Lyme Disease, Chronic

Chronic Lyme disease refuted by experts.

NEJM original article

Summary and Comment

Is "Chronic Lyme Disease" Real?
Patients with chronic symptoms but no objective criteria for infection are receiving long-term antibiotic therapy.


Lyme disease, caused by Borrelia burgdorferi in North America and other Borrelia species in Europe, is the most common tick-borne infection in the Northern hemisphere and is a significant public health problem.

Whereas early Lyme disease, late Lyme disease, and post–Lyme disease symptoms/syndrome are recognized conditions, the term "chronic Lyme disease" has recently been popularized by a small number of practitioners. Chronic, nonspecific symptoms (e.g., fatigue, headache, dizziness) are attributed to persistent or incurable B. burgdorferi infection, and patients are subsequently treated with long-term parenteral antibiotics. The Ad Hoc International Lyme Disease Group has written an editorial summarizing the controversy surrounding the diagnosis and treatment of chronic Lyme disease.

Objective manifestations of Lyme disease include erythema migrans (the most common presentation of early Lyme disease), certain neurologic and cardiac manifestations, and pauciarticular arthritis (the most common presentation of late Lyme disease). These symptoms respond well to conventional antibiotic therapy. Symptoms of post–Lyme disease include fatigue, musculoskeletal pain, and difficulties with concentration or short-term memory following resolution of objective manifestations of infection. These symptoms are usually mild, typically resolve within months, and antibiotic therapy is not indicated; when the difficulties persist longer than 6 months, the condition is termed post–Lyme disease syndrome. Laboratory testing (usually acute- and convalescent-phase serologies; less commonly, PCR or culture) is a key component of Lyme disease diagnosis; in most cases, the testing allows clinicians to confirm evidence of current or past B. burgdorferi infection.

By contrast, chronic Lyme disease is the term assigned to patients reporting chronic symptoms without objective clinical, laboratory, or epidemiologic criteria for infection. They receive chronic parenteral antibiotic therapy for periods of many months to years, despite the absence of any scientific evidence to support this practice.

The authors divide patients receiving a diagnosis of chronic Lyme disease into four categories:


Those with symptoms of unknown cause and no evidence of B. burgdorferi infection

Those with an identifiable illness other than Lyme disease unrelated to B. burgdorferi infection (e.g., multiple sclerosis)

Those with symptoms of unknown cause and antibodies against B. burgdorferi but no history of objective clinical findings consistent with Lyme disease

Those with resolution of objective manifestations of Lyme disease after antibiotic therapy who have symptoms of unknown cause (some have post–Lyme disease symptoms or syndrome)


Chronic antibiotic therapy for chronic Lyme disease has resulted in life-threatening anaphylaxis, cholecystectomy after biliary complications from ceftriaxone administration, a fatality due to candidemia from intravenous catheter infection, and other serious adverse events related to intravenous catheters.

Comment: The authors systematically refute the pseudoscience behind the diagnosis and treatment of so-called chronic Lyme disease in this well-referenced editorial. The writing and the tables summarizing the manifestations of B. burgdorferi infection and the laboratory diagnosis of Lyme disease are lucent and practical.

— Mary Wu Chang, MD

Published in Journal Watch Dermatology October 3, 2007

Citation(s):

Feder HM et al. A critical appraisal of "chronic lyme disease." N Engl J Med 2007 Oct 4; 357:1422.

Original article (Subscription may be required)