Lyme Disease
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Volume 91 No. 7 July 2008 Lyme Disease UNDER THE JOINT VOLUME 91 NO. 7 July 2008 EDITORIAL SPONSORSHIP OF: Medicine Health The Warren Alpert Medical School of Brown University HODE SLAND Edward J. Wing, MD, Dean of Medicine R I & Biological Science PUBLICATION OF THE RHODE ISLAND MEDICAL SOCIETY Rhode Island Department of Health David R. Gifford, MD, MPH, Director Quality Partners of Rhode Island Richard W. Besdine, MD, Chief Medical Officer COMMENTARIES Rhode Island Medical Society Nick Tsiongas, MD, MPH, President 206 When Is a Somatic Disorder Psychiatric? Joseph H. Friedman, MD EDITORIAL STAFF Joseph H. Friedman, MD 207 The Awkward Birth Pangs of Bolero Editor-in-Chief Stanley M. Aronson, MD Joan M. Retsinas, PhD Managing Editor CONTRIBUTIONS Stanley M. Aronson, MD, MPH SPECIAL ISSUE: Lyme Disease Editor Emeritus Guest Editors: Jerome Larkin, MD, and Jennifer Mitty, MD, MPH EDITORIAL BOARD 208 Introduction: Lyme Disease Stanley M. Aronson, MD, MPH Jerome Larkin, MD, and Jennifer Mitty, MD, MPH Jay S. Buechner, PhD John J. Cronan, MD 209 Ticks and Tick-Related Illness James P. Crowley, MD Jerome M. Larkin, MD Edward R. Feller, MD 212 Lyme Disease In Children and Pregnant Women John P. Fulton, PhD Peter A. Hollmann, MD Jerome M. Larkin, MD Sharon L. Marable, MD, MPH 213 Musculoskeletal Manifestations of Lyme Disease Anthony E. Mega, MD Imad Bitar, MD, and Edward V. Lally, MD Marguerite A. Neill, MD Frank J. Schaberg, Jr., MD 216 Neurological Complications of Lyme Disease Lawrence W. Vernaglia, JD, MPH Syed Rizvi, MD, and Amanda Diamond, MD Newell E. Warde, PhD 219 Updates and Controversy In the Treatment of Lyme Disease OFFICERS Jennifer Mitty, MD, MPH, and David Margolius Nick Tsiongas, MD, MPH President COLUMNS Diane R. Siedlecki, MD 224 GERIATRICS FOR THE PRACTICING PHYSICIAN – Dementia Screening: Should President-Elect We Screen Asymptomatic Older Adults? Vera A. DePalo, MD Ana Tuya Fulton, MD Vice President Margaret A. Sun, MD 226 THE CREATIVE CLINICIAN – Rituximab In Treating Refractory Thrombotic Secretary Thrombocytopenic Purpura: Three Case Reports Mark S. Ridlen, MD Samir Dalia, MD, Brendan McNulty, MD, and Gerald A. Colvin, DO Treasurer 229 HEALTH BY NUMBERS – Estimating the Incidence of New Onset Lyme Barry Wall, MD Disease in Rhode Island Immediate Past President John P. Fulton, PhD DISTRICT & COUNTY PRESIDENTS 232 PUBLIC HEALTH BRIEFING – The RI Board of Medical Licensure and Geoffrey R. Hamilton, MD Discipline, 2007 Year Summary Bristol County Medical Society Robert Crausman, MD, Mary E. Salerno, MA, Linda Julian, Lauren Dixon, Herbert J. Brennan, DO and Bruce McIntyre, JD Kent County Medical Society Rafael E. Padilla, MD 235 PHYSICIAN’S LEXICON – The Eight Little Wrist Bones Pawtucket Medical Association Stanley M. Aronson, MD Patrick J. Sweeney, MD, MPH, PhD Providence Medical Association 235 Vital Statistics Nitin S. Damle, MD 236 July Heritage Washington County Medical Society Jacques L. Bonnet-Eymard, MD Woonsocket District Medical Society Cover: “What Makes Lyme Disease Tick?” oil. The artist is an itinerant New England physician. Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235 Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100 per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode Island Medical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postage paid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235 Promenade St., Suite 500, Providence, RI 02908. Classified Information: RI Medical Journal Marketing Department, P.O. Box 91055, Johnston, RI 02919, phone: (401) 383-4711, fax: (401) 383-4477, e-mail: [email protected]. Production/Layout Design: John Teehan, e-mail: [email protected]. 205 VOLUME 91 NO. 7 JULY 2008 Commentaries When Is a Somatic Disorder Psychiatric? This issue is devoted to Lyme disease, column in the last few decades. Undoubt- confront him, the father then falling an important illness in our state, which edly many more will. Restless legs syn- helplessly to the ground because of cata- boasts, on Prudence Island, the highest drome was described about 30 years ago plexy. seropositive region in the world. It is a but didn’t “catch on” until recently, get- In the 1800s the term “neurosis” disease with interesting clinical phenom- ting a big boost from drug companies described neurological syndromes that ena, similar to, but less devastating than that market drugs that treat the disorder. had no known pathological basis. Char- its spirochete cousin, syphilis. Like syphi- Most doctors, who didn’t suffer from cot, the great French neurologist, who lis, it may cause a chronic illness, quite RLS, considered it a non-entity. After all, renamed “Paralysis agitans” Parkinson’s different than the acute illness. Unlike everyone gets restless sometime. But then disease (PD), classified that disease as a syphilis, which may have been the final as