And now if you excuse me, I’m going to get back to trying to hit Infernape with golf balls. That’s how Pokémon Go works, right?
I don’t have much to write about this week. Yeah, yeah, I know. How is that different than the last 50 blog entries? And I will have even less to say next time.
But nothing of real interest has crossed my screen the past two weeks, not that I have really been looking. One of my favorite stories as a kid was Ray Bradbury’s All Summer in a Day. It takes place in the Oregon of my memory.
It is summer in the great Pacific NW and the outdoors and sunshine beckon. Who wants to skim the SCAM when there is hiking, biking, and golf? Golf has become more interesting this year. I tend to hit the links late and we play until dark. It has been a challenge not no kill the Pokémon Go players who wander the course at sunset, roaming in the gloaming clueless as to the dangerous projectiles flying by. Fore! Those are Titleists, not Poké Balls.
Once the sun goes down it has been the conventions that have trumps my attention, so why not a short entry touching on a few aspects exploring issues and controversies in science, medicine, and politics? (more…)
Borrelia burgdorferi, the spirochete bacteria that causes Lyme disease.
While Lyme disease itself is a real and often serious infectious illness, the existence and proper treatment of so-called chronic Lyme disease is dubious, and some would say controversial. However, like many controversies we cover, the science itself is not very controversial, but the topic is made so by a persistent minority of outliers who refuse to accept the scientific consensus.
The issue has been raised yet again by a study published recently in The New England Journal of Medicine: “Randomized Trial of Longer-Term Therapy for Symptoms Attributed to Lyme Disease.” The study was negative, but I will get into the details below.
Lyme in an infection caused by the bacteria Borrelia burgdorferi, and related species. In Europe the infecting species are B. afzelii and B. garinii. These bacteria are spirochetes, which refers to their spiral shape. They are related to the bacterium which causes syphilis, Treponema pallidum, which is also a spirochete.
Syphilis and Lyme both have three stages of illness – a primary infection, secondary symptoms, and then a persistent tertiary syndrome. With Lyme disease, stage 1 involves local infection, including headache, fever, chills, and local arthritis. Stage 2 is disseminated Lyme, including the classic target- or bullseye-shaped rash at the site of the bite, pain, weakness, fatigue, and diffuse arthritis. Stage 3 is persistent late stage infection, and includes ongoing stage 2 symptoms, heart involvement, and neurological involvement. (more…)
The little burrowing bacteria that bores into your pores to cause Lyme disease, EEEEEWWW!!! Darkfield 400x microscopy image of the 10-25µm long Borrelia burgdorferi spirochaete which causes Lyme disease (1993). Provided by the CDC’s Public Health Image Library (PHIL #6631) via the Wikimedia Commons
I hate those oh hell moments. I was up way too late last night, but who can pass up the opportunity to see Patti Smith playing Horses (and more) for the 40th anniversary of the album. Only 44? Behind the Eagles? No way. I would nudge it up a few more spaces. Hard to believe I was 18 when that album came out. Horses is one of the few albums that made the transition from vinyl to CD. It was a tremendous show, and at 69 Patt performs with the energy and passion of a 29 year old. And she sure can spit. I had the evening off, so food and drinks at Swine until well past midnight. First time my wife and I closed a bar. I am too old for this.
But as I was blearily drinking my a.m. coffee on a dreary PDX morning, I opened the browser to SBM and there was a post by Jann. Oh hell. That means I have a post due tomorrow and I had lost track of the time over the holidays. I thought my next post was next Friday. Oh. Hell. So unlike most posts which I write over a week, this one was done in about 4 hours. And I am sure it will show.
How do you diagnose an infection?
Not always so simple. You always start with a history and, for infectious diseases, an exposure history is paramount. People get what they are exposed to, so you want to know travel, animals, diet, water, sex etc. If you have ridden a horse to have sex in an Indian lake while drinking raw milk (not really an unusual history in my practice; people do the darndest things) you have exposure risks for a variety of infections. If you have not left the Willamette Valley it is unlikely that the cause of the illness is malaria, although you always have to consider that the infection came to the patient rather than the other way around. (more…)
The black-legged tick responsible for spreading the bacteria that causes Lyme disease
I noted with understanding that the Doubtful News can’t take it anymore. The relentless tsunami sewage slurry of pseudo-science (who says I can’t alliterate?) has worn her down. She is:
currently experiencing a phase in which I can’t seem to bring myself to promote another ridiculous story in the media about a haunted location, scary sounds from the sky, or the latest outrage fueled by ancient superstition. You might call that… jaded. It’s been over four years now of nearly daily effort to keep track of the weird world of woo. It can wear one down when virtually or literally the same thing appears and reappears over and over as if it hasn’t already been passed around a million times.
