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Home , Lyme disease, Syphilis, Willy Burgdorfer

Dolli Lane, 96th Medical Group laboratory technician, reviews sample through microscope November 19, 2015, at Eglin Air Force Base, Florida, after recently discovering rare spirally twisted , known to cause tickborne relapsing , and cultured by Centers for Disease Control (U.S. Air Force/Ilka Cole)

o one is immune to, and there is no cure for, tickborne diseases. The Myths of N Just one bite can destroy a person’s career. At age 43, Air Force Colonel Nicole Malachowski was found unfit for duty due to neurologi- cal damage resulting from a tickborne disease. Colonel Malachowski was the Separating Fact from Fiction first woman to fly with the Thunder- birds and then commanded the 333rd for Military Personnel Fighter Squadron. She also served as the deputy director for U.S. Air Force By Montgomery McFate Readiness and Training in the Office of the Under Secretary of Defense for Personnel and Readiness and as the executive director of the White House I love everything in the world. Except for . “Joining Forces” Initiative (2015–

—Dalai Lama

Dr. Montgomery McFate is a Professor at the U.S. Naval War College.

JFQ 100, 1st Quarter 2021 McFate 73 2016).1 While she was commanding an link between the arthritic symptoms and many of the most recent medical studies F-15 fighter squadron, Colonel Mala- the bite of an insect. In the early 1980s, indicate that Lyme can evade detection chowski began experiencing a rapid Dr. Wilhelm Burgdorfer discovered that and cause severe chronic symptoms.) As onset of multiple symptoms. She wrote the causative agent of Lyme a result of the so-called Lyme wars, the that she suffered from was a spirochete type of bacteria, subse- disease itself has become shrouded in a quently named burgdorferi in his number of myths. Separating fact from intractable pain, insurmountable , honor. After extensive field investigations, fiction is critical for military personnel cognitive dysfunction and major problems scapularis, commonly referred to and their families since members of the with my speech and short-term . I as the deer tick or blacklegged tick, was Armed Services could face a heightened endured disorientation, , anxiety identified as the main of Lyme risk of contracting Lyme disease based on and even moments of temporary paralysis. infection east of the Rocky Mountains. their occupations, locations, and recre- I was unsafe to be left alone. I could not In areas west of the Rocky Mountains, ational activities. play with my children, care for myself, or , also known as the west- interact with my husband. . . . There were ern blacklegged tick, was the primary It Is Not That Severe: False times I would have welcomed death. I vector. Lyme disease can produce a wide thought I was tough as a combat-proven Lyme disease is now a serious epi- variety of symptoms, but typical signs fighter pilot but tickborne illness destroyed demic in the , with positive of infection are a round red at the me. It brought me to my knees and ruth- lab tests reported from all 50 states and site of the tick bite, fatigue, swollen lessly broke me.2 Washington, DC.6 The CDC calculates joints, , fever, night sweats, annual U.S. incidence at more than cognitive impairment, and sensitivity Servicemembers are particularly 300,000 cases; however, true incidence to light.11 Many medical professionals at risk for Lyme disease; they live, is certainly higher.7 Although the major- in the United States tend to minimize work, and play on bases where Lyme is ity of cases have been reported from the the dangers of Lyme and may mistak- rampant. Some 75 percent of all U.S. northeastern part of the country, infected enly believe that the symptoms of the military installations are located in states ticks can be found in about 50 percent disease are not severe. For example, in where 99 percent of the approximately of U.S. counties.8 An increase in both the words of Dr. Katerina Silverblatt of 500,000 tickborne disease cases reported temperature and humidity as a result of Heights Pediatrics in Brooklyn, “We’ve to the Centers for Disease Control and is predicted to increase never had a from Lyme Prevention (CDC) from 2004 to 2016 the number of Lyme cases by more than that would be of any consequence.”12 occurred.3 Moreover, training drills often 20 percent in the coming decades.9 In On the contrary, many complications take place in woods and fields that harbor short, Lyme disease has already reached from Lyme disease are severe indeed. a variety of tick species. In their leisure epidemic proportions in the United For example, the spirochete bacteria of time, many Servicemembers and veterans, States, and the situation will certainly get Lyme disease can penetrate the heart, and their families, also enjoy hunting, worse. As the disease spreads, military even causing death.13 Dr. Neil Spector, fishing, camping, and in the great personnel, veterans, and their families will who taught medicine at Duke University, outdoors, which increases their risk of be at even higher risk for contracting the began experiencing muscle pain, fatigue, encountering ticks.4 Lyme disease is most disease. and irregular heartbeat.14 Doctors who prevalent in rural counties with relatively More than 40 years after children in treated him could find nothing wrong high socioeconomic status, abundant for- began getting sick from tick and dismissed his symptoms as stress estation, wet conditions, and mid-range bites, there is still no cure for many of the related. “I was confused,” recalled Dr. temperatures. These American counties people who have been bitten. A bitter Spector. “Should I believe a team of doc- tend to be exactly the sort of places where political battle has ensued in the United tors assuring me that nothing was wrong? veterans like to retire, and indeed, “Lyme States among professional medical orga- Or follow my gut instinct exhorting me disease incidence rates were higher in nizations, patient advocates, and even the to unearth the mystery responsible for counties with greater military veteran CDC concerning the origin, diagnosis, my downwardly spiraling health? I was population compositions.”5 and treatment of the disease. Mainstream beginning to question my sanity.” Left Commonly referred to as Lyme medical opinion has been that there is undiagnosed and untreated, the Lyme disease, Lyme borreliosis was first dis- no such thing as chronic Lyme because bacteria entered his heart. Only a heart covered in the United States in Lyme, the bacteria could not survive treatment transplant initially saved Dr. Spector’s life, Connecticut, in 1976. More than 20 with , evade detection, and but he lost his battle with Lyme disease in children developed what doctors initially cause ongoing symptoms.10 However, June 2020.15 His experience was not un- mistook for a juvenile form of rheuma- individuals who suffer from the disease usual: Cardiac manifestations of Borrelia toid . Strangely, each of these and patient advocacy organizations point burgdorferi infection occur in up to 8 per- children had exhibited a rash resembling to their own experiences as evidence that cent of patients,16 with most of the severe a bull’s eye, which led the doctors to see a the disease may linger for years. (Indeed, cases occurring in men of military age.17

74 Commentary / The Myths of Lyme Disease JFQ 100, 1st Quarter 2021 Technical Sergeant Jessica Roofe, 86th Aerospace Medicine Squadron NCO in charge of epidemiology, prepares tick to be sent for testing, September 9, 2016, at Ramstein Air Base, Germany (U.S. Air Force/Tryphena Mayhugh)

In addition to heart problems, Lyme might play a role in the suicide risk for psychogenic fugue state. My life was being can affect the brain. Lyme bacteria can Lyme patients, but scientists also believe destroyed by Lyme disease and no one had cross the blood-brain barrier, infecting that biological effects of Lyme on the a clue. At work, I had been highly awarded the . This mani- nervous system (including brain inflam- throughout my career, but it became a real festation of the disease—called Lyme mation, neuronal dysfunction, and white struggle and I did not understand why. —occurs in up to 15 matter ) could be a fac- When I went to work that morning, I was percent of patients bitten by an infected tor.23 One study demonstrated 33 percent tired, frustrated, and in a state of dread tick.18 Symptoms