Number An Appraisal of “Chronic Lyme Disease” To the Editor:

 Volume 358:428-431 January 24, 2008 Number An Appraisal of "Chronic Lyme Disease" To 
the Editor: Feder et al., Oct. 4 issue,1 review the great controversy surrounding "chronic Lyme 
disease."v For most patients with this diagnosis, the authors advocate against the use of 
antibiotics. But before the decision is made not to use antibiotics for patients with 
post–tick-bite symptoms, anaplasma, babesia, bartonella, 2 and ehrlichia must be ruled out. 
These tick-borne 2 intracellular pathogens are difficult to diagnose and can establish 
long-term, persistent infection. 3,4,5 Anaplasma, babesia, and bartonella are underdiagnosed: 
the nonspecific symptoms of infections with these organisms tend to be ascribed to the more 
easily identifiable Lyme disease, which often accompanies them.2,3,4,5,6 Indeed, when studied 
prospectively, 65 of 161 patients with Lyme disease, 40%, were coinfected with babesia, and 11 of 
161, 7%, with anaplasma.6 Accurate diagnosis of these infections helps steer successful 
treatment: babesia 3 and bartonella 5 are especially difficult to eradicate. Accurate diagnosis is 
also important, since babesia 3 and anaplasma 4 can spread through blood transfusion. As Feder
et al. note, "chronic Lyme disease" is often unrelated to borrelia. If symptoms occur after a tick 
bite in the absence of evidence of active borrelia infection or if they persist despite 
anti-borrelia treatment, another tick-borne infection should be suspected. If such an infection 
is found, the patient may indeed benefit from appropriate antibiotics

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