Clinical Studies
Fatigue in patients with erythema migrans

https://doi.org/10.1016/j.diagmicrobio.2016.07.026Get rights and content

Highlights

  • Fatigue was assessed in patients with Lyme disease presenting with erythema migrans (EM).

  • Over 50% of patients with EM had fatigue, and approximately 20% had severe fatigue based on the FSS-11 scale.

  • Having a large number of symptoms was associated with both the presence and severity of fatigue.

  • This finding suggests that fatigue with EM may be a component of the acute sickness response.

Abstract

Fatigue is a common symptom in patients with Lyme disease.

The purpose of this study was to characterize fatigue in untreated adult patients presenting with erythema migrans. Selected variables were assessed to determine if any correlated with the presence or severity of fatigue.

Fatigue was assessed on the day of the evaluation by a Visual Analogue Scale (VAS), over the past 14 days by the 11-item Fatigue Severity Scale (FSS-11) and over the past 28 days based on a question from the 36-item Short Form General Health Survey version 2.

Fifty-one patients with erythema migrans whose mean age was 49.8 years, and 33 (64.7%) of whom were male, were evaluated in this study. The 3 measures of fatigue were positively correlated with one another (P  0.01). Twenty-six (51%) had fatigue based on a VAS score above 0. Ten (19.6%) had severe fatigue based on an FSS-11 score of ≥4. The strongest correlate for higher fatigue scores was having a greater total number of symptoms.

Based on the FSS-11 assessment tool, approximately 20% of early Lyme patients have severe fatigue. Having a high total number of symptoms was associated with both the presence and severity of fatigue. Because prior studies have demonstrated the presence of elevated levels of proinflammatory cytokines and other molecules in the serum of highly symptomatic patients with erythema migrans, the symptom of fatigue in early Lyme disease may be a component of what has been referred to as the acute sickness response.

Section snippets

Methods

Adult patients with Lyme disease were enrolled between 2011 and 2015 in a prospective study to assess outcomes. Exclusion criteria included: a history of Lyme disease within 12 months or ongoing symptoms from a more remote bout of Lyme disease; pregnancy or being postpartum; an immunocompromising condition; having a diagnosis of fibromyalgia, chronic fatigue syndrome, or traumatic brain injury; any prolonged history of undiagnosed or unexplained somatic complaints; and any underlying disease or

Results

Fifty-one adult patients with untreated erythema migrans were evaluated in this study. The mean age was 49.8 years (range, 20–86 years), and 33 (64.7%) were male (Table 1). Twenty-one (41.2%) had multiple erythema migrans skin lesions. The mean duration ± SD of the erythema migrans skin lesion was 7.88 ± 5.51 days (median, 7 days; range, 1–22 days) (patients who presented on the same day as the skin lesion was discovered were regarded as having a duration of 1 day in this analysis).

All 3 measures of

Discussion

Fifty-one adult patients with erythema migrans were assessed by 3 different measures of fatigue. An 8-cm VAS assessed the presence and severity of fatigue on the day of the visit. The FSS-11 assessed the severity of fatigue over the prior 14 days. What we have termed the “28d-FS” determined the frequency that fatigue was experienced over a 28-day time frame.

Based on a positive score on the VAS, 26 (50.1%) had fatigue on the day of study entry. Based on the FSS-11, 10 (19.6%) of the enrolled

Funding

RO1 CK 000152 from the Centers for Disease Control and Prevention (CDC) to GPW. This publication was also made possible by support from CTSA grant numbers UL1 TR000142 and KL2 TR000140 from the National Center for Advancing Translational Science, components of the National Institutes of Health (NIH), and NIH roadmap for Medical Research to EDS. The findings and conclusions of this paper are those of the authors and do not necessarily represent the official position of the CDC or the NIH.

Disclosures

Dr Wormser reports receiving research grants from Immunetics, Institute for Systems Biology, Rarecyte, and Quidel Corporation. He owns equity in Abbott; has been an expert witness in malpractice cases involving Lyme disease; and is an unpaid board member of the American Lyme Disease Foundation. Dr Shapiro has received royalty payments from UptoDate; has been an expert witness in malpractice cases involving Lyme disease; and is an unpaid board member of the American Lyme Disease Foundation.

Acknowledgments

The authors thank Denise Cooper, Julia Singer, Sophia Less, Artemio Zavalla, and Lisa Giarratano for their assistance.

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