include , of late-stage Lyme disease patients were and fear, and I drove 100 miles past the facial palsy, , and stroke.19 suicidal, and by conservative calculations, base. I only drank a small amount of the When Lyme disease infects the central about 1,200 people infected with Lyme scotch; the bottle was still nearly full. I have nervous system, it may also cause severe commit suicide each year.24 The risk of never been a big drinker and as a result I psychiatric symptoms such as psycho- suicide is highest in children. One study fell asleep on the beach. I woke up the next sis, , , and demonstrated 41 percent of children who day wondering how I got there and why .20 In 2011, researchers at the had been diagnosed with Lyme disease and drove back to the base and turned my- International Alzheimer’s Research had suicidal thoughts and 11 percent had self in for Away Without Leave. After being Center in found evidence made suicidal gestures.25 diagnosed, treated and having recovered, I of spirochetes (the type of bacteria that Statistics on suicide often seem ab- can relate to other veterans living with un- causes and Lyme disease) in the stract, but the experience of one veteran diagnosed and untreated Lyme disease.26 brains of Alzheimer’s patients,21 confirm- might help illuminate the psychiatric ing that Alzheimer’s disease may have dangers of Lyme disease: Another severe complication of a bacteriological component and that Lyme disease is the from a may play a role.22 I woke up on a beach out of the country pregnant woman to her unborn baby. In Those who suffer from Lyme dis- with a bottle of scotch in one hand and my a systematic review of the medical case ease have an increased risk of suicide. handgun in the other. I did not remember studies from the United States, Europe, Of course, and chronic pain driving there. My doctor said I was in a and Asia between 1969 and 2017,

JFQ 100, 1st Quarter 2021 McFate 75 scientists identified negative outcomes psychiatrist. “Just ask any VA doctors test negative when in fact they are actu- for the fetus or newborns in 61 percent whether or not they understand Lyme ally infected. of , including spontaneous disease,” Sims wrote in a letter to his Most doctors use a two-tier , , and death shortly Member of Congress. “The likely for Lyme diagnosis, which was developed following birth. Babies who survived response is either no or just take the by the Food and Drug Administration, experienced a variety of congenital CDC tests. Surely, they are doctors, CDC, and others in 1994 and adopted irregularities and health issues, includ- but, they have not been trained to clini- by the Infectious Diseases Society of ing jaundice, respiratory distress, and cally diagnose Lyme disease. . . . They America as a standard protocol. The first heart abnormalities.27 Autism spectrum are visibly shaken and uncomfortable step is an enzyme immunoassay (enzyme- disorders are also associated with Lyme with Lyme disease. Consequently, veter- linked immunosorbent assay, known as disease.28 Interestingly, states’ ans with Lyme disease are misdiagnosed ELISA) followed by an test of autism spectrum disorder correlate and mistreated.” In 2015, Sims wrote (known as the ). Not only with their prevalence of Lyme.29 to President Barack Obama for help. is the accuracy of these tests a dismal 50 Many people—including many medi- The VA responded to the Presidential to 60 percent,34 but requiring a positive cal professionals—discount the severity inquiry and hired a Lyme disease spe- result on two different tests for a diagno- of Lyme disease. Yet scientists who study cialist, who finally diagnosed Sims with sis excludes many patients who actually Lyme disease recognize that the closest the disease after 33 years of misdiagno- do have Lyme disease. A 2005 survey of biological analogy to Lyme is syphilis. sis. Sims wrote: patients by the California Lyme Disease Like syphilis, Lyme disease is caused by Association revealed that 73 percent a highly invasive with a unique I was misdiagnosed for over three decades of patients were denied a diagnosis for form called a spirochete. Like syphilis, the and left untreated for Lyme disease. This Lyme disease at least once due to a nega- Lyme