite the initial negative Lyme disease test.
  3. The man had neurologic Lyme disease despite the absence of signs of meningitis.

What questions does these cases raise?

  1. How often have doctors dismissed Lyme disease if the screening tests are negative?
  2. Should the doctors have treated for Babesia? He is over 50, placing him at a higher risk of complications of Babesia. I have patients with Babesia who are symptomatic and finding it difficult to function. It would have been helpful to have the man return for follow-up to assess his symptoms and function.
  3. What is the long-term outcome for this 75-year-old Chinese man with Lyme disease and Babesia?

Treating Tick-Borne Disease In My Practice

In my practice, each individual requires a careful assessment. That is why I order a broad range of blood tests for other illnesses in addition to tick-borne infections. I also arrange consultations with specialists as needed.

Many patients are complex, as highlighted in this Inside Lyme Podcast series.

We need more doctors with skills recognizing tick-borne illness if a patient has a negative Lyme disease test. We hope that professionals evaluating individuals with a negative Lyme disease test can use this case to remind them to look for tick-borne illnesses and treat accordingly.

Inside Lyme Podcast Series

This Inside Lyme case series will be discussed on my Facebook and made available on podcast and YouTube.  As always, it is your likes, comments, and shares that help spread the word about this series and our work. If you can, please leave a review on iTunes or wherever else you get your podcasts.

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References:
  1. Lamichhane J, Haider R, Bekkerman M, et al. A Case of Undetected Neuroborreliosis in a 75-Year-Old Chinese Male. Case Rep Infect Dis. 2018;2018:6764894.
  2. Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med. 1990 Nov 22;323(21):1438-44.
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