When the Tick is Already 'Forgotten', but the Disease is Not: Understanding Late Stages of Lyme Borreliosis

Currently, Ukraine is witnessing a rise in cases of tick bites, and numerous individuals are expressing concerns about the increasing frequency of these incidents. This observation is indeed corroborated by medical professionals, particularly by Olga Golubovska, a professor, doctor of medical sciences, and a distinguished physician in Ukraine. She highlights that while there has been extensive discussion regarding the prevention of bites, appropriate clothing, and post-walk inspections, it is equally crucial to pay attention to how tick-borne infections can manifest later and how to avoid missing these signs.

This topic is particularly relevant as many people tend to focus on the classic presentation of the disease: a tick bite followed by a characteristic ring-shaped erythema, and only then seeking treatment. However, the reality is far more complex. Erythema does not always appear, and many individuals may not even recall being bitten by a tick. Therefore, it is vital for healthcare professionals across various specialties, as well as patients, to understand that Lyme disease is not merely a skin condition but a systemic illness that can manifest through damage to the heart, nervous system, and joints.

This is especially pertinent for cardiologists, who frequently encounter cases of Lyme carditis. These cases are not uncommon and can lead to disturbances in heart conduction, such as atrioventricular blockages of varying degrees, including the most severe third-degree block. Golubovska recounts a real clinical case of a young woman who, despite not recalling a tick bite and lacking any erythema, began experiencing periodic dizziness. She attributed this to fatigue but ultimately lost consciousness. Hospitalization revealed a third-degree atrioventricular blockage and confirmed borreliosis. Following antibacterial therapy, the woman recovered, underscoring the importance of timely diagnosis.

Doctors, particularly cardiologists, should inquire about unclear symptoms from patients, such as irregular heartbeats or dizziness, and when necessary, conduct not only standard ECGs but also 24-hour monitoring, as such disturbances are not always immediately apparent.

Neurologists must also exercise caution, as there is a condition known as neuroborreliosis, which can manifest, for instance, as facial nerve paresis. A person may wake up with a distorted face, and this does not always indicate a stroke. In such cases, it is essential to think more broadly, as there have been patients who exhibited no classic meningeal symptoms, yet lumbar puncture revealed an inflammatory process in the cerebrospinal fluid, indicative of Lyme disease.

Diagnosis in these situations is more challenging, as it requires consideration of the clinical picture, medical history, and results from both blood and cerebrospinal fluid tests. If there is no complete laboratory confirmation, but the clinical picture aligns, doctors are entitled to consider it a possible case and treat accordingly.

Late stages of the disease also raise numerous questions. For example, how can one differentiate Lyme arthritis from rheumatological diseases? The answer is not always straightforward; sometimes, it can only be determined through serology. However, in chronic forms, antibodies may not rise or may only show slight increases, and occasionally positive tests can result from cross-reactive immune responses.

This leads to situations where neither infectious disease specialists nor rheumatologists can confidently establish a diagnosis. This is the same medical 'crossroad' that is becoming increasingly common. In such cases, doctors may decide on a trial treatment, but this should always be a well-considered decision, not a blanket approach for all patients.

Treatment in the late stages of the disease must include antibacterial medications. The first line of treatment consists of agents that penetrate well into cells, as the pathogen has the ability to 'hide'. This includes doxycycline, azithromycin, and protected penicillins. These medications act directly on the Borrelia bacteria, provided they have not yet entered a 'hidden' state.

The duration of treatment depends on the stage of the disease. According to international guidelines, doxycycline is prescribed for 10 days, while azithromycin or amoxicillin is given for 14 days. In cases involving nervous system damage, treatment may extend up to a month using cephalosporins.

In complex cases, treatment may be prolonged and involve combinations of medications. However, such decisions must be clearly justified. There are regimens where treatment lasts for months, but this is not standard and does not apply to all patients.

Particular attention should be given to patients who may have contracted the infection abroad, especially in the USA, where more virulent strains circulate. Golubovska recalls a case of a patient who contracted borreliosis in the USA and later presented with a severe condition. The treatment proved to be significantly more complex, involving multiple antibiotics and lasting about two months.

Monitoring test results after treatment is also a crucial aspect. Patients often ask when they should retake tests, and it is important to understand that...