disease spirochete can invade the led to homelessness. Survived attempted tive ELISA test result according to the central nervous system and other major suicides. Untreated patients can lose ev- CDC criteria.35 systems of the human body. Also like erything, as I did, and become part of the This two-tier diagnosis system was syphilis, Lyme disease begins with a local- unemployed, underemployed, disabled, and never intended to be used for the di- ized infection, spreads throughout the homeless populations that die by suicide and agnosis of Lyme disease. Rather, it was body, and may result in chronic degenera- commit violent acts related to the psycho- developed by the CDC as a “surveillance tive disorders and possible mortality.30 logical impact of Lyme disease.32 case definition,” which is “a set of uniform Indeed, the bacteria that cause syphilis criteria used to define a disease for public and Lyme are so similar that scientists Why is Lyme disease so difficult to health surveillance.”36 Only patients who who study syphilis use Lyme bacteria as a diagnose? In the early stage of the disease, test positive according to the surveillance surrogate in the lab.31 approximately 50 percent of patients de- case definition for any particular disease velop an migrans, or bull’s-eye are counted in epidemiological reporting. It Is Easy to Diagnose: False rash, at the site of the bite.33 The other 50 For Lyme disease, the surveillance case Ruben Lee Sims enlisted in the Air percent do not develop a rash but experi- definition is an acknowledged tick bite, the Force and served in Vietnam. While ence flu-like symptoms, including fever, appearance of a bull’s-eye rash, and, for serving in the military, Sims was bitten headache, and joint swelling. Many people those who do not live in a region where by a tick and contracted Lyme disease. simply assume that they had a case of the Lyme is common, laboratory evidence of Military doctors neither diagnosed nor flu, never suspecting that their symptoms infection.37 Medical doctors generally use treated Sims appropriately and instead were caused by an infected tick. the CDC surveillance case definition to discharged him after 14 years of service Suspecting that their symptoms might diagnose patients, and insurance compa- in 1984, citing “hypochondriasis with be Lyme disease, some individuals go to nies often require patients to meet these psychogenic pain disorder” (meaning their primary care doctor and get tested. criteria before they will cover medical care. pain from psychological factors rather The only type of test currently available However, as the CDC notes, “Surveillance than a physical cause). After his dis- for Lyme disease is a serological assay, or case definitions are not intended to be charge from Active duty, Sims entered blood test, that detects whether the body used by healthcare providers for making the care of the Department of Veterans has developed in reaction to a clinical diagnosis or determining how Affairs (VA). He suffered from mul- the presence of the bacteria. Antibodies to meet an individual patient’s health tiple symptoms common to late-stage may not develop immediately, so if the needs.”38 In short, the misinterpretation chronic Lyme: vision problems, night test is taken too soon after a person is bit- and misapplication of CDC epidemiology sweats, joint swelling, heart , ten by a tick, the results will be negative. guidelines by the medical community and depression. Despite his classic Lyme Moreover, individuals with compromised make Lyme disease even more difficult to symptoms, the VA refused to perform or weak immune systems may not pro- diagnose because it excludes a vast number the tests that could have confirmed the duce detectable levels of antibodies in of patients through the use of excessively disease and instead referred him to a response to an infection, and so they will narrow criteria.39

76 Commentary / The Myths of Lyme Disease JFQ 100, 1st Quarter 2021 Colonel Nicole Malachowski, USAF (Ret.), former commander of 333rd Fighter Squadron, first female pilot selected to fly as part of Air Force Air Demonstration Squadron “Thunderbirds,” and ambassador for Wounded Warrior Project, shares her story with base personnel during visit to Schriever Air Force Base, Colorado, December 19, 2019 (U.S. Air Force/Katie Calvert)

