Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease — United States

Patient A

A woman in her late 30s with fatigue and joint pain received a diagnosis of chronic Lyme disease, babesiosis, and Bartonella infection by a local physician. Despite multiple courses of oral antibiotics, her symptoms worsened, and a peripherally inserted central catheter (PICC) was placed for initiation of IV antibiotic treatment. After 3 weeks of treatment with IV ceftriaxone and cefotaxime, the patient’s joint pain continued, and she developed fever and rash. She became hypotensive and tachycardic and was hospitalized in an intensive care unit, where she was treated with broad spectrum IV antibiotics and required mechanical ventilation and vasopressors. Despite maximal medical support, she continued to worsen and eventually died. The patient’s death was attributed to septic shock related to central venous catheter–associated bacteremia.

Patient B

An adolescent girl sought medical advice regarding years of muscle and joint pain, backaches, headaches, and lethargy. She had received a diagnosis of chronic fatigue syndrome, but sought a second opinion from an alternative medicine clinic and was told she had chronic Lyme disease. The patient was treated with oral antibiotics, including rifampin, trimethoprim-sulfamethoxazole, and doxycycline, for 3 months; these were discontinued because of abnormal liver enzyme test results Three months later, a PICC was placed to administer IV antibiotics, including ceftriaxone. After receiving both IV and oral antibiotic therapy for 5 months without improvement, the antibiotics were discontinued, but the PICC was not removed.

One week after antibiotics had been discontinued, the patient developed pallor, chills, and fever to 102.9°F (39.4°C); after consultation with the alternative medicine clinic, she was given another dose of ceftriaxone through the PICC. Later that day she was evaluated in an emergency department with fever to 105.3°F (40.7°C), hypotension, and tachycardia consistent with septic shock. Blood and PICC tip cultures grew Acinetobacter spp. She was hospitalized in an intensive care unit and required vasopressors as well as broad-spectrum antibiotics to treat the infection. The PICC was removed, and the patient was eventually discharged after several weeks of hospitalization.

Patient C

A woman in her late 40s received multiple arthropod bites and subsequently developed a flu-like illness with pain in her arms, legs, and back. One year after her symptoms began, she received a diagnosis of Lyme disease using the recommended two-tiered serologic test (positive enzyme immunoassay test result followed by positive immunoglobulin G Western immunoblot). She was treated with two 4-week courses of oral doxycycline.

The patient developed fatigue, cognitive difficulties, and poor exercise tolerance, and 2 years after her initial diagnosis she received a diagnosis of chronic Lyme disease based on the results of unvalidated tests. She was treated with intramuscular penicillin for approximately 5 weeks without improvement, then IV ceftriaxone for 4 months, followed by IV azithromycin for 6 months administered via a tunneled IV catheter.

One year later, she received additional IV ceftriaxone via a new IV catheter, plus oral doxycycline, tinidazole (an antiparasitic medication), and azithromycin for approximately 4 weeks. The patient developed back pain, shortness of breath, and malaise, and was hospitalized. The catheter was removed, and blood and catheter tip cultures yielded Pseudomonas aeruginosa. She was treated with aztreonam for 4 weeks; however, her back pain worsened, and she was readmitted to the hospital. A computed tomography scan indicated destruction of both the 9th and 10th thoracic vertebrae, and magnetic resonance imaging of her spine confirmed osteodiscitis. A bone biopsy and culture grew P. aeruginosa with the same antibiotic susceptibility profile as her previously diagnosed bacteremia. She was treated for osteodiscitis, and her back pain eventually improved.

Patient D

A woman in her 50s developed progressive weakness, swelling, and tingling in her extremities and received a tentative diagnosis of chronic inflammatory demyelinating polyneuropathy. Despite various treatments over a 5-year period, her symptoms did not substantially improve, and a diagnosis of amyotrophic lateral sclerosis was made.

The patient was subsequently evaluated by another physician and was told she had chronic Lyme disease, babesiosis, and Rocky Mountain spotted fever. Initial treatment with herbs and homeopathic remedies had no effect. She was treated with IV ceftriaxone and oral trimethoprim-sulfamethoxazole, acyclovir, fluconazole, and tinidazole. After 7 months of intensive antimicrobial treatment, her pain improved, but the weakness worsened. She discontinued treatment after developing C. difficile colitis that caused severe abdominal cramps and diarrhea. The C. difficile infection became intractable, and her symptoms persisted for over 2 years, requiring prolonged treatment. The patient subsequently died from complications of amyotrophic lateral sclerosis.

Patient E

A woman in her 60s with autoimmune neutropenia, mixed connective tissue disease, and degenerative arthritis received a diagnosis of chronic Lyme disease neuropathy, for which she received IV immunoglobulin every 3 weeks via a tunneled venous catheter with an implanted subcutaneous port. After undergoing treatments for >10 years, she developed fevers and neck pain and was hospitalized; the catheter was removed, and blood and catheter tip cultures yielded methicillin-sensitive Staphylococcus aureus. She was treated with IV antibiotics via a newly placed PICC. Although the patient was advised to have the PICC removed once the antibiotic course finished, she chose to keep it for further IV immunoglobulin therapy.

Two months later, she was readmitted for recurrent fevers. The PICC was removed, and cultures of the tip grew coagulase-negative Staphylococcus; blood cultures were negative. She was treated with IV antibiotics and discharged.

The patient subsequently received a new implanted subcutaneous venous catheter and restarted IV immunoglobulin therapy, after which she was readmitted for fever and back pain. Blood cultures were positive for methicillin-sensitive S. aureus, and magnetic resonance imaging indicated inflammation of the lumbar facet joints, epidural space, and paraspinal muscles, consistent with infection. Despite appropriate antibiotic treatment, her back pain worsened, and she required surgical drainage of a paraspinal abscess.

Discussion

Antibiotics and immunoglobulin therapies are effective and necessary treatments for many conditions; however, unnecessary antibiotic and immunoglobulin use provides no benefit to patients while putting them at risk for adverse events. When used for extended periods, the risks associated with these treatments increase, so it is important that they be used appropriately.

These cases highlight the severity and scope of adverse effects that can be caused by the use of unproven treatments for chronic Lyme disease. In addition to the dangers associated with inappropriate antibiotic use, such as selection of antibiotic-resistant bacteria, these treatments can lead to injuries related to unnecessary procedures, bacteremia and resulting metastatic infection, venous thromboses, and missed opportunities to diagnose and treat the actual underlying cause of the patient’s symptoms (8,10).^†,§ Patients and their health care providers need to be aware of the risks associated with treatments for chronic Lyme disease.

The number of persons who undergo treatments for chronic Lyme disease is unknown, as is the number of complications that result from such treatments. Systematic investigations would be useful to understand the scope and consequences of adverse effects resulting from treatment of persons with a diagnosis of chronic Lyme disease. Data sources to consider include clinician surveys, administrative claims databases, or implementation of state or local reporting systems for adverse outcomes related to these treatments.