polysomnography became popular, it neurosis. The term was then hijacked by common answer for sporadic dementias turned out that 60% of people who re- Freud and colleagues, although it should and behavioral disorders 100 years ago, ported RLS had a peculiar kicking move- be pointed out that Freud studied with Lyme is being used to explain a large num- ment during sleep, obviously something Charcot. Affixing the term neurosis did ber of fairly nebulous symptoms that oc- that was organic and not emotionally not imply that a pathology wouldn’t be cur in the general American population. based. This year two genes have been found, just that it wasn’t known. Inter- It may be the only illness in which an of- found to explain RLS, and more are likely estingly however, some psychoanalysts in ficial medical group has been sued by a to be found. the mid-20th century published papers state government (Connecticut) for issu- Writer’s cramp had been considered blaming childhood conflicts for the ing evidenced-based guidelines that con- a psychiatric syndrome until recently. It tremors, and rigid personalities for tradict non-scientific beliefs embraced by is very clear how one might divine an muscle rigidity, in PD, misunderstand- a politically influential voting block. unconscious urge to twist one’s hand, ing, perhaps, the difference between Medicine by democracy, as it were. when it occurred only when writing, but Charcot’s neurosis and Freud’s. There are two fascinating aspects to not doing anything else, an explanation In this issue the authors grapple with this issue. One is the problem that clini- that makes a lot more intuitive sense than the battle between the infectious disease cal physicians (in contrast to test-based an organic physiological one. There is no experts who base recommendations on physicians like radiologists, more evidence today that these are or- evidence-based medicine, and self pro- interventionalists and pathologists) face ganic than there was before, but we’ve claimed Lyme experts who base opinions everyday, of discriminating the “psy- developed a greater reliance on psychi- on their common experience, without chogenic” from the organic, a topic I atric experience to exclude a psychody- addressing the pathophysiology of “post never tire of. The other is political. namic formulation rather than found an treatment Lyme disease”. Post treatment There is no doubt that political be- objective measure of organicity. This is an Lyme disease is an entity, perhaps based liefs influence medicine. It is hard to unusual form of nosology. We often do on an organic etiology, probably, like imagine that cultural change rather than tests to exclude certain diagnoses, and, neurasthenia, a disorder that is so diffuse scientific evidence alone altered the psy- like Sherlock Holmes, conclude that that it includes a large overlap between chiatric classification of homosexuality. when all the various possibilities one can the organic and the psychological, mak- How did “neurasthenia” develop into think of have been eliminated, what is left ing it a daunting challenge to figure out. chronic fatigue syndrome? Why is must be the truth. Yet one can never be The fact is that long term antibiotic treat- Chronic Fatigue Syndrome not in DSM “sure” in excluding psychiatric etiologies. ment hasn’t worked and causes compli- IV, but classified by the Centers for Dis- Another organic disorder that pro- cations. Yet a lay organization has sued ease Control and Prevention? Why is vided fuel for psychoanalysis is cataplexy, an organization of bone fida experts to fibromyalgia or Irritable Bowel Syn- the sudden loss of body tone, causing claim that double blind placebo con- drome not in DSM? Where does mul- people with narcolepsy to fall to the trolled trials have been inadequate, not tiple chemical sensitivity syndrome be- ground when experiencing a sudden because of study design but because their long? When is a physiologically inexpli- emotion. I will never forget, in the early results fly in the face of the organization’s cable syndrome a somatoform disorder, days of sleep medicine, hearing a lecture common experience. or a conversion disorder rather than a from a sleep doctor pioneer, who de- If blood letting didn’t work, why specific organ system disorder? scribed a teenage boy who would delib- would we use it, asked our predecessors Many disorders have moved from erately provoke his father to the point of two hundred years ago, or steroids a mere the psychological column to the organic getting him to jump out of his chair to 20 years ago? I think there is a rationale 206 MEDICINE & HEALTH/RHODE ISLAND for a democratic process for disease clas- Disclosure of Financial Interests Ingelheim, Sepracor, Glaxo; Speakers’ Bureau: sification, limiting voting to experts, but Joseph Friedman, MD, Consultant: Acarta Astra Zeneca, Teva,Novartis, Boehringer-Ingelheim, surely not for disease treatment.