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The guideline of the German Society of Neurology (DGN) (1) and the corresponding publication in the Deutsches Ärzteblatt (2) contain a number of serious errors, resulting in misguidance in the medical and forensic fields. Especially with regard to the late stage of the disease, the DGN guideline is not based on the evidence-based literature, but on a structured consensus. Thus, it represents an S2k guideline and not an S3 guideline, as it is wrongly labelled. In contrast to the DGN, the German Society of Dermatology (DDG) has described its 2017 guideline on Lyme borreliosis correctly as an S2k guideline.
As prerequisites for the diagnosis of late-stage Lyme neuroborreliosis, typical clinical features, inflammatory CSF syndrome, intrathecal antibodies, and Lyme Borrelia-positive serology in the blood are demanded. However, while these requirements are backed by strong evidence in the early stage of the disease, this is not the case in the late stage. In addition, in 30% of cases with late-stage disease, Borrelia antibodies are missing (3).
In contradiction to the statement in the DGN guideline, the high diagnostic significance of the lymphocyte transformation tests is supported by numerous articles in the literature (3).
The post-treatment Lyme disease syndrome (PTLDS) is a hypothesis. The claim that PTLDS is a sign of defect healing cannot be supported by the literature. It is incomprehensible that the DGN guideline negates a causal relationship between an initial Lyme borreliosis and the (hypothetical) PTLDS.
The DGN guideline explicitly states that the available literature on the antimicrobial therapy of late-stage Lyme neuroborreliosis is insufficient. Nevertheless, the guideline recommends a treatment similar to that for early-stage disease. The article does not mention that the persistence of Borrelia infection after antimicrobial therapy is comprehensively described in the literature (4). Similarly, the assertion that 4-week antimicrobial therapy guarantees the elimination of Lyme borreliosis is unfounded (4).
PD Dr. med. Walter Berghoff
Praxis für Innere Medizin, Rheinbach, Germany
Dr. med. Petra Hopf-Seidel
Praxis für Neurologie und Psychiatrie, Ansbach, Germany
Dr. med. Barbara Weitkus
Privatpraxis für Borreliosepatienten, Mittenwalde, Germany
Dr. med. Charlotte Steiner
Praxis für Psychiatrie und Psychotherapie, Nürnberg, Germany
Conflict of interest statement
The authors declare that no conflict of interest exists.
|1.||Rauer S, Kastenbauer S, et al.: S3-Leitlinie Neuroborreliose 2017, In: Deutsche Gesellschaft für Neurologie (eds.): Leitlinien für Diagnostik und Therapie in der Neurologie. www.dgn.org/leitlinien (last accessed on 23 April 2019).|
|2.||Rauer S, Kastenbauer S, Fingerle V, Hunfeld KP, Huppertz HI, Dersch R: Clinical practice guideline. Lyme neuroborreliosis. Dtsch Arztebl Int 2018, 115: 751–6 VOLLTEXT|
|3.||Deutsche Gesellschaft für Neurologie (DGN): Leitlinien der Neurologie. AWMF-Registernummer 030/071 Klasse: S3, Leitlinienreport, Abschnitt Dissensbericht der Deutschen Borreliose Gesellschaft in (1). www.dgn.org/leitlinien (last accessed on 23 April 2019).|
|4.||Middelveen MJ, Sapi E, Burke J, et al.: Persistent borrelia infection in patients with ongoing symptoms of lyme disease. Healthcare (Basel). 2018; 6. Pii:E33 CrossRef MEDLINE PubMed Central|