Wednesday, April 29, 2015

Sunday, April 19, 2015

The Aftermath of Lyme Disease

(check this post out on our new site, Infectious News)

Every so often, a disease becomes shrouded in rumor and innuendo until it is difficult to parse out truth from fiction.  People can take “pro” and “anti” stances, and the topic becomes unnecessarily charged.  Anyone suffering from that disease can become either an involuntary “champion” or the subject of intense eye-rolling.  This is clearly the case with Lyme disease, or more specifically, an ailment called “post-treatment Lyme syndrome” (NOTE: this is distinctly different from the widely circulated name “chronic Lyme disease”, which is a hotly contested and widely debated concept).

Most people who become infected with Borrelia burgdorferi following a bit from an infected tick will develop classic symptoms of Lyme disease including a high fever, malaise, headache, painful joints, and in somewhere between 60-80% of cases, a very distinctive rash.  This rash is called erythema migrans, but is more commonly known as a “bull's eye rash” for obvious reasons (see images below)!  The rash is where a lot of the trouble comes from.  Most of us in the Northeast know that a fever and a bull's eye rash means that one must get to the doctor for Lyme treatment immediately.  Patients presenting this way are usually prescribed the appropriate antibiotic (doxycycline as a standard) in a timely manner and almost always recover fully.  Those patients who are the 20-40% without the bullseye rash can run into trouble getting a timely diagnosis and the appropriate treatment.  This is a problem.

Bull's Eye Rash Schematic (top, and Image (below, Grand Haven Tribune)

B. burgdorferi initially replicates very happily around the site of the tick bite, and then eventually makes its way to the joints.  Occasionally it finds its way into the heart.  Eventually the bacteria invade the spinal cord and brain if left untreated.  One could see where a timely diagnosis and treatment would be critical, given that inflammation and damage done to joints, heart muscle, and especially brain does not readily heal.  Even if the bacteria are eliminated by antibiotic therapy, the damage they generated tends to leave lasting consequences.  These can include joint degeneration, arrhythmias and other cardiac complications, cognitive impairment, hearing or vision loss, loss of motor coordination, possible psychiatric effects, and above all, chronic pain.  Such ailments are life-altering, and should be taken as such.

The internet is likely both the best and worst thing that could have happened for post-treatment Lyme syndrome.  Patients suffering from chronic illness often benefit from connecting with others in similar situations.  On the other hand, there is space for ambiguity in this case because some of its clinical presentations are not visible and the mechanisms underlying the disease are still being discovered as we speak.  Ambiguity and the uncensored internet are not necessarily a good combination, and are breeding grounds for zealots and charlatans (such as these from the "FDA" at, not to be confused with the actual FDA at  All manner of problems have become connected to “chronic Lyme disease”, often with a complete and total lack of peer-reviewed evidence, such as this and this.  This leads some to conclude that anyone with post-Lyme complications is a malingerer, a drug seeker, a conspiracy theorist, or in need of a mental health evaluation.  As described above, this is not the case.  That said, every claim made on the internet cannot and should not be counted as fact.  In preparing this short piece I have spent quite a bit of time reading the most recent peer-reviewed research, and was left feeling a bit overwhelmed by the nuance of this disease.  It is extremely complex, and the design of each study coupled with its statistical methods therefore become critical in evaluating the conclusions.  I definitely feel that an hourly “Lymeology” series is in order to tease some of these nuances apart.  Sufficed to say that there is quite a bit of complexity and much more work still needed to be done and published, and in those situations, rumor and innuendo can take over.  When they do, the entire topic becomes nuclear and polarizing.  Those who suffer?  The 10% of patients left with lasting complications whose treatment is often a clinician’s best guess rather than an established standard of care.  

In closing, it’s just about tick season, and it is predictedto be a bad one.  If you want to avoid a first-hand experience with this topic, it’s best to prevent infection in the first place.  Here’s how.   

