Chronic Lyme Disease. Clinical case

Long-term (years) neurological and rheumatic symptoms after a Lyme borreliosis (LB), such as fatigue, sleep disturbances, arthralgia, myalgia, memory impairment, cephalgia, are defined as chronic Lyme disease (CLD). There is no general opinion among specialists regarding the causes of chronization. Some clinicians suggest the persistence of B. burgdorferi, but most researchers explain the occurrence of CLD by the induction of autoimmune reactions with mainly rheumatic and neurological symptoms. Part of the patients, who did not have the usual anamnestic diagnostic landmarks after the CLB diagnosis (arthritis, erythema, the fact of contact with a tick), were not examined and, accordingly, were not treated. In the absence of specificity in the clinical picture, there is no suspicion of CLD always, therefore sometimes extremely severe, but nonspecific symptoms of late LB are mistakenly explained by metabolic, inflammatory, neoplastic or infectious diseases, fibromyalgia or chronic fatigue syndrome. The objective: to highlight the problem of CLD on the example of a clinical case of a patient with long-term joint syndrome, other rheumatic and neurological complaints of high intensity. According to all formal signs, the diagnostic hypothesis about the onset of rheumatoid arthritis (RA) was justified. But some clinical circumstances significantly reduced the probability of RA. There were no specific articular deformations and symmetry of the lesion, a completely normal results of additional research methods, no activity of markers of the systemic inflammatory reaction, and the origin of neurological complaints remained unclear. A history of contact with a tick, erythema, and other general symptoms of an acute infectious disease in the past, which the patient denied, was purposefully collected. After the serological examination by the blot analysis method, the result was obtained: IgM B. burgdorferi – positive; B. afzelii – positive; B. garinii – positive; IgG B. afzelii – positive. The clinical diagnosis was formulated as LB, late period, stage of persistent infection; Lyme arthritis, moderate severity; secondary infectious encephalopathy with scattered microorganism symptoms, vegetative dysfunction, vestibulo-atactic syndrome. Taking into account the presence of active arthritis, antibacterial and anti-inflammatory drugs were used. Subsequently, we recommended non-steroidal anti-inflammatory drugs only as needed, and as the main treatment – duloxetine 30 mg per day. A year after hospitalization, we observed a minimization of symptoms, as well as long periods of their complete absence. Swollen and tender joints were absent. At the same time, after three and six months, the results of IgM and IgG blot analyzes remained positive and similar to the previous ones. Thanks to the active accumulation, systematization and analysis of epidemiological, experimental and clinical data, timely confirmation of CLD diagnosis, at the very least, in the presence of typical landmarks of suspicion of this pathological condition, allows avoiding diagnostic errors, a large number of unnecessary laboratory and instrumental examinations, as well as unwanted, and sometimes dangerous pharmacotherapy. Understanding the variety of CLD manifestations requires the solution of many applied and possibly fundamental issues related to the chronization of LB, because for family doctors, in general, internists, clear diagnostic guidelines, as well as recommendations regarding the patient’s route and, especially, treatment, need further improvement. Awareness of the CLD main syndromes, in particular a wide range of neurological symptoms and manifestations of the musculoskeletal system, allows to optimize the differential diagnostic search, but does not guarantee protection against errors, since the clinical aspect of positive serology of CLD is practically not mandatory diagnostic factor.