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Guidelines for the Clinical Diagnosis of Lyme Disease
- Angelina A.M. Blaauw, MD; and
- Sief van der Linden, MD
- University Hospital Utrecht; 3508 GA Utrecht, the Netherlands University Hospital Maastricht; 6202 AZ Maastricht, the Netherlands
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TO THE EDITOR:
The recent position papers on Lyme disease [1, 2] emphasize the importance of the pretest probability of disease in the laboratory evaluation of patients and promote rational diagnosis and treatment. However, several issues deserve more attention. Studies that described results in patients outside North America were excluded for puzzling and untrue reasons [2]. Moreover, the real issue is estimating the pretest probability of disease and application of test characteristics, such as likelihood ratios.
We assume that principles of diagnosis and treatment of patients with Lyme disease can be validly extrapolated to regions outside North America. Inclusion of studies that describe results in patients outside North America could have clarified some points. In fact, we have already published nomograms [3, 4]-to some degree identical to the ones in the position papers-illustrating that the likelihood ratio of a positive result on a serologic test (ELISA) for Lyme disease is rather low (3.5) compared to key elements of the clinical history and physical examination. Our studies [3, 4] and the study by Fahrer and colleagues [5] also point out that positive results on Lyme serology without any clinical manifestations (an issue not addressed in the position papers) occurs frequently. This considerably reduces likelihood ratios. In addition the panel's estimate for the hypothetical patient scenario of recurrent oligoarticular inflammatory arthritis (0.50) seems extremely high and should be supported by evidence. Among 73 patients with unclassified monoarthritis, oligoarthritis, or polyarthritis, definite Lyme disease was found in only 1 [3]. The pretest probability of Lyme disease in one of our studies was only 9% [4]. Finally, data from paired serum samples do exist, although obtained in epidemiologic studies outside North America [5].
Angelina A.M. Blaauw, MD
University Hospital Utrecht; 3508 GA Utrecht, the Netherlands
Sief van der Linden, MD
University Hospital Maastricht; 6202 AZ Maastricht, the Netherlands
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