Perspective of tick size, for your nightly checks (image:

Sunday, April 12, 2015

Happy 60th, Polio Vaccine

April 12, 1955, 60 years ago today, a much celebrated medical breakthrough was announced.  Before this breakthrough, those suffering from the disease it prevents could be left with partial paralysis, atrophied limbs, confinement to braces, wheelchairs, or iron lungs.  That is a description of survivors, of course.  Not everyone lived through polio.  It was a disease that primarily affected children, though its most infamous patient was the longest-serving president in U.S. history.  It most frequently struck in the warmer months, and as such, summer fevers always instilled a sense of dread in parents of small children.  Was it a case of sniffles or the start of polio?  Would their child recover, be left paralyzed, or die?  If the first child recovered, would he spread it to his siblings?  Would they recover?  Terrifying.  

Patients in "iron lungs"
(Photos: University of Pennsylvania [top]; Polio Canada [bottom])

The medical intervention was the first successful polio vaccine, developed by Dr. Jonas Salk.  While the story of polio immunizations has something for everyone (really!  There is competition, political scandal, jealousy, pettiness...a veritable soap opera), the aspect that is worth celebrating on this day is its inarguable success.  This photo speaks volumes about how this breakthrough was received by families with small children:

Parents and children line up to receive Dr. Salk's vaccine and 
ensure their protection from polio

That line stretched for blocks.  At this stage of life and career I do not often have realizations about diseases that gut-punch me.  Somehow, though, I never thought about the fact that in 1955 my own grandparents would have been standing in those lines, toting my mother and father, aunts and uncles.  If you are in proximity to my age (35), that should give you pause.  But for Jonas Salk, perhaps you would not be here.  In our current global situation which paradoxically contains both voluntary vaccine exempters and outbreaks of polio from infrastructure-related vaccine lapses (most recently noted in SyriaSomalia, and South Sudan), we would do well to remember and celebrate April 12.  

A grateful nation acknowledges the gift

Friday, April 10, 2015

New Reports of "the Next Tick-Borne Plague", Powassan Virus, are Getting Attention

(Photo: Getty Images)

A recent report about the detection of Powassan virus, described as "even worse than Lyme disease!", in southern Connecticut ticks has gotten a lot of attention.  The report from the CT ag station by Anderson and Armstrong was not so surprising, though: Powassan has been detected in New England for many years.  In fact, they reported it in 2012 as well.  Another report by Nofchissey et al. showed that it has been infecting deer in Connecticut, New Hampshire, and Maine as far back as 1979.  This Morbidity and Mortality Weekly Report review indicated human Powassan cases were reported in New Hampshire, Maine, and Massachusetts in 2013 (2014 numbers not yet published).  So we see that Powassan has been "with us" for quite some time.  Does this mean that I feel that this story is overblown?  No, not at all.  I am grateful to see the attention being paid to tickborne encephalitides, because frankly they are scary.  Powassan and its nasty friends can cause encephalitis, or an inflammation of the brain.  This is a terrible pathological state to be in.  The mortality/fatality rate for encephalitis is quite high, but something that is not discussed as much is the morbidity, or rate of long-term health problems in survivors.  It turns out that surviving encephalitis, in some instances, is no gift.  Fortunately, the majority of persons infected with Powassan will have no symptoms of any kind, or will simply feel a bit under the weather for a few days.  We may hear about a spike in cases this summer, but I suspect that will be due in part to the report from the ag station.  As happened in Minnesota, exemplified by this letter to the editor of Emerging Infectious Diseases, surveillance went up, diagnosis was attempted more often, and thus it was found more frequently.  The attention this brings is a good thing in another way: the intervention here is tick and insect protection.  By more people undertaking it, there will be intrinsic protection against Lyme disease, Eastern equine encephalitis, west Nile virus, ehrlichiosis, rickettsiosis, La Crosse virus, and many others.  I'll count that as a success!