Lyme disease is also difficult to diag- successfully for Lyme patients may not had not played squash regularly with a nose because ticks may transmit multiple effectively treat these . doctor. In the absence of a bull’s-eye in addition to Borrelia burg- Given the difficulty of diagnosing rash, it might have taken years to get a dorferi, many of which have symptoms Lyme disease due to coinfections, ex- correct diagnosis and even longer to get that are similar to Lyme and occur in clusionary diagnostic criteria, inaccurate adequate treatment. conjunction with it. Lyme disease is testing, and lack of clear symptoms, bacterial, but other tickborne diseases patients must often rely on luck. In June It Is Easy to Treat: False can be parasitic or viral. One common 2019, the New York Times published an Standard medical practice is to prescribe of Lyme disease is , article titled “My Son Got Lyme Disease. 28 days of antibiotics for treatment which is caused by a parasite that infects He’s Totally Fine,” which recounted of Lyme disease, and many medical red blood cells and causes headache, how the author’s son developed a swol- professionals believe that this is suf- nausea, mood changes, and in some cases len knee. After a magnetic resonance ficient to cure it. In the words of Dr. or . Viral tickborne imaging scan showed on Eugene Shapiro, professor of pediatrics , such as the Powassan , the boy’s knee and ankle, an orthopedist and epidemiology at Yale, for example, cause swelling in the brain and have a suggested it might be juvenile arthritis or “It’s baloney that you can’t cure Lyme 10 percent mortality rate. No treatment an autoimmune disorder. Treatment for disease; it’s eminently curable.”41 exists for . In the past few inflammation was not effective, so other Unfortunately, in more than 50 per- years, the Asian longhorned tick has been causes for the strange symptom were cent of cases, Lyme disease is not cured discovered in the United States. These sought. The mystery was solved only after by a single round of therapy.42 ticks can transmit a type of hemorrhagic the author’s husband had a chat with his These cases are designated as chronic Lyme fever as well as an enzyme that causes squash partner—who happened to be a or post-treatment Lyme disease (PTLD). an allergy to red meat. These pathogens doctor.40 This lucky little boy got a quick Individuals may appear to respond well cannot be detected by the standard Lyme diagnosis and was prescribed antibiotics. to the initial treatment with antibiotics disease blood tests, and antibiotics used But imagine if the father of the family and experience a relief of symptoms, but

JFQ 100, 1st Quarter 2021 McFate 77 scientists have recently discovered—is that Lyme bacteria are actually shape shifters: When exposed to a hostile en- vironment of antimicrobial drugs, the bacteria change from a spirochete to a round body or “cyst” form.49 The most common treatment for Lyme disease—a course of —kills 98 percent of the Lyme bacteria but actually induces the surviving 2 percent of Lyme bacteria to shape shift to cyst form.50 In other words, when a tick bite is treated with doxycycline, the antibiotic can force the Lyme bacteria to shift their shape into a form that can evade the and resist treatment with antibiotics. Lyme “doesn’t stay in the blood- stream for long,” according to Richard Ostfeld, a biologist who studies the ecology of Lyme. “Instead,” Ostfeld continues, “Borrelia manages to insinuate itself into parts of the body that have fewer circulating antibodies, where it is harder for antibiotics to reach.”51 According to Dr. inoculating ticks, May 1954 (Rocky Mountain Laboratories one article, the “defensive morphologi- Historical Collection/Nicholas J. Kramis) cal forms of Borrelia burgdorferi” such then relapse either months or years later. members of the medical establishment as cysts and biofilms make it difficult to A subsequent round of antibiotics may have dismissed the existence of chronic detect the bacteria in the blood of infected lead to the same results. In some cases, this Lyme altogether on the grounds that patients and also