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Volume: 3
Issue: 16
Date: 04-Oct-95


Table of Contents:

I.    LYMENET: News From the Michigan Lyme Disease Association
II.   AM J MED: Ocular manifestations of Lyme disease
III.  J CLIN MICROBIOL: Immunoblot interpretation criteria for
      serodiagnosis of early Lyme disease
VI.   About The LymeNet Newsletter


Newsletter:

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*                  The National Lyme Disease Network                  *
*                         LymeNet Newsletter                          *
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IDX#                Volume 3 - Number 16 - 10/04/95
IDX#                            INDEX
IDX#
IDX#  I.    LYMENET: News From the Michigan Lyme Disease Association
IDX#  II.   AM J MED: Ocular manifestations of Lyme disease
IDX#  III.  J CLIN MICROBIOL: Immunoblot interpretation criteria for
IDX#        serodiagnosis of early Lyme disease
IDX#  VI.   About The LymeNet Newsletter
IDX#


QUOTE OF THE WEEK:

     "Medicine and civilization advance and regress together.
     The conditions essential to advance are intellectual
     courage and a true love for humanity.  It is as true
     today as always in the past that further advance or even
     the holding of what has already been won depends upon
     the extent to which intellectual courage and humanity
     prevail against bigotry and obscurantism."


     -- Howard W. Haggard, M.D.
        Yale University, 1929
        Quote submitted by a reader



I.    LYMENET: News From the Michigan Lyme Disease Association
--------------------------------------------------------------
Sender: Kim Weber, Editor, MLDA <TickTalk2@aol.com>


FRUSTRATED RESIDENTS SPEAK-OUT ON LYME DISEASE

Are doctors reluctant do diagnose and report Lyme disease after being
told by state health officials there is no Lyme in Michigan?  Are
patients' pleas for help being ignored?  That's just what many
residents from lower Michigan were saying at two public hearings,
August 22 and 24th, where they had the opportunity to recount their
personal experiences with this disease.  It is problems like this
that initiated an investigation by State Reps., Penny Crissman,
R-Rochester, John Jamian, R-Bloomfield Twp., and Sandra Hill,
R-Montrose Twp.  More than 400 residents attended the two hearings.  
A busload of more than 50 people from Jackson came with the South
Central Support Group, one of thirteen groups stationed in Michigan.


Many witnesses had expressed their frustration with the lack of
recognition and response by their local health departments and the
Michigan Department of Public Health, despite a growing number of
sufferers who are being diagnosed.  Among these cases is Mary
Patterson, 18-year old daughter of L. Brooks Patterson, Oakland
County Executive.  After seeing ten physicians and being told "it was
all in your head", Dr. Arolnold Markowitz of Keego Harbor finally
diagnosed Mary.  By then, she was sick, weak and had lost 28 pounds.
After his experience with physicians who know little about Lyme
disease, L. Brooks Patterson was prompted to become involved with
the hearings.  He recommended requiring continuing education on Lyme
disease for doctors and improved reporting of cases.


CONTROVERSY IN DIAGNOSING AND REPORTING

Richard D. Wheat, administrative assistant for the Michigan Dept. of
Public Health, Office of Legal & Legislative Affairs, said that along
with reporting of cases, there are approximately 300 physicians
participating in active surveillance in Michigan.  However, physicians
not involved in this study, are treating a number of patients for
Lyme disease.  Some of these physicians may be reluctant to fill out
the cumbersome paperwork in the reporting of cases and may also fear
investigation of their practices.


The controversy surrounding Dr. Joseph Natole of Saginaw, who did
comply with reporting requirements, may play a role in the
intimidation of these physicians.  Dr. Natole, lauded by patients at
the hearings for his willingness to treat in the face of
recrimination, has stood up to allegations of over diagnosing Lyme
disease.  Formal charges by the Michigan State Attorney General led
to hearings last year in Lansing; and are now pending on the ruling
from an administrative judge and Board of Medicine.  Another
physician, who is closely watching the investigation and expressed
concern over his own practice, testified that he has treated over 170
patients in nine years.  He was dismayed that the medical community
has "their head buried in the sand" when it comes to recognizing Lyme
disease in our state.


