Rosenheimer Str. 6-8, 83043 Bad Aibling, Germany · info@clinicum-stgeorg.de
Understanding Lyme Disease
Lyme disease is an infection with Borrelia burgdorferi and related spirochetes, transmitted by the bite of an infected tick. Treated early, most cases resolve with antibiotics. Diagnosed late or treated incompletely, it can become a chronic, multi-system illness, and the biology of the bacterium explains why.
A flu that did not behave like the flu. A knee that swelled with no injury. Then the fatigue, the word-finding, the tingling, a heart that flutters at rest. You have searched your symptoms often enough to have seen the word Lyme, and often enough to have been told it is unlikely.
Lyme disease presents with a wide range of symptoms that can mimic dozens of other conditions. The classic erythema migrans, the expanding bull's-eye rash, appears in most but not all cases, so many patients never get the early warning sign that would lead to prompt treatment.
Symptoms develop in stages: the rash and flu-like illness of early infection, then weeks to months later the disseminated stage with nerve, joint or heart involvement, then the late stage. In chronic Lyme disease several symptom clusters overlap at once:
How common are persistent symptoms? In a prospective Dutch cohort, a share of patients still had persistent symptoms after treatment for Lyme borreliosis, more than in matched controls (Ursinus et al., 2021). That group, whatever name is used for it, is who the Lyme treatment program is written for.
Through the bite of an infected tick. That is the established route, and it accounts for the great majority of cases. Other routes are discussed, and the honest state of the evidence for each is given below, because it matters for family screening and for prevention.
The documented route. Ixodes ticks carry Borrelia in their gut and transmit the spirochetes during feeding, usually after the tick has been attached for more than a day. Nymphal ticks are the size of a poppy seed, which is why many patients never saw the tick. The same ticks carry the co-infections Babesia, Anaplasma and others, often in the same bite (Sanchez-Vicente et al., 2019).
Borrelia can cross the placenta, and case reports describe infection of the fetus. A systematic review of the literature on gestational Lyme disease found the evidence limited and inconclusive on how often this happens and what it does to the newborn (Waddell et al., 2018). A pregnant patient with known infection is treated, and the newborn is followed.
Borrelia DNA has been found in mosquitoes and horse flies, and transmission by them is sometimes claimed. Transmission to humans by these insects has not been demonstrated, and we do not treat it as a route. Prevention effort belongs on ticks.
Not established. We have treated families in which several members, parents and children, were infected with Borrelia; the usual explanation is shared exposure to the same tick habitat, not transmission between people. When one family member is diagnosed, screening the others is sensible for that reason.
Standard Lyme testing has limitations that leave many patients without answers. Knowing them is the first step toward proper care.
The two-tier test (an ELISA followed by a Western blot) measures the antibody response, not the bacterium. A meta-analysis of North American studies found its sensitivity low in the first weeks of infection, before antibodies have formed, and higher in late disease (Waddell et al., 2016). It also cannot distinguish a past infection from an active one. The diagnosis page explains which tests the hospital adds.
Lyme disease has been called "the great imitator" because its symptoms overlap with fibromyalgia, ME/CFS, multiple sclerosis, rheumatoid arthritis, lupus and depression. Patients are often diagnosed with one of these and treated for the symptom for years before anyone investigates an infectious cause.
The 2020 guideline of the Infectious Diseases Society of America attributes most persistent symptoms after treatment to a post-infectious process and advises against prolonged antibiotics (Lantos et al., 2021). Other clinicians and researchers see persistent infection in a subset of patients. The practical effect of the divide is that many patients who completed a standard course and remain ill are told nothing more can be done.
Borrelia burgdorferi is an unusual bacterium. It has several mechanisms for evading the immune system and surviving antibiotic treatment, and each has been studied in the laboratory.
Borrelia spirochetes change their outer surface proteins to avoid immune detection, a process called antigenic variation, and can dampen immune pathways that would otherwise clear them. This is one reason antibody tests can stay negative in a long-standing infection.
In the laboratory Borrelia forms biofilms, communities of bacteria in a protective matrix that shields them from antibiotics and from immune cells (Sapi et al., 2012). Bacteria inside a biofilm tolerate far higher antibiotic concentrations than free-swimming spirochetes.
Borrelia forms drug-tolerant persister cells that survive antibiotic exposure in vitro (Sharma et al., 2015), and in rhesus macaques spirochetes were found in tissue after antibiotic treatment of disseminated infection (Embers et al., 2012). Whether, and how often, the same happens in people is the open question at the center of the controversy.
Chronic Borrelia infection sets off inflammatory cytokines that act on the brain, nerves, joints, heart and gut. This inflammation accounts for much of what patients feel: fatigue, cognitive impairment, pain and mood changes. Over time it can become self-sustaining even as the bacterial burden falls, which is why the plan treats the inflammation as well as the infection.
Given the biology above, a single-modality approach, antibiotics alone or alternative therapies alone, is rarely enough in established chronic Lyme disease. At St. George Hospital the plan since 1995 has addressed the dimensions of the illness together, chosen per patient from the work-up.
The plan targets:
The program combines the following therapies into one coordinated plan, written from the individual findings. For patients from abroad it runs as inpatient Lyme disease treatment in Germany, two to five weeks on the ward with a video consultation in English before travel.
Controlled elevation of the core body temperature to 41.6–42.0 °C / 106.9–107.6 °F with antibiotics given during the session. Borrelia is heat-sensitive in the laboratory, and heat improves the penetration of antibiotics into tissue.
What a whole-body hyperthermia session involves →Intravenous and oral antibiotic protocols chosen for the forms of Borrelia found and for the specific co-infections, as described on the treatment page.
How we treat chronic Lyme disease →Blood filtration that removes inflammatory proteins, immune complexes and fibrinogen from the plasma when the work-up shows them raised.
What H.E.L.P. apheresis involves →Therapies to support balanced immune function, including thymus peptides, micronutrient infusions and immune-stimulating protocols.
What immune therapy involves →Protocols for Herxheimer reactions and the endotoxins released during bacterial die-off: IV glutathione, liver support and binders.
Our detoxification therapies →Physical therapy, psychotherapy, nutritional support and pain management for the full impact of chronic Lyme disease on daily life.
How the Lyme therapies combine →The persistence of Borrelia after antibiotic treatment has been shown in the laboratory and in animals: drug-tolerant persister cells in culture (Sharma et al., 2015), biofilms in vitro (Sapi et al., 2012), spirochetes in the tissue of treated macaques (Embers et al., 2012). The evidence for persistence in humans is indirect, and that is the limit we state plainly.
What the trials show on the other side: two controlled trials of prolonged antibiotics in patients with persistent symptoms found no benefit over placebo (Klempner et al., 2001), and a later trial found no effect of prolonged antibiotics on cognition (Berende et al., 2019). More of the same antibiotic, on its own, is not the answer for most patients; that finding is one reason the hospital's plan has more than one component. Heat raises the vulnerability of Borrelia to antibiotics in vitro (Reisinger et al., 1996), which is the rationale for combining hyperthermia with antibiotics; clinical trials of that combination do not yet exist, so it is an individual treatment attempt, decided with the patient after medical consultation, and its course is measured in the follow-up.
In our clinical experience since 1995, with more than 12,000 Lyme patients, the combined program is what we offer the patient for whom the standard course has not been enough. What it does for an individual shows in the follow-up measurements, which is why they are taken before, during and after the stay.
Early Lyme disease is treated with a two to four week course of antibiotics, usually doxycycline, amoxicillin or cefuroxime, and most patients recover. For chronic Lyme disease St. George Hospital combines antimicrobial therapy with whole-body hyperthermia, apheresis, immune support and detoxification in an inpatient program written from the individual work-up; the combination is an individual treatment attempt decided after medical consultation.
Some early infections are cleared by the immune system, but there is no way to know in advance who will clear it and who will go on to arthritis, nerve or heart involvement months later. Untreated Lyme disease is the usual route into the late and chronic forms. A tick bite with a rash or flu-like illness should be treated.
Symptoms can return. Three explanations are discussed in the literature: a new tick bite, persistence of the bacterium or its remnants in tissue, and an inflammatory or autoimmune process set off by the infection. The work-up at St. George Hospital looks at all three, because the treatment differs for each.
No. Babesia is a parasite of red blood cells carried by the same ticks, and it is treated with different drugs. It is one of the co-infections that often travel with Borrelia and complicate the picture; the co-infections page describes Babesia, Bartonella, Anaplasma and Ehrlichia and how they are tested.
The standard two-tier antibody test is least sensitive in the first weeks, before antibodies form, and it cannot tell a past infection from an active one. In late disease it is more sensitive, but a negative result in a patient with a typical history still does not exclude Lyme. The diagnosis page explains which additional tests the hospital uses.
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