allow the Lyme bacteria pattern of response and relapse continues it “includes a broad array of illnesses or to evade the patient’s immune system and for decades. A recent study estimates that symptom complexes for which there is resist even the most aggressive antimicro- the number of people in the United States no reproducible or convincing scientific bial treatments.52 In short, Lyme disease is suffering from PTLD will exceed 2 million evidence of any relationship to B. burg- not always easy to treat. by the end of 2020.43 dorferi infection.”47 Many scientists who study Lyme dis- From a diagnostic perspective, the Conclusion ease have struggled with the question of problem with chronic Lyme is that the The majority of doctors in the United why 20 percent of patients fail to respond standard diagnostic tests for infection are States believe that Lyme disease is easy to to treatment with antibiotics. One of often negative and, thus, there is no evi- diagnose and easy to treat and is severe the first avenues of exploration has been dence of actual infection. As Dr. Marcelo only in rare cases. However, both the to determine whether Lyme, like other Campos at Harvard Medical School scientific evidence and the experience of bacteria such as staph and , noted: patients demonstrate that Lyme disease could develop a resistance to antibiotics. can often be challenging to diagnose The bacteria that cause Lyme disease, Conventional medicine has a hard time and difficult to treat. In many cases, the however, do not develop antibiotic resis- treating something we cannot see or isolate. symptoms can be debilitating and, in rare tance. According to one study, “Given However, we cannot ignore that people’s cases, lethal. “What we’re dealing with is that antibiotic resistance has not been lives changed after the diagnosis of Lyme way more sophisticated bacteria than any observed for B. burgdorferi, the reason disease. Their suffering is real. And the other bacteria we know,” according to for the recalcitrance of late-stage disease frustration is widespread. On one side, we Ginger R. Savely, a Lyme disease special- to antibiotics is unclear.”44 With that have distressed patients tired with the lack ist at Union Square Medical Associates line of inquiry shut down, scientists have of answers; on the other side, we have doc- in San Francisco. “The more you really proposed and tested different theories, tors who cannot find a biological proof of study the bacteria and how it works, the including the possibility that chronic what is happening.48 more you become incredibly impressed Lyme is actually the result of coinfections by how many mechanisms this bacteria from the original tick bite45 or that it is One reason that biological proof of has for survival and how difficult it is to simply an autoimmune response.46 Some an existing infection cannot be found—as get rid of it.”53

78 Commentary / The Myths of Lyme Disease JFQ 100, 1st Quarter 2021 Lyme disease is the most widespread New basic research into Lyme disease Directed Medical Research Programs, “Tick- Borne Disease Research Program,” March vector-borne disease in the United and the repurposing of old drugs such as 2019, available at . there is neither a reliable diagnostic is no cure and no easy treatment for this 4 Carlo Rossi et al., “Characterizing the test nor an effective treatment for it. In serious and debilitating disease. Given Relationship Between Tick Bites and Lyme Disease in Active Component U.S. Armed 2018, the Tick-Borne Disease Working the dire health consequences, the poor Forces in the Eastern United States,” Medical Group—composed of representatives diagnostic tools, the effects of climate Surveillance Monthly Report 22, no. 3 (March from a variety of Federal agencies— change in increasing tick habitats, and 2015), 2–10. noted in a report to Congress that the of the disease in 5 Justin T. McDaniel et al., “Military Vet- “progress has been hampered by a lack geographical areas where the military eran Residential Location and Risk for Lyme Disease,” Journal of Veterans Studies 3, no. 45 of attention at the Federal level and by lives, works, and plays, Lyme should (August 2018), 45–56, available at . epidemic proportion of Lyme disease in force. At the moment, unfortunately, 6 “Lyme Disease Health Trends,” Quest the United States, Federal funding for the Department of Defense (DOD) Diagnostics, July 2018, available at . National Institutes of Health, for exam- noted above, DOD participates in the 7 Centers for Disease Control and Preven- ple, spends on average $77,355 for each U.S. Government Tick-Borne Disease tion (CDC), “How Many People Get Lyme new case of HIV/AIDS and $36,063 Working Group, and Lyme is one of Disease?” December 21, 2018, available at for every new case of C virus, the congressionally directed medical . 