Doctor’s Dilemma, a paper
Edward L. McNeil, M.B., B.S., M.D.
The West Nile Virus is spreading as every day we hear of new cases and people dying from the disease.
It is not the only infectious disease that is spreading and is killing people although it does not kill quickly nor dramatically enough to be considered newsworthy. The health authorities are justifiably worried about cases of BSE (Bovine Spongiform Encephalitis) in cattle and other animals, that has plagued some European countries but has now been identified in the US. BSE is the source of Creutzfeldt-Jakob disease in humans that destroys the brain. Unlike West Nile Virus, it takes many years before symptoms appear at which time there is no effective treatment for it and the patients die.
Other diseases, far more common, spreading rapidly and expected to infect one-half million people within the next few years, come from being bitten by a tick, a mosquito or a flea. They are commonly known as tick-borne diseases, the one most well known being Lyme disease (Borrelia burgdorferi or its variant strain).
When Lyme disease was first recognized in Connecticut, the majority of the victims were infected by a single germ subsequently called Borrelia Burgdorferi, after Dr. Burgdorfer who identified it.
Unfortunately, most of those who have been bitten by a disease-carrying tick can now be infected with more than one disease from a single bite. One is Ehrlichia, another is Borrelia burgdorferi, and Babesia which is a malarial cousin and gives similar symptoms to malaria. The three mentioned organisms are not the only ones that can infect from the same bite, as these organisms depend on the geographical area from which they came. These diseases are not only prevalent in the USA but are found in every European country, Scandinavia, the Balkans and as far away as Australia.
Ticks are great travelers. They can catch a ride on a plane or a bird. They can be carried from one country or continent to another, attaching themselves to humans or their luggage. The disease they carry can be transmitted by blood transfusions and from mother to fetus, an infected fetus more likely to abort and, if born, to be diseased and die at an early age.
The doctors’ dilemma is they have been told early treatment with a short course of an antibiotic, usually Doxycycline, will cure Lyme disease. This may appear to be so but such treatment will not guarantee a recurrence will not occur, months or years later, without a further tick bite. This is especially so if more than one pathogen was in the bite.
That is not the only dilemma faced by the doctors because many of the blood tests to indicate Lyme disease are unreliable. A patient with negative results can be told they do not have Lyme disease when they indeed do. Treatment is then denied and the patients sentenced to an advancement of their disease(s) to a chronic form with increasing disability and death. Sadly, it is not unusual for patients to see 10 to 15 different doctors before a diagnosis is made. This is applicable to both the USA and the UK.
Diagnosis has to be made by taking a complete history of symptoms and physical signs elicited by a thorough examination, especially of the nervous system. For treatment to ameliorate some of the disabling symptoms, a prolonged course of antibiotics is necessary. Such treatments have shown success when prescribed by physicians specializing in the treatment of the tick-borne diseases and who have personally treated more than 5000 cases. Those who consider prolonged courses of antibiotics are harmful do not seem to apply the same judgement to other infectious diseases, such as Tuberculosis or AIDS, or to the use of prolonged courses of antibiotics for young people with acne.
A lot of expensive research is being done regarding what happens at the cellular level in the tick-borne diseases, but until repeatable, accurate tests are available to identify which pathogens are infecting a particular patient, research to show the effectiveness of particular treatments, is futile. Until that time, doctors are justified in diagnosing the tick-borne diseases clinically and ermpirically, treating with long-term antibiotics, judging the response over months rather than days. Long term exhibition of antibiotics is less likely to cause resistance to the antibiotics than short courses.
After penicillin with the advent of the antibiotic age, many considered we had conquered infectious diseases for good. How wrong they were. Emerging and changing infectious diseases now present an awesome challenge around the planet. In the fight against the harmful germs, we have not begun to win and great losses are to be expected. We may consider humans smart but the microbes have shown themselves to be even smarter in this present age.
This paper was originally presented to the Second National Lyme Convention held in Gettysburg PA on Saturday, July 27 and Sunday, July 28, 2002. Reprinted by permission of Dr. McNeil.
Dr. Ted McNeil is an acadamician in the International Academy of Aviation and Space Medicine. He was a pioneer in International Medical Air Rescue and wrote the first text book on the subject. He also worked with NASA and designed the equipment for performing surgery in a weightless environment. Later, Dr McNeil worked as an emergency room physician in Connecticut. He is interested in all changing and emerging infectious diseases and gave a presentation on the subject to the Acadamy in Paris in September, 2001, in which he discussed tick-borne diseases among others.
Now retired and living in Florida, Dr. McNeil himself suffers from tick-borne diseases (sadly Dr McNeil has since passed away. He bequeathed money to the UK based Lyme Disease Action on his death. May he rest in peace).