I sympathize. I have had a touch of SCAM ennui of late. It is a bit due to the repetitiveness of the SCAMs. I still find the variations on the theme of pseudo-sciences curious. It is like infectious diseases where every case has unique and subtle diversity so no two SCAMs are the same. But there are almost 4,000 clinical trials on acupuncture and I would wager that they all have several of the same half-dozen fatal errors. It is like hand hygiene at work. We have known for, oh what, 160 years, that hand hygiene prevents the spread of disease but people still can’t do it right. We know how to do a good clinical trial but the SCAMsters just can’t seem to figure it out.
The ennui is not the seeming futility of the endeavor. I have always been comfortable with futility, secure, as an example, in the knowledge that someday I will be consumed by the bacteria I spent a career killing. Unless, of course, they get me cremated right away. I keep looking for a motto for the SfSBM; I am attracted to “Sisyphus had it easy.” (more…)
The black-legged tick, responsible for spreading Borrelia burgdorgeri, the bacteria that causes Lyme disease
As the saying goes, when you do not have the facts, argue the law. This tried and (?) true approach was successful in New York where a law was passed protecting those who are, shall we say, creative in treating patients with Lyme and ‘chronic’ Lyme.
The bill protects those from investigation of misconduct:
based solely on treatment that is not universally accepted by the medical profession.
The major bone of contention has been extended courses of IV antibiotics for ‘chronic’ Lyme, but there are a wide variety of treatments that may be used by so called “Lyme literate” doctors.
The number of therapies divorced from reality that are offered to Lyme patients is remarkable. I do not know if chronic Lyme patients have greater use of pseudo-medical therapies than other pseudo-diagnoses, but I am impressed by the offerings in a recent review:
Results. More than 30 alternative treatments were identified, which fell into several broad categories: these included oxygen and reactive oxygen therapy; energy and radiation-based therapies; nutritional therapy; chelation and heavy metal therapy; and biological and pharmacological therapies ranging from certain medications without recognized therapeutic effects on Borrelia burgdorgeri to stem cell transplantation. Review of the medical literature did not substantiate efficacy or, in most cases, any rationale for the advertised treatments.
Conclusions. Providers of alternative therapies commonly target patients who believe they have Lyme disease. The efficacy of these unconventional treatments for Lyme disease is not supported by scientific evidence, and in many cases they are potentially harmful.
The western black-legged tick, carrier of the Borrelia burgdorferi bacteria which causes Lyme disease.
The practice of infectious disease (ID) is both easy and difficult. If you read my ID blog on Medscape you are aware of my trials and tribulations in diagnosing and treating infections.
ID is easy since, at least in theory, diseases have patterns and an infecting organism has a predictable epidemiology and life cycle. So if you can recognize the pattern and relate it to the life cycle and exposure history, you can often make a diagnosis before the cultures come back.
My favorite story is the time I was asked to see a young girl with endocarditis. The history was she had a week of fevers, headache and myalgia that went away for five days, returned for a week, went away for five days and returned yet again.
So I asked her “How was your vacation at Black Butte?”
The look of astonishment on her face as she asked how I knew she had been to Black Butte was so satisfying. (more…)
New York may soon join a handful of other states who reject science-based guidelines for the treatment of Lyme disease in favor of ideological guidelines based on the vociferous lobbying of patients and “Lyme literate” health care providers. Ignoring science is an unfortunate but well-known legislative phenomenon. I’ve discussed it a number of times on SBM, in the form of Legislative Alchemy, the process by which credulous state legislators turn practitioners of pseudoscience into state-licensed health care professionals, such as naturopaths, chiropractors, homeopaths and acupuncturists.
