CLINICAL JUDGMENT FOR MULTISYSTEMIC ILLNESS

The Need for Clinical Judgment in the
Diagnosis and Treatment of Lyme Disease


Elizabeth L. Maloney, M.D.



extract


The wide array of Lyme disease symptoms is consistent with Borrelia burgdorferi’s ability to infect multiple organ systems; nervous system involvement creates the potential for varied and atypical symptoms. Common symptoms include: EM rash, fever, fatigue, headache, neck pain, joint or muscle pain, paresthesias, memory impairment, weakness of facial muscles, mood disorders, neuropathic pain.



further extract


It is the multisystemic nature of the illness that provides physicians
with useful diagnostic information. In fact, with the exception of an
isolated EM rash or swollen joint, patients with symptoms restricted to
a single system are unlikely to have Lyme disease. Recognizing the
potential for disease is different from “seeing it everywhere.” Failure
to recognize Lyme disease may lead to serious harm, as antibiotics are
delayed and the infection is unchecked.


The nonspecific nature of many Lyme disease symptoms leads
some to suggest that such symptoms hold no diagnostic value. Lyme
disease is like many other illnesses that present with nonspecific and
often subtle symptoms—symptoms that may go unrecognized by
physicians. Examples include hypothyroidism, ovarian cancer, and
acute sub endocardial myocardial infarction. What gives the
individual symptoms of Lyme disease value is their occurrence in
clusters; a single symptom means little but four or five may, for all
practical purposes, make the case. Just as abdominal bloating, urinary
urgency, and pelvic pain raise “red flags” for gynecologists, the
combination of fatigue, paresthesias, arthralgias, and memory
complaints presenting in a single patient commands the attention of
physicians aware of these potential Lyme disease symptoms.


Steere et al. noted that patients with early Lyme disease who
lacked an EM rash presented with an average of four or more
symptoms. Fever, chills, malaise, and myalgia, all nonspecific, were
present in 46%-71% of the patients with definite Lyme disease alone.
In this group, it was the clustering of nonspecific symptoms in the
appropriate setting that led to the correct diagnosis of Lyme disease.


Logigian et al. also noted the nonspecific nature of identi-fying
symptoms: “The most common form of chronic central nervous
system involvement in our patients was subacute encephalopathy
affecting memory, mood, and sleep, sometimes with subtle
disturbances in language.


Diagnosis of this condition may be difficult
because the typical symptoms are nonspecific” [emphasis added].


To provide a clinical level of diagnostic sensitivity higher than two tier
testing, physicians need to recognize the symptom clusters and
maintain a high index of suspicion for Lyme disease.



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