We present a 44 year-old male with a diagnosis of Chronic Lyme Disease (CLD) who presented after a recent course of antibiotics with shortness of breath for three months. He revealed a six year history of losing strength in his arms and legs. Due to agitation, he was given lorazepam, diazepam, and morphine in order to perform a chest x-ray that was interpreted as normal. An arterial blood gas showed chronic respiratory acidosis. Labs showed mildly elevated inflammatory markers (ESR and CRP), troponin, and CPK. He was to be admitted to the general medicine floors for work-up for elevated troponin. Hours later, he became hypoxic and bradycardic, and was intubated. Of note, he brought eight years of past medical records revealing an extensive evaluation of his progressive neurologic symptoms. This ultimately led to the corrected diagnosis of Progressive Muscular Atrophy (PMA), explaining his six-year weakness and decompensation after receiving benzodiazepines and opioids.
Few patients with Lyme disease experience mild and subjective symptoms of fatigue, musculoskeletal pain, and concentration problems persisting after treatment and resolution of the acute infection. The presence of these ongoing symptoms may lead to a diagnosis of “Chronic Lyme Disease.” However, the diagnosis criteria and treatments of CLD are ill-defined and are often based on clinical judgment rather than verified clinical and laboratory tests.
As the diagnosis of CLD becomes more popular, perhaps due to spotlight in the public media, so too do the issues associated with its management. First, in a patient with low pretest probability, the non-specific, costly tests are unlikely to yield conclusive results. Second, the pharmacological treatment for some patients include not only antibiotics with extensive side effect profiles for prolonged periods of time (occasionally being given parenterally), but also knowingly harmful treatments such as bismuth injections or inoculation with plasmodia. Third, the labeling of CLD can mask the diagnosis of severe disease processes, including potentially treatable conditions such as neoplasms. Patients may be more willing to accept the diagnosis of CLD due to the fact that they feel it is potentially curable or because they want an explanation for their non-specific symptoms. In this case, it led to diagnostic error, masking PMA, a rare subset of Amyotrophic Lateral Sclerosis, where respiratory insufficiency determines fatal prognosis.
Our patient with PMA came in with a misdiagnosis of CLD for which he completed multiple courses of antibiotic treatments. The diagnosis and treatment of CLD is poorly defined, can incur significant costs, and can delay adequate and potentially life-saving treatment. This case demonstrates the need for hospitalists to verify diagnoses of vague and ill-defined chronic infectious diseases, as they are often attributed to more serious medical conditions with rare or unexplained symptoms.
To cite this abstract:DePietro RH, Banerjee T, Go R. Chronic Lyme Disease: A Diagnosis in Disguise. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 491. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/chronic-lyme-disease-a-diagnosis-in-disguise/. Accessed July 20, 2019.