Download De ziekte van Lyme: een diagnostische uitdaging

NEDERLANDS TIJDSCHRIFT VOOR DERMATOLOGIE EN VENEREOLOGIE | VOLUME 23 | NUMMER 03 | Maart 2013
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De ziekte van Lyme: een
­diagnostische uitdaging
Prof. dr. B.J. Kullberg
Internist-infectioloog, afdeling Interne Geneeskunde,
Universitair Medisch Centrum St Radboud Nijmegen
Correspondentieadres:
Prof. dr. B.J. Kullberg
E-mail: [email protected]
Lyme borreliosis is a spirochetal infectious disease
caused by the tick-borne Borrelia burgdorferi
sensu lato complex. Lyme disease now has been
recognized as one of the most common vector-borne
infections in the northern hemisphere. Erythema
migrans, although not present in all patients, is
the skin lesion representing the earliest and most
easily recognized manifestation of Lyme disease.
Dissemination of the spirochete to multiple organs
and tissues, including the skin, the joints and the
central nervous system, occurs early in the course of
infection. Neurological involvement can affect both
the peripheral and central nervous system, causing
a wide range of acute or chronic symptoms.
Unfortunately, the available serological diagnostic
tests are not optimal. False-negative serology results
occur during the acute phase, and differential
diagnosis has become increasingly difficult. Also,
patients may remain seropositive years after
adequate antibiotic treatment. In clinical practice,
the diagnosis of Lyme disease is based on the
epidemiological history and clinical findings,
supported by serological tests.
Treatment for patients with erythema migrans
typically involves oral doxycycline or amoxicillin
during 7-14 days, and most patients treated with
either of these agents for local infection have
an excellent response. However, not all patients
with early disease have a favorable outcome, and
disseminated disease may develop in some patients.
Treatment with ceftriaxone is usually effective
in acute disseminated Lyme disease, including
that manifested by neuroborreliosis, carditis, or
meningitis.
While diagnosis and treatment of acute Lyme
disease is relatively easy, this is far more
problematic for (possible) chronic or persistent
Lyme disease (PLD). Many patients present with a
history and complaints compatible with persistent
Lyme disease.
There is considerate controversy about the diagnosis
of these patients, and diagnostic tests currently
available cannot exclude or confirm the diagnosis of
active Lyme disease. These patients are increasingly
demanding empirical treatment for possible or
presumed persistent Lyme disease. Patients with
possible PLD often present with musculoskeletal
symptoms, with or without arthritis, paraesthesia,
cognitive impairment and fatigue. Various
pathophysiological explanations for PLD have been
proposed, including persistent Borrelia infection,
autoimmune mechanisms, or psychological factors.
The lack of appropriate diagnostic techniques makes
it highly difficult to either prove or rule out active
infection in most of these patients. At present, the
scientific basis for long term antibiotic treatment
for chronic symptoms related to possible PLD is
weak, if not non-existent. Randomized trials on
prolonged antimicrobial therapy for (presumed)
PLD have been of limited quality and were generally
underpowered, thus unable to either exclude or
confirm a beneficial effect of long-term antibiotics.
This has led to much controversy and high medical
consumption, and is an area of ongoing studies.
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