Persistence of Borrelia burgdorferi despite antibiotic treatment

 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.

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