lassic teachings state that acute infections are usually only seen in those with some form of immune compromise. Flu-like symptoms rapidly evolve to include shaking chills, high fevers, hemolysis and pancytopenia. Fatalities have been reported. Visualizing Babesial forms on peripheral smears can make the diagnosis in this situation. In those with intact immune systems, a mild flu-like illness appears one to two weeks after exposure and clears without treatment over six to eight weeks. In either case, it is imperative to also test for Borrelia and Ehrlichia.

However, when coinfection exists, this acute presentation is much less common, and it is rare to see parasite forms on smear. Suggestions of coinfection include severe headaches, dyspnea, dry cough, dizziness, and encephalopathy out of proportion to the other Borrelial symptoms. Testing is not at all definitive, yet should include CBC, Babesia smear (very low yield), serologies (IgG and IgM) and if necessary, PCR of peripheral blood. Newer direct assays are currently being researched, as this is an active area of investigation. Always consider coinfection in your current Lyme patients who are not responding fully and be prepared to treat cased on clinical presentation even with negative tests.

EHRLICHIOSIS

While it is true that this illness can have a fulminant presentation, I am convinced that milder forms do exist especially when other tick-borne organisms were transmitted. When present in a Lyme patient, persistent leucopenia is an important clue. Thrombocytopenia is much less common, but likewise should not be ignored. Headaches, myalgias, and ongoing fatigue seem to relate to this illness, but are extremely difficult to separate from symptoms caused by Bb. At this time, we have to rely on serologies for laboratory diagnosis, as currently available PCR assays are of unknown sensitivity and specificity, and direct visualization of leucocytes is of low yield. As there may be a variety of pathogenic Ehrlichia-like organisms that will not be picked up by current testing technology, clinical diagnosis remains the primary diagnostic tool. Again, consider this diagnosis in a Lyme Borreliosis (LB) patient not responding well to therapy.

LYME BORRELIOSIS

ERYTHEMA MIGRANS ... http://www2.lymenet.org/domino/file.nsf/UID/guidelines

---------------------------------------------------------------------- To summarize:

1. There has never been a study in the history of this illness that even in the simplest way proves that currently recognized short-course (two to four week) therapy results in a bacteriologic cure.

2. There has never been a consensus in patients who are still symptomatic after short treatment courses as to what constitutes the "post Lyme syndrome" if bacteriologic cure is indeed presumed, nor how Bb induces it, and what perpetuates it.

3. Patients must be kept on therapy until free of active symptoms or they either will never recover fully, or suffer a relapse and risk further, possibly permanent damage.

4. Extended durations of antibiotic therapy clearly have helped literally thousands of patients who were not helped by short courses of treatment. When carefully applied, the safety of prolonged therapy has been demonstrated.

5. Finally, we have to recognize that in some patients, LB may not be curable in a strict bacteriologic sense, and open ended, ongoing suppressive antibiotic therapy may be necessary.

The gaps in our knowledge of Lyme require an approach that is a mixture of up to date data with the best in old-fashioned bedside clinical assessment