evidence that adequate antibiotic therapy eventually eradicates Borrelia even from poorly accessible sites such as synovium. Paradoxically, in the recent Infectious Diseases Society of America guidelines on the treatment of Lyme disease (2), a single-dose antibiotic strategy for preventing Lyme disease due to tick bites was endorsed, despite 50 years of evidence that early, inadequate antibiotic therapy can abrogate both cutaneous and serologic evidence of persistent spirochetal infection while failing to eliminate the bacteria (3-5). Kannian and colleagues (1) do not discuss the resultant seronegative Lyme disease (5) that may leave inadequately treated Lyme arthritis patients with persistent infection and without identifying anti-Borrelia antibodies. Like Lyme arthritis, seronegative disease can also be cured by a single course of definitive antibiotic therapy.
The report by Kannian et al documents that waxing and waning antibody levels and specificities have little predictive value in diagnosing antibiotic-resistant Lyme arthritis. However, it reinforces the dictum that it is prudent to treat Lyme disease definitively at the time of diagnosis. The described increase in antibody titers following antibiotic treatment has previously been described in both syphilis and Lyme disease (6,7) and is consistent with the booster effect of liberating microbial antigens in infected subjects. It is sometimes accompanied by a Jarisch-Herxheimer reaction in both diseases.
Kannian et al do not provide data regarding the correlation between the duration of infection and Lyme arthritis. Typically, infection is heralded by an erythema migrans rash occurring in the spring, and, without treatment, arthritis can present weeks or months later. Did antibiotic-resistant arthritis occur primarily in subjects who did not receive antibiotics for several months after infection? The authors speculate on the importance of cell-mediated immunity in arthritis, and Borrelia-specific T cells have been found in joint effusions (8). In contrast to antibody titers, does cell-mediated immunity activity correlate with attacks of arthritis?
Despite the lack of the predictive value of antibody titers, clearly a definitive course of antibiotics will cure Lyme arthritis although symptom resolution may take several months. There is little evidence that repeated courses of antibiotics will hasten a cure, although they do increase morbidity (9). In contrast, single-dose therapy as advocated by Kannian and colleagues may result in seronegative disease and persistent occult infection, and should be eschewed.