Lyme disease is an infectious disease transmitted by a tick bite. Its symptoms are a rash, fever, headache and fatigue, although not all symptoms may appear. According to the Infectious Diseases Society of America (IDSA):
Lyme disease is diagnosed by medical history, physical exam, and sometimes a blood test. It may take four to six weeks for the human immune system to make antibodies against Borrelia burgdorferi and therefore show up in a positive blood test. That is why patients with the Lyme rash usually have a negative blood test and diagnosis is based on the characteristic appearance of the rash. Patients with other clinical manifestations such as Lyme arthritis will usually have a blood test. Anyone who has symptoms for longer than six weeks and who has never been treated with antibiotics is unlikely to have Lyme disease if the blood test is negative.
Treatment with antibiotics usually eliminates the symptoms, but delayed treatment can result in more serious problems. (more…)
It’s that time of year when every day I can expect to see at least one patient with a concern about Lyme disease. In Lyme-endemic regions such as Western Massachusetts, where I practice pediatrics, summer brings a steady stream of children to my office with either the classic Lyme rash (erythema chronicum migrans, or ECM), an embedded tick, a history of a tick bite, or non-specific signs or symptoms that may or may not be due to Lyme disease. Sometimes the diagnosis is relatively straightforward. A child is brought in after a parent has pulled off an engorged deer tick, and there is a classic, enlarging ECM rash at the site of the bite. More often the presentation is less clear, requiring detective work and science-based reasoning to make an informed decision and a diagnostic and therapeutic plan based on the best available evidence. Depending on the story, the plan may include immediate treatment without any testing (as in the straightforward case described above), immediate testing without treatment pending test results, or waiting as we watch and see how a rash progresses before doing anything. An example of this latter course of action would be when a patient comes in with a pink swelling at the site of a new tick bite. In this case, it may not be clear if the swelling is a Lyme rash or simply a local reaction to the bite, a much more common occurrence. The classic ECM rash (an enlarging, red, circular, bull’s-eye rash at or near a tick bite) typically develops 1-2 weeks after a tick bite, but can occur anywhere from 3-30 days later. It then expands and darkens over another 1-3 weeks before fading. This classic rash is not the most common rash of Lyme disease, however, as it occurs in only about 30% of cases. Instead, the rash may be uniformly pink or red (or even darker in the center) without the target-like appearance, or may be a linear rash, expanding outward from the tick bite site. In the case of a patient who comes in with a vague, pink swelling within a day few days of a tick bite, we will typically wait and see what happens to the rash. If it is a local reaction, it will likely resolve within another few days. With Lyme disease, the rash will continue to enlarge and declare itself as an ECM rash. Another unclear and not uncommon situation is when a patient comes in with non-specific symptoms such as fatigue, musculoskeletal pains, and headache. If warranted by the history and the physical exam, we may in this case order Lyme testing. This may not give us an answer even if the patient has Lyme disease, because results are often negative in the first few weeks of the disease. In this case, if symptoms persist or evolve, we will repeat the testing in another few weeks at which point true Lyme disease will test positive and can then be treated. The good news is that the treatment of Lyme disease, particularly in the early, localized phase of the disease, is extremely safe and effective with a 14-day course of antibiotics. The testing is also relatively straightforward, with very good sensitivity and specificity when performed correctly. And this is where the bad news comes… (more…)
A black-legged tick responsible for spreading the bacteria that cause Lyme disease.
I recently had a pleasant, brief email exchange with Kris Newby, the producer of the latest medical advocacy pic, Under Our Skin. There’s been a number of similar movies lately, mostly about quacky cancer therapies. This one is apparently much better made, and follows the controversy regarding “chronic” Lyme disease.
I’d heard an interview about the movie on Diane Rehm, and was rather unnerved by it. It sounded like a typical I-drank-the-Kool-Aid-now-I’m-gonna-make-a-movie kind of thing. Still, I haven’t written about it, because I haven’t seen the movie. That’s going to change. Kris is being kind enough to send me a copy, despite my warning that I’m very likely to pan it.
Anyway, in our conversation, she recommended that I check out a particular piece in the Journal of Medical Ethics. Before I go into the significance of this paper, let me give you a little background. Stick with me here, I’ll make it brief. (more…)