> From: milo7@aol.com (Milo7) > Xref: sn-us sci.med.diseases.lyme:114881
(Example of what the Annals decided not to publish in response to Sigal's latest opus):
Raphael B. Stricker, M.D.
From the Department of Medicine, California Pacific Medical Center, San Francisco, CA.
To the Editor:
The proverb at the beginning of Leonard Sigal's medievalist treatise on Lyme disease (1) comes from an era when people were routinely burned at the stake for holding dissenting opinions. Sigal's narrow-minded view of a controversial illness encourages us to return to this practice.
In dividing individuals who deal with the complexities of Lyme disease into "rationalists" (those who know everything about the disease and are infallible) and "empiricists" (those who attempt to deal with the reality of the disease and are misguided), Sigal makes one of the oldest mistakes in science: he assumes that we do know everything about Lyme disease, and that empiricism based on clinical observation, animal modeling and newer research techniques cannot possibly add to this wealth of knowledge. If the world had followed Sigal's reasoning, we would still be dying of smallpox and bubonic plague while receiving "fresh air therapy" for malaria and tuberculosis.
In addition to his philosophical hubris, Sigal makes two fatal clinical errors: he completely ignores other tickborne coinfections such as Babesia, Ehrlichia and Bartonella that complicate the clinical course of Lyme disease, and he disregards the convincing animal models that demonstrate persistence of Borrelia burgdorferi infection despite "adequate" antibiotic regimens (2). In any other field, these observations would be cause for great concern and significant research spending. Thanks to the "rationalism" demonstrated in Sigal's article, we are assured that there is no need to worry about these unresolved issues when it comes to Lyme disease.
Sigal reiterates the "rationalist" argument that patients who are diagnosed with Lyme disease may in fact have some other serious illness that has been missed, and that antibiotic therapy may be a nefarious hazard that makes these patients sink deeper into their wheelchairs. The "empiricist" reality is that suffering patients seek out "Lyme-literate" physicians after receiving "million dollar" workups that rule out all other known diseases and are performed by an average of nine doctors per patient (Stricker RB, unpublished observation). Once these patients are properly diagnosed with tickborne disease(s) and given appropriate antibiotic therapy, they often get out of their wheelchairs and express great resentment toward the arrogant "rationalist" physