A worldwide phenomenon
The diagnosis and treatment of certain diseases, such as Lyme borreliosis, babesiosis and bartonellosis, have long been at the heart of a major controversy within the medical and scientific community. This debate, which has been going on for over 30 years, focuses on the reliability of treatments and diagnostic tests for these diseases, and more specifically on the management of their chronic form [1].
The controversy began with Lyme disease and has grown considerably over the years, to the point of being dubbed the "Lyme wars". This term illustrates the profound divergence of positions among the various experts, with some claiming that conventional treatments are sufficient, while others maintain that the chronic form of the disease requires more complex approaches and prolonged treatments [2-3].
This ideological war reflects not only disagreements on medical protocols, but also on the very recognition of the existence of a chronic form of these diseases, which continues to fuel an intense and unresolved debate.
1. The opinion of the Governmental Infectious Disease Societies
Since time immemorial, the Infectious Diseases Society of America (IDSA) and the Center for Disease Control (C.D.C.) in the United States have established recommendations for the diagnosis and treatment of numerous diseases such as Lyme borreliosis, babesiosis and bartonellosis [4-5-6]. Most other countries in the world, such as Switzerland with its Swiss Society for Infectious Diseases (SSI) and other medical institutions, largely follow these guidelines [7-8-9].
These medical societies consider that the management of these diseases according to their recommendations is generally effective, and assert that these infections cannot persist after appropriate antibiotic or antiparasitic treatment. They do not recommend prolonged treatment, and believe that diagnostic tests such as two-tiered testing with ELISA and Western blot are sufficiently reliable for diagnosing Lyme borreliosis [7].
Despite a considerable number of publications (>700) demonstrating that the persistence of these infections is at the root of chronic symptoms, and highlighting the problem of diagnostic testing [10], these societies have still not adapted their recommendations and appear to be firmly opposed to any change. Nor do they seem to take into account studies showing objective improvement in patients after prolonged treatment with polyantibiotics or antiparasitics [11-12].
In October 2023, the CDC (Centers for Disease Control and Prevention) finally acknowledged that Lyme borreliosis can cause persistent symptoms after infection, as can COVID-19 [13]. However, the CDC maintains that the cause of these symptoms remains unknown, reinforcing the idea of a "Post-treatment Lyme disease syndrome" [14].
2. The opinion of ILADS and specialist doctors
Many doctors and specialist researchers claim that certain bacterial and parasitic infections are the cause of chronic disease [3]. They argue that persistence phenomena (cystic, dormant forms, also known as "persisters", and biofilms) are the most likely cause of these chronic infections [15-16]. In particular, these specialists reject the term "Post-treatment Lyme disease syndrome", preferring instead to use the term "Chronic Lyme disease".
Today, numerous publications have confirmed the persistence of Borrelia and its mechanisms, identifying it as the probable cause of many chronic symptoms.
A December 2023 publication in the International Journal of Molecular Science neatly sums up the situation regarding Lyme borreliosis [17] :
The diverse strategies used by spirochetes to avoid the host immune system and persist in the host include active immune suppression, induction of immune tolerance, phase and antigenic variation, intracellular seclusion, changing of morphological and physiological state in varying environments, formation of biofilms and persistent forms, and, importantly, incursion into immune-privileged sites such as the brain. Invasion of immune-privileged sites allows the spirochetes to not only escape from the host immune system but can also reduce the efficacy of antibiotic therapy.
Faced with this lack of recognition in the USA, the International Lyme and Associated Diseases Society (ILADS), which brings together thousands of physicians and specialists in Lyme disease and co-infections, has compiled a list of over 700 studies suggesting that Borrelia and other tick- and insect-borne pathogens, such as Babesia and Bartonella, can persist despite conventional treatments [10].
This list includes over sixty studies dating back to the 1980s, demonstrating that bacterial persistence is not a recent phenomenon. It is well documented in other tick-borne diseases, such as brucellosis, Q fever and syphilis, also caused by a spirochete, a mobile, spiral-shaped bacterium related to Borrelia.
ILADS physicians also highlight the importance of co-infections (Babesia, Bartonella, Anaplasma, Ehrlichia, Rickettsia, etc.) in chronic infections. These co-infections, often confused with Lyme borreliosis, considerably influence the diversity and severity of symptoms, as well as the persistence of infections [18]. However, due to prevailing health policies, these facts remain widely disputed, and public funding for research in this field appears to be stagnating.
Finally, ILADS considers two-tiered testing to be insufficient and inadequate for diagnosing Lyme borreliosis, due to its low sensitivity, which varies between 50% and 80% depending on the stage of infection [1-3] .
As a result, ILADS' recommendations for the diagnosis and treatment of Lyme borreliosis differ markedly from those of IDSA.
ILADS recommends [3]:
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not to rely solely on the two-step test (ELISA + WB) and to use laboratories specializing in vector-borne diseases;
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simultaneous use of several antibiotics (polyantibiotherapy) and antiparasitic molecules if necessary;
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treatment lasting at least 3 to 6 weeks;
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prolonging treatment in the event of persistent symptoms.