The challenge of Lyme disease: tired of the Lyme wars.

Few diseases have aroused more emotional attention in the press and the public than Lyme disease. Discussions have not only focused on the increasing incidence 1 or the choice of appropriate treatment, but also on perceived inadequacy of serological testing and whether or not persisting fatigue, cognitive dysfunction and musculoskeletal pain are 'real disease' and related to persistent infection. Large numbers of patients with such symptoms attributed to Lyme disease seek medical opinions, but no consensus on approach or treatment exists. In this issue of the Journal, Coumou et al. provide a review on several aspects of Lyme disease. 2 This review is extremely helpful for understanding the epidemiology and immunopathogenesis of the disease. Does it also provide a framework for the Dutch physician confronted with a patient with putative Lyme borreliosis, as the authors state? Probably not, since this publication precedes and potentially contradicts the revised national CBO Treatment Guidelines for Lyme Disease, which will be published later this year. The CBO guidelines, initially released in 2004, have been subject of much debate. 3 Whereas the guideline recommendations on prevention and treatment of early Lyme disease – the easy part – have been generally accepted, the lack of recommendations for the approach to patients with persistent symptoms after standard treatment of short duration has been criticised. The difficult diagnosis and paucity of studies of sufficient quality on this subject have prompted the 2004 CBO Guidelines Committee to refrain from addressing this subject in depth. In contrast, in the pending 2011 revision of the guidelines, recommendations may be expected on the approach to the patient with chronic fatigue and other persistent symptoms attributed to Lyme disease, including algorithms on possible persistence and empirical or second-line therapy. Therefore, the views by Coumou et al. in the present issue of the Journal cannot be viewed as a therapeutic guide replacing the revised 2011 CBO guidelines, which were developed according to the recommendations for evidence-based development of guidelines by a multidisciplinary committee, including the National Society for Lyme Patients (NVLP). 4 Therapy of early uncomplicated Lyme disease or erythema migrans is usually successful, and a short duration of therapy (10 to 15 days) leads to cure in 84 to 95% of cases. 5-6 Indeed, for the large majority of patients, if correctly diagnosed and timely treated, Lyme disease is not an insidious illness. Reported failure rates in patients with late manifestations, such as …