8 Rebecca J. Eisen, Lars Eisen, and Charles yet only $768 for each new case of Lyme research programs.58 However, DOD B. Beard, “County-Scale Distribution of Ixodes disease. In the same report to Congress, has dedicated only $900,000 in fiscal scapularis and Ixodes pacificus (: ) it was noted that “Federal funding for year 2020 to supporting basic research in the Continental United States,” Journal of tick-borne diseases today is orders of on Lyme and other tickborne diseases.59 53, no. 2 (March 2016), magnitude lower, compared to other In terms of Lyme prevention, beginning 349–386. 9 Igor Dumic and Edson Severnini, “‘Tick- threats, and it has failed to in 2013, the Army began issuing Army ing Bomb’: The Impact of Climate Change on ”56 increase as the problem has grown. combat uniforms (ACUs) treated with the Incidence of Lyme Disease,” Canadian Lack of attention to Lyme disease— (an ),60 which Journal of Infectious Diseases and Medical despite its epidemic proportions and is an important step in the prevention of (October 2018), available at debilitating symptoms—has led many tick bites. However, any comprehensive . 10 Alison Tonks, “Lyme Wars,” BMJ 335, patient advocacy groups to begin funding program to counter tickborne diseases no. 7626 (November 2007), 910–912, avail- their own research. The Global Lyme must also include chemical pest control, able at . needed basic research, including mapping management, public education, and 11 CDC, “ of Untreat- the genome of Borrelia burgdorferi and targeting reservoir hosts such as deer and ed Lyme Disease,” August 15, 2019, available at . effective against biofilm colonies. In some tickborne disease education and preven- 12 Apoorva Mandavilli, “My Son Got Lyme cases, private foundations have picked up tion program that targets the entire joint Disease. He’s Totally Fine,” New York Times, the slack where the Federal Government defense enterprise, and there definitely June 27, 2019. 13 has fallen short and committed sig- should be. JFQ “Three Sudden Cardiac Deaths Associat- ed with Lyme —United States, Novem- nificant funding to cutting-edge Lyme ber 2012–July 2013,” Morbidity and Mortality research. The Steve & Alexandra Cohen Weekly Report 62, no. 49 (2013), 993–996. Foundation, for example, has provided Notes 14 “Neil Spector, MD, Physician-Scientist, $60 million to support more than 25 Mentor, Author, Dies at 63,” APSCO Post, July 1 Lyme disease research projects. Privately Department of Defense Congressionally 10, 2020, available at . drug capable of killing Lyme in all of its Tick-Borne Disease,” May 29, 2018, avail- 15 Tick-Borne Disease Working Group, forms: disulfiram, which has been used able at . Department of Health and Human Services, 2 of alcoholism.57 The drug is now under- Dorothy Kupcha Leland, “Touched by 2018), 22, available at

JFQ 100, 1st Quarter 2021 McFate 79 dorferi,” Laboratory Investigation 84, no. 11 32 Tick-Borne Disease Working Group, Phenomenon of Borrelia Persisters,” Parasites (November 2004), 1439–1450. 2018 Report to Congress. & Vectors 12, no. 1 (May 2019). 17 Gerold Stanek et al., “Lyme Borrelio- 33 CDC, “Lyme Disease,” available at 51 Campos, “Lyme Disease.” sis,” Lancet 379, no. 9814 (February 2012), . 52 Eva Sapi et al., “Evidence of In Vivo Ex- 461–473. 34 Lisa A. Waddell et al., “The Accuracy of istence of Borrelia Biofilm in Borrelial Lympho- 18 Enea Gino Di Domenico et al., “The Diagnostic Tests for Lyme Disease in Humans, cytomas,” European Journal of Microbiology and Emerging Role of Microbial Biofilm in Lyme a Systematic Review and Meta-Analysis of Immunology 6, no. 1 (February 2016), 1–16. Neuroborreliosis,” Frontiers in Neurology (De- North American Research,” PLoS One 11, no. 53 Ann M. Hoppel, “The Lyme Wars: cember 3, 2018), available at . 