Practice parameters for the diagnosis of patients with nervous system Lyme borreliosis (Lyme disease)

Abstract

The Quality Standards Subcommittee (QSS) of the American Academy of Neurology seeks to develop scientifically sound and clinically relevant practice parameters for neurologists to assist in clinical decision making. Although studies of Lyme borreliosis (Lyme disease) have appeared in recent medical and lay literature, diagnosis remains difficult. Limitations in diagnostic technology result in confusion because the generally used, readily available diagnostic tests are indirect; that is, they indicate possible exposure to the causative organism, Borrelia burgdorferi, not active infection. In endemic Lyme borreliosis areas, significant numbers of asymptomatic individuals may have serologic evidence of exposure to B. burgdorferi. [1] Consequently, coincidentally positive serologic tests may lead to the inappropriate attribution of unrelated disorders to this infection. By contrast, in nonendemic areas, serologic false positives may outnumber true positives, again potentially leading to overdiagnosis. These problems, inherent in any serologic testing, are further compounded by differences in technique among laboratories, often resulting in discordant results. [2,3] These problems may lead to under- or overdiagnosis and inadequate or unnecessary treatment, then to unnecessary morbidity and cost as well as inconvenience. In seropositive individuals, the potential cost and morbidity of leaving a true B. burgdorferi infection untreated must be balanced against the risks and costs of unnecessary treatment. For each patient, the physician's analysis must include: 1. The probability that the symptomatic seropositive patient has Lyme borreliosis 2. The probability that antibiotic treatment will alleviate the symptoms 3. The probability that therapy will prevent the future occurrence of late Lyme borreliosis (neurologic, dermatologic, cardiac, and rheumatologic problems) 4. The discomfort, cost, and inconvenience of receiving a prolonged course of intravenous therapy and the potential for mild or severe adverse reactions 5. Anxiety resulting from not treating a patient who has a positive blood test and nonspecific symptoms. The term ``Lyme arthritis'' was introduced …