Part of the problem is the difficulty in diagnosis, due to the
unreliability and interpretation of current tests.  This leaves the
diagnosis mainly a clinical one.  Laurie Eichstead, V.P., MLDA,
testified that this is very difficult for most physicians, who only
receive approximately five minutes of lecture on Lyme disease in
medical school.  Eichstead, who has a background in nursing and works
in a hospital said,  "physicians are torn by the health department's
information negating Lyme disease.  Instead of learning what Lyme
disease is and how to treat it, they are hearing that it is not a
problem and how not to diagnose this disease."


One area of intense interest centers in Oakland County, where two
physicians are treating a number of patients for Lyme disease.  Many
of these patients believe they were bitten in Oakland County.  From
1984-1994, the CDC reported 56 cases from Oakland County.  However,
in the last year alone, cases have increased ten-fold.


At the Rochester hearing, Dr. Ronald Davis, chief medical officer for
the Michigan Department of Health responded that there is little risk
of Lyme disease in the lower peninsula.  His testimony cam on the eve
of an announcement that he would assume a new position as director of
the Center for Health Promotion and Disease Prevention at Henry Ford
Health System, Inc., effective Sept. 25th.


The assertion that Lyme disease is not a threat in the lower peninsula
is based on research done by Dr. Ed Walker, M.S.U., entomologist.  
However, Jane Huegel, President, MLDA, stated that 90% of the CDC
grants were used for this study in Menominee County, in the upper
peninsula, an area already know for Lyme disease.  She said that many
of the areas, where cases were reported, have been inadequately
surveyed.  When there was cooperative research done between Dr. Walker
and the MLDA in Frankenmuth, 7.8% ear punch biopsies turned out to be
positive using PCR testing on mice.  Jean Schluckebier, Secretary of
the Board of Directors, MLDA, said that the health dept., wouldn't
accept these results, and that she is tired of hearing all the reasons
why don't have Lyme disease in Michigan.


LOOKING TOWARD DIFFERENT VECTORS

"If we have this many people with Lyme disease and no deer ticks, then
we should be looking for a different vector", testified Schluckebier.  
She said these questions were being raised back in 1989 in joint
meetings with Dept. of Agriculture, Michigan Department of Health and
MSU scientists.


Rev. Kenneth Lindland of Jackson, whose son, Paul, suffers from Lyme
disease also suggested that different vectors be seriously
considered.  He cited Missouri as an example where there is a high
incidence of Lyme disease, yet the deer tick is not considered suspect
for the transmission of Lyme in that region.


Studies conducted in Missouri point to the lone star and American dog
ticks as the best candidates for carrying Lyme disease.  Dr. Edwin
Masters has published articles on his research isolating the bacteria  
in patients and potential vectors.  He concludes that an atypical Lyme
spirochete may account for the great numbers of Lyme cases that fit
the classic picture, yet fail to culture positive for this organism.


The Michigan Lyme Disease Association is currently soliciting funds
and involved in a large research project with entomologists who are
scheduled to drag for ticks in "hot spots" this fall.  The association
has targeted areas where reported cases are clustered.  When asked
about the possibility of considering other vectors in Michigan, Jan
Huegel, MLDA President said, "our research will predominantly be
looking for the Ixodes scapularis (deer tick), but we aren't ruling
out other vectors such as A. americanum (lone star) and D. variabilis
(American dog) ticks.


After listening to compelling testimonies, Reps., Crissman, Jamian and
Hill will now take our concerns and suggestions to Lansing where they
can work on solutions to the problems of reporting, diagnosis and
treatment.  Before receiving a standing ovation, L. Brooks Patterson
also proposed that Governor Engler impanel a blue ribbon committee for
investigating Lyme disease in our state.


AFTER W-O-R-D-S

Within one week of the hearings and press coverage, the MLDA received
over 95 calls, most of which were from the lower peninsula.  There
were some residents that requested information and, then, there were
those that fit the classic picture of Lyme disease and couldn't find
adequate medical care.  Oakland/Macomb support group leader, Linda
Purdy followed-up on many of these calls and mailed out information.  