2018 Report to Congress. at . Ärzteblatt 115, no. 45 (2018), 751–756. definitions.html>. 54 Ronald Rosenberg et al., “Vital Signs: 20 Di Domenico et al., “The Emerging Role 37 Michael Specter, “The Lyme Wars,” Trends in Reported Vectorborne Dis- of Microbial Biofilm.” New Yorker, June 24, 2013, available at . Report 67, no. 17 (2018), 496–501, available Following Koch’s and Hill’s Criteria,” Journal 38 CDC, “Surveillance Case Definitions.” at . 22 Judith Miklossy, “Bacterial Amyloid and 2018 Report to Congress. 55 Tick-Borne Disease Working Group, DNA Are Important Constituents of Senile 40 Mandavilli, “My Son Got Lyme Disease.” 2018 Report to Congress. Plaques: Further Evidence of the Spirochetal 41 Ibid. 56 Ibid. and Biofilm Nature of Senile Plaques,”Jour - 42 Emily R. Adrion et al., “Health Care 57 Venkata R. Pothineni et al., “Identi- nal of Alzheimer’s Disease 53, no. 4 (2016), Costs, Utilization and Patterns of Care Follow- fication of New Drug Candidates Against 1459–1473. ing Lyme Disease,” PLoS One 10, no. 2 (Feb- Borrelia Burgdorferi Using High-Throughput 23 Robert C. Bransfield, “Suicide and Lyme ruary 2015). The CDC says 10 to 20 percent. Screening,” Drug Design, Development, and and Associated Diseases,” Neuropsychiatric 43 Allison DeLong, Mayla Hsu, and Harriet Therapy 10 (April 2016), 1307–1322; Kenneth Disease and Treatment 13 (2017), 1575–1587, Kotsoris, “Estimation of Cumulative Number B. Liegner, “Disulfiram (Tetraethylthiuram available at . U.S., 2016 and 2020,” BMC Public Health 19, and : Report of Experience in Three 24 Ibid. no. 352 (2019), available at . 2019), available at . Lyme Disease,” Journal of feri, the Causative Agent of Lyme Disease, 58 Department of Defense Congressionally and Clinical Neuroscience 13, no. 4 (2001), Forms Drug-Tolerant Persister Cells,” Anti- Directed Medical Research Programs, “Tick- 500–507. microbial Agents and 59, no. 8 Borne Disease,” February 20, 2020, available at 26 Quoted in Bransfield, “Suicide and Lyme (2015), available at . and Associated Diseases.” pmc/articles/PMC4505243/>. 59 Department of Defense Congressionally 27 Lisa A. Waddell et al., “A Systematic 45 Stephen J. Swanson et al., “Coinfec- Directed Medical Research Programs, “Defense Review on the Impact of Gestational Lyme tions Acquired from Ixodes Ticks,” Clini- Health Program: Department of Defense Tick- Disease in Humans on the Fetus and New- cal Microbiology Review 19, no. 4 (October Borne Disease Research Program; Anticipated born,” PLoS One 13, no. 11 (2018), avail- 2006), 708–727, available at . February 4, 2020, available at . 46 Allen C. Steere, Dawn Gross, Abbie L. army.mil/pubs/press/2020/20tbdrppreann>. 28 Robert C. Bransfield, “Neuropsychiatric Meyer, and Bridgette T. Huber, “Autoimmune 60 Lisa Ferdinando, “Army Launches Lyme Borreliosis: An Overview with a Focus Mechanisms in Antibiotic Treatment-Resistant Website About Permethrin-Treated ACUs,” on a Specialty Psychiatrist’s Clinical Practice,” Lyme Arthritis,” Journal of Army News Service, September 4, 2013, Healthcare (Basel) 6, no. 3 (2018), avail- 16, no. 3 (May 2001), 263–268, available at available at . army_launches_website_about_permethrin_ care6030104>. 47 Henry M. Feder, Jr., et al., “A Critical treated_acu>. 29 Mason Kuhn et al., “Long Term Antibi- Appraisal of ‘,’” New otic Therapy May Be an Effective Treatment for England Journal of Medicine 357, no. 14 (Oc- Children Co-Morbid with Lyme Disease and tober 2007), 1422–1430. Autism Spectrum Disorder,” Medical Hypotheses 48 Marcelo Campos, “Lyme Disease: 78, no. 5 (2012), 606–615. Resolving the ‘Lyme Wars,’” Harvard Health 30 John J. Halperin, “A Tale of Two Publishing, June 18, 2018, available at . available at . Cystic Forms by Different Stress Conditions 31 “New Findings Could Help Target in Borrelia burgdorferi,” APMIS 112 (2004), Bacteria that Cause Lyme Disease, Syphi- 57–62. lis,” Science Daily, November 19, 2013, 50 Natalie Rudenko, Maryna Golovchenko, available at . “Metamorphoses of Lyme Disease Spirochetes:

80 Commentary / The Myths of Lyme Disease JFQ 100, 1st Quarter 2021