From: odp@ldgo.columbia.edu (carl brenner)
Subject: Re: Yet another Lyme question
Organization: Lamont-Doherty Geological Observatory
Date: Sun, 27 Sep 1992 17:27:18 GMT

In article <1877@hsdndev.UUCP>, rind@binoc.bih.harvard.edu (David Rind) writes:
> In article <1992Sep26.165717.5932@lamont.ldgo.columbia.edu>
>  odp@ldgo.columbia.edu (carl brenner) writes:
> >In article <1863@hsdndev.UUCP>, rind@binoc.bih.harvard.edu (David Rind) writes
> >> Neither of these papers discusses relapse rates.  
> >> The second paper did find the development of what the authors called 
> >> "minor late symptoms" in significantly less than half the patients that 
> >> they studied (judging from the abstract -- I haven't pulled the actual
> >> paper).
> >
> >I almost get the feeling you didn't even read my post. I used a *direct*
> >*quote* from the first paper that said that low doses of tetracyclines and 
> >penicillin were associated with an "inordinately" high failure rate.
> 
> Yes, I read your post.  The referenced paper nonetheless does not discuss
> relapse rates.  It does talk about late sequellae of disease developing
> (in many fewer than 50% of patients).  If I treat strep throat for
> 1 day and because of inadequate therapy, the sore throat comes back, this
> is a relapse (or if it didn't ever go away, a failure to cure).  If 
> rheumatic fever develops, an immunologic sequella of strep infection, this
> is not a relapse.
> 
> >It was a CONTROLLED study, David!! *None* of the 16 controls had positive
> >PCR assays. I agree that PCR is not perfect, but when one group is 8/12 and
> >the other is 0/16, I think it's pretty convincing. Why, when confronted with
> >evidence like this, do you choose to look for an explanation that denies the
> >obvious? I really have a hard time understanding this. 
> 
> As I wrote, I have not pulled the paper in question.  Were the controls
> people who had been proven to have Lyme but who were cured without
> neurologic sequellae?
	
	Whoa, let's back up.
	It's clear we are not on the same page. Let me review the discussion,
just so you understand where I'm coming from.
	This thread got started when someone else (not me) said something
about a 50% failure rate. You asked for a reference. At this point I jumped
in, said I didn't know what study the original poster was referring to, but
offered the Luft, et. al. paper as one that presented evidence for early CNS
invasion by the spirochete. This paper also pointed out that low doses of
penicillin and and tetracycline in the treatment of early Lyme were associated 
with an inordinately high failure rate, though you are quite right that the
Luft paper is not really about treatment (nor did I claim it was). The 
reference Luft gave for this statement was the Steere, et. al. paper, which
neither of us has read. You say that the abstract for this paper says nothing
about failure rates per se, but I am sure that if we read the whole paper we
could find the information that Luft was using to make this statement.
	The Luft paper used 12 patients with early disseminated Lyme disease
(less than 2 weeks of active disease). Six patients had multiple EM lesions
and six had acute cranial neuritis without EM. (Five of the six non-EM patients
had positive ELISAs.)
	The control group never had Lyme.
	Eight of the twelve subjects' CSF were PCR postive, none of the
controls were. (The twelve subjects were tested prior to treatment, so this
was not a test of treatment success.)
	The point of the paper was that there is compelling evidence that Bb
disseminates to the CNS more quickly than previously believed; at the end of
the paper the authors speculate that the CNS acts as a sanctuary for the
spirochete (hardly big news, many physicians have been saying this for years),
accounting for treatment failures when they occur. 
	I think it's an important paper because the spirochete is very difficult
to culture and researchers have had a hell of a time finding the bugs. As a 
result, precious little is known about where they hang out, and at what point
they arrive there (and whether or not it's similar from patient to patient).
	We know that the bacteria can be cultured from the brains of hamsters
only seven days after infection, but it hasn't ben clear whether the same
rapid CNS dissemination occurs in humans. Now we have pretty good evidence that it
does. I would also add parenthetically that most of the authors of this paper
are from SUNY Stony Brook, which is known for its conservative approach to
treatment.
	I believe that the treatment of early Lyme, if handled correctly, should
approach a very high success rate. Failures are due to physician negligence more
than any unsolvable medical problem. Unfortunately, undertreatment still occurs
with alarming frequency, for a variety of reasons.
	Late Lyme is another story. I think the success rate there is quite poor.

> I get "confronted" with all sorts of "obvious" conclusions in medicine.
> People write papers saying that the link between increased use of 
> inhalers and asthma deaths mean that inhalers are killing people.  Then
> I have to decide whether the authors' "obvious" conclusion holds up
> under scrutiny before I start changing my practice.  I do my best to
> keep an open but skeptical mind.

	Well, I hope this recapitulation makes it clearer to you why I felt
that the evidence was "obvious." One of the weirdest things about Lyme is the
dissonance between what the researchers are saying and what the patients are
experiencing, and I believe this paper provides a framework for explaining
why patients continue to have symptoms after inadequate treatment regimens. 

> -- 
> David Rind
> rind@binoc.bih.harvard.edu


Carl Brenner