Focus on COVID-19 leads to delayed diagnosis of Lyme disease

Hello, and welcome to another Inside Lyme Podcast. I am your host Dr. Daniel Cameron. In this episode, I’ll be discussing a unique case involving a 67-year-old man whose diagnosis of Lyme disease was delayed because clinicians suspected his symptoms were due to COVID-19.

The case report, by Novak and colleagues, entitled “Lyme Disease in the Era of COVID-19: A Delayed Diagnosis and Risk for Complications” was published recently in the journal Case Reports in Infectious Diseases.¹

The authors report that this case “illustrates the overlap of symptoms among disparate infectious diseases and the risk of a narrow approach and focus on COVID-19 in patients with undifferentiated febrile illnesses, such as Lyme disease.”

In July 2020, the man presented with symptoms consistent with COVID-19. He had chills, body aches, fever, headache, and neck ache.

Doctors concluded he suffered from a viral-like illness and instructed him to quarantine until results from his COVID-19 test were obtained. His COVID tests were negative.

The patient’s symptoms slowly resolved without treatment.

6 weeks after symptom onset

Six weeks later, however, he developed a rash on his arm. A dermatologist diagnosed the rash as an insect bite reaction rather than Lyme disease.

However, test results for early Lyme disease were positive with 3 of 3 IgM Western blot bands. In addition, 4 of 10 IgG Western blot bands were positive.

The patient was treated with one week of doxycycline.

After 7 days of doxycycline, the man developed double vision due to sixth nerve palsy. He also suffered from headaches, neck stiffness, and new onset fatigue.

At this point, the patient was referred to a Lyme disease telemedicine referral clinic, where a diagnosis of Lyme disease was confirmed.

“This delayed diagnosis of Lyme disease in the patient we describe resulted in disseminated infection and sixth nerve palsy,” the authors write.

The patient’s spinal tap was negative. He was treated with 200 mg of doxycycline twice a day.

After 4 weeks of treatment, his sixth nerve palsy had resolved. However, he still had minimal double vision with extreme right gaze, along with difficulty initiating sleep, mild anxiety, mild daytime fatigue, and subtle, difficulty with his short-term memory.

Diagnostic issues during a pandemic

In this case, doctors focused on screening the patient for COVID-19 and recommending he quarantine. However, the man never developed COVID-19.

“They [clinicians] did not suggest further testing or give input on what could have been the cause of the chills, muscle aches, etc., ” the patient wrote. As a result, his diagnosis of Lyme disease was delayed for 6 weeks.

Novak and et al. proposed that the diagnostic delay was due to clinicians focusing solely on COVID-19 rather than examining other possible causes. Lyme disease was not considered until the patient developed an erythema migrans (EM) rash, 6 weeks after his onset of symptoms.

The man’s diagnosis was confirmed by a Lyme disease telemedicine referral clinic and he improved with treatment.

The man wrote about his frustrations with diagnostic delays even before the COVID-19 pandemic.

“I have spoken to several former business colleagues about my experience with Lyme disease. Their comments were similar; friends/family members who had Lyme disease in past years expressed the same complaint: Lyme disease was not tested for in the first stages of the illness because of the lack of a rash. Their stories were remarkably similar to mine. They experienced health problems before Lyme testing was finally considered and done.”

Editor’s perspective

The patient was left with chronic manifestations of Lyme disease. The authors did not address whether a persistent infection might be the cause of these chronic manifestations.

The following questions are addressed in this podcast episode:

1. Was this man’s case of Lyme disease typical?
2. Why is the author’s inclusion of “July” important?
3. What is a 6^th nerve palsy?
4. The patient developed an EM rash 6 weeks after symptom onset. Is this unsual?
5. The dermatologist unfortunately attributed the rash to an insect bite reaction?
6. What is the significance of Western blot test results?
7. Why was the spinal tap normal?
8. Is it unusual to develop new symptoms (in this case, double vision) AFTER a week of antibiotic treatment? What would cause this?
9. Have you seen diagnostic delays for Lyme disease patients during the COVID-19 pandemic?
10. What are some of the causes of diagnostic delays?
11. What are the consequences of diagnostic delays?
12. The patient still had several symptoms following 1 month of treatment. What are your concerns regarding the remaining chronic manifestations?
13. How has the use of telemedicine helped you in caring for your Lyme disease patients?

• Thanks for listening to another Inside Lyme Podcast. You can read more about these cases in my show notes and on my website @DanielCameronMD.com. As always, it is your likes, comments, reviews, and shares that help spread the word about Lyme disease. Until next time on Inside Lyme.

Please remember that the advice given is general and not intended as specific advice as to any particular patient. If you require specific advice, then please seek that advice from an experienced professional.