Persistence of Borrelia burgdorferi despite antibiotic treatment Michael A. Patmas, MD. JSTD 1994; 1:101. It has been suggested that Lyme Disease may trigger fibromyalgia and that antibiotic therapy beyond 30 days is almost always unnecessary. Recently, two cases demonstrated persistence of borrelia burgdorferi despite lengthy antibiotic treatment were noted. Case number: In October 1991, a 35 year old Caucasian female, registered nurse, was referred for evaluation. She had reported a lesion compatible with Erythema Chronicum Migrans about one year earlier. After a short course of oral antibiotics, she noted fatigue, myalgia, and arthralgias and was given 2 weeks of intravenous ceftriaxone 1 g daily with resolution of her symptoms. Over the next several months, however her symptoms gradually returned. An ELISA titer was elevated, and she was started on ceftriaxone 2 g intravenously daily. After 10 days, the patient developed a vigorous Jarisch-Herxheimer reaction and was referred to the author. The patient was switched to cefotaxime 3 g intravenously every 12 hours with improvement in symptoms. After 6 weeks, the intravenous cefotaxime was changed to oral Clarithromycin 500mg daily for 6 37more weeks, with complete resolution of all signs and symptoms. One week later the patient discovered that she was 1 month pregnant, and after normal gestation, delivered a health male infant. The placenta was examined at Brigham and Women's Hospital in Boston Massachusetts, where several spirochetes were noted in perivascular and intervillous spaces on modified dieterle silver stain. Case Number 2: A 47 year-old caucasian female was well until an untreated tick bite in 1985. She subsequently developed a progressive arthritis diagnosed as Rheumatoid. After failed treatment with nonsterodal anti-inflammatories and remittive agents, the author saw the patient for the first time in 1990. Aspiration of fluid from the right knee was positive by specific antibody ratio for Lyme Disease as the University of Medicine and Dentistry of New Jersey -- Robert Wood Johnson University Hospital Lyme Disease Research Center. The patient was started on Ceftriaxone 2 g i ntravenously daily for 4 weeks. She had a significant objective response to treatment, but quickly relapsed after it was discontinued. A second 4 week course of ceftriaxone was given with only moderate improvement. The patient then sought treatment at several university center where she received experimental treatment for rheumatoid arthritis including monoclonal antibody therapy. There was no improvement in her condition. By July 1992, the patient developed bilateral aseptic necrosis of her hips. A right total hip replacement was performed and a histopathologic examination revealed several spirochetes on modified dieterle silver stain of synovial tissue performed at the Brigham and Women's Hospital. The patient was then started on continous oral antibiotic treatment with Azithromycin 250mg daily. Approximately 6 months later, the patient underwent left total knee replacement and once again spirochete-like structures were observed in synovial tissue on modified dieterle silver stain. These two cases suggest that despite lengthy courses of aboth intravenous and oral antibiotics, Borrelia burgdorferi may persist. The presumption that residual symptoms are due to Fibromyalgia may not always be true and is not assured simply because a patient has received 30 days of treatment. Careful histopathologic examination by modified dieterle silver stain my suggest otherwise.