Dr. Daniel Cameron: Inside Lyme Podcast
Lyme Podcast: Lyme disease forces 24-year-old army officer out of the military
Welcome to an Inside Lyme case study. I find that the best way to get to know Lyme disease is through reviewing actual cases. I will be discussing a 24-year-old army officer who was forced out of the military due to Lyme disease.
We often think of Lyme disease as a threat to the public engaging in enjoyable outdoor activities, like hiking, camping, and gardening. But Lyme disease and other tick-borne illnesses are a constant threat to individuals serving in the military, who spend much of their time working in heavily forested or mountainous terrain.
Weiss and colleagues first described this case in the Journal of the Pediatric Infectious Disease Society in 2017.
The young man had completed an arthroscopic repair of a labral tear of his hip. A labral tear is an injury to the soft tissue that covers the hip joint. He was expected to return to active military duty.
He developed unexplained knee swelling during his recovery.Lyme disease and other tick-borne illnesses are a constant threat to individuals serving in the military, who spend much of their time working in heavily forested or mountainous terrain. Click To Tweet
Doctors removed 75 cubic centimeters of fluid from his knee, which is about 2 ½ ounces. He was treated for a possible Gonorrhea infection. But the tests for Gonorrhea were negative, and the swelling persisted.
The man, who trained at a U.S. Military Academy, was subsequently diagnosed with Lyme disease. Knee swelling is common in Lyme disease. Knee swelling is typically caused by inflammation of the synovial membranes. The synovial sac contains a very thin layer of slippery, viscous joint fluid, called synovial fluid. The swelling can lead to pain.
This swelling is called bursitis if it occurs in the hips or shoulder and sacroiliitis if it occurs in the lower back where the spine meets the hip.
Discovery of Lyme disease
Polly Murray, a housewife in the Lyme Connecticut area, described joint swelling in family members and neighbors. She brought her concerns to the attention of Dr. Allen Steere at Yale School of Medicine. Her observations led to the discovery of Lyme disease.
Up until the discovery of Lyme disease, individuals with synovitis of the knee had been diagnosed with Juvenile Rheumatoid Arthritis. Juvenile Rheumatoid Arthritis is commonly referred to as JRA.
Doctors had been diagnosing patient with JRA even if the rheumatoid arthritis tests were normal. Doctors had been treating JRA with anti-inflammatory drugs such as ibuprofen.
All that changed with the discovery of a spirochete that caused Lyme disease. Doctors could now treat these individuals with antibiotics.
The young man’s Lyme disease test of the synovial fluid was positive for Borrelia. burgdorferi by antibody titer and PCR. B. burgdorferi is the scientific term for the bacteria that causes Lyme disease. A PCR is a DNA based test. His blood tests were negative for Lyme disease.
Persister cells or reinfection
The doctors could not be certain whether the military officer’s Lyme disease was caused by a latent infection 15 years earlier or reinfection.
If the Lyme disease dated back to when the young man was nine years of age, the author raised the possibility of persister cells. Persister bacteria were first described in tuberculosis. Persister cells are cells that lie dormant and are difficult to treat. Persister cells have observed in Lyme disease in the lab.
The authors write, “Persister bacteria are a dormant form of bacteria that can survive extended periods by inactivating metabolic activity. Persister cells can endure the aggressive use of antibiotics because most antibiotics require active metabolic processes to carry out their function.”
The authors add, “In this case, exposing the synovial ﬂuid of the hip joint during surgery could have triggered activation of dormant B. burgdorferi.”
I am following the persister bacteria research. We will need more research to understand better whether persister bacteria played a role in this man’s synovitis.
The authors also raised the possibility that the young man was newly infected with Lyme disease while serving in the military. Reinfection is most likely as synovitis typically occurs early in Lyme disease.
He was treated with 30 days of doxycycline. The Lyme disease tests of the synovial fluid were negative for B. Burgdorferi after completing his doxycycline treatment.
During treatment, the young man developed swelling in his other knee.
Over the next several weeks, doctors periodically removed fluid from the young man’s knees. The swelling in both knees continued despite time and anti-inflammatory medications.
One of the knees became more swollen and painful. The doctors sent the knee fluid to the laboratory again. The synovial fluid from the knee was positive again for B. burgdorferi in the synovial ﬂuid.
The young man was treated with a month of intravenous ceftriaxone.
The young man remained ill with severe fatigue, memory issues, headaches, sleep disturbances, and complaints of angina. He continued to have chronic knee, hip pain, and minor effusions in both knees.
He developed a Baker’s cyst. A Baker’s cyst is a fluid-filled bulge behind the knee that can occur with synovitis. A Baker’s cyst can be an early sign of Lyme disease. The Baker’s cyst could have also been related to a tear of the meniscus in the knee.
The doctors did not advise additional antibiotics. They concluded that the knee pain was due to reactive arthritis. They prescribed a 200-milligram dose of hydroxychloroquine sulfate. Hydroxychloroquine sulfate has been used to treat auto-immune diseases like lupus and rheumatoid arthritis.
He remained ill on follow-up. He would experience chronic knee and hip pain and knee effusions. He also experienced worsening neurologic symptoms consisting of headaches and nonrestorative sleep.
The authors did not describe the onset and severity of these neurologic symptoms.
Unfit for duty
The young man’s career was over. “Eventually, a medical retention decision point was reached, and he was deemed unﬁt for duty,” wrote Weiss and colleagues.
It must have been frustrating for the 24-year-old army officer to be forced out of the military due to Lyme disease.
It was a financial loss for the military to lose a trained cadet. “The average 4-year cost for educating a single U.S. Military Academy cadet is currently over $300,000,” writes Weiss and colleagues.
There are additional long-term costs. “Medically retiring an officer results in life-long disability payments and medical coverage,” explains Weiss and colleagues.
I agree with the authors’ conclusion: “This case highlights the need for increased surveillance for Borrelia burgdorferi in military training areas and for the early and aggressive diagnosis and treatment of military personnel who present with the symptoms of acute Lyme disease,” explains Weiss and colleagues.
Post-treatment Lyme disease syndrome (PTLDS)
The authors concluded their paper with a discussion of post-treatment Lyme disease syndrome (PTLDS).
Some doctors are using the term for individuals who remain ill for more than six months after antibiotic treatment. These individuals typically suffer from pain, fatigue, and poor cognitive function. They also suffer from poor function.
Some doctors have concluded that patients who suffer from PTLDS do not suffer from a persistent infection. Yet, there is no reliable test to test whether a persistent tick-borne infection has cleared.
What can we learn from this case?
- Military personnel are at risk of tick-borne infections. There is other research affirming the risk to the military and their families.
- Lyme disease can lead to synovitis, bursitis, and sacroiliitis.
- Lyme disease can lead to loss of function. In this case, the young man was deemed unfit for duty.
What questions does this case raise?
- How often are our military personnel and their families affected with tick-borne infections?
- What is the best treatment protocol for military personal with Lyme disease, which remains ill?
- How many military personnel and their families fail treatment.
- Should the young man have received additional antibiotic treatment?
- Should doctors diagnosing military personal with PTLDS inform patients that there are no reliable tests to prove the absence of a persistent infection?
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 diagnosing and treating Lyme disease for men and women serving in the military and their families. We hope that if a professional evaluating these men and women and their families can use this case to remind them to look for Lyme disease and treat accordingly.
We also need to give doctors the freedom to treat these difficult cases without undue interference by colleagues, insurance companies, medical societies, and medical boards.
Inside Lyme Podcast Series
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- Weiss T, Zhu P, White H, et al. Latent Lyme Disease Resulting in Chronic Arthritis and Early Career Termination in a United States Army Officer. Mil Med. 2019.