The MLDA is committed to the education and research of Lyme disease,
and will continue to  work with our legislature to address and resolve
these issues that can no longer be ignored.



=====*=====


II.   AM J MED: Ocular manifestations of Lyme disease
-----------------------------------------------------
AUTHORS: Lesser RL
REFERENCE: Am J Med 1995 Apr 24;98(4A):60S-62S
ORGANIZATION: Department of Ophthalmology and Visual Science,
             Yale University School of Medicine, New Haven,
             Connecticut, USA.
ABSTRACT:


Although ocular manifestations of Lyme disease have long been noted,
they remain a rare feature of the disease.  The spirochete invades
the eye early and remains dormant, accounting for both early and late
ocular manifestations.  A nonspecific follicular conjunctivitis
occurs in approximately 10% of patients with early Lyme disease.
Keratitis occurs often within a few months of onset of disease and
is characterized by nummular nonstaining opacities.  Inflammatory
syndromes, such as vitritis and uveitis, have been reported; in some
cases, a vitreous tap is required for diagnosis.  Neuro-ophthalmic
manifestations include neuroretinitis, involvement of multiple
cranial nerves, optic atrophy, and disc edema.  Seventh nerve paresis
can lead to neurotrophic keratitis.  In endemic areas, Lyme disease
may be responsible for approximately 25% of new-onset Bell's palsy.
Criteria for establishing that eye findings can be attributed to
Lyme disease include the lack of evidence of other disease, other
clinical findings consistent with Lyme disease, occurrence in

patients living in an endemic area, positive serology, and, in
most cases, response to treatment.  Management of ocular
manifestations often requires intravenous therapy.



=====*=====


III.  J CLIN MICROBIOL: Immunoblot interpretation criteria for
     serodiagnosis of early Lyme disease
--------------------------------------------------------------
AUTHORS: Engstrom SM, Shoop E, Johnson RC
REFERENCE: J Clin Microbiol 1995 Feb;33(2):419-27
ORGANIZATION: Department of Microbiology, University of Minnesota
             Medical School, Minneapolis.
ABSTRACT:


We monitored the antibody responses of 55 treated patients with early
Lyme disease and physician-documented erythema migrans.  Six
sequential serum samples were obtained from patients before, during,
and until one year after antibiotic therapy and analyzed by in-house
enzyme-linked immunosorbent (ELISA) and immunoblot assays.  An
immunoblot procedure utilizing a gradient gel and an image analysis
system was developed.  A relational database management system was
used to analyze the results and provide criteria for early disease
immunoblot interpretation.  Recommended criteria for the
immunoglobulin M (IgM) immunoblot are the recognition of two of three
proteins (24, 39, and 41 kDa).  The recommended criteria for a
positive IgG immunoblot are the recognition of two of five proteins
(20, 24 [> 19 intensity units], 35, 39, and 88 kDa).  Alternatively,
if band intensity cannot be measured, the 22-kDa protein can be
substituted for the 24-kDa protein with only a small decrease in
sensitivity.


Monoclonal antibodies were used to identify all these proteins except
the 35-kDa protein. With the proposed immunoblot interpretations, the
sequential serum samples were examined.  At visit 1, the day of
diagnosis and initiation of treatment, 54.5% of the serum samples
were either IgM or IgG positive.  The peak antibody response, with
80% of the serum samples positive, occurred at visit 2, 8 to 12 days
into treatment.  The sensitivities of the IgM and IgG immunoblot for
detecting patients that were seropositive into the study period were
58.5 and 54.6%, respectively, at visit 1 and 100% at visit 2.  Twenty
percent of the patients remained seronegative throughout the study.
The specificities of the IgM and IgG immunoblots were 92 to 94% and
93 to 96%, respectively. The IgM immunoblot and ELISA were similar
in sensitivities, whereas the IgG immunoblot had greater sensitivity
than the IgG ELISA (P = 0.006).



=====*=====


VI.   ABOUT THE LYMENET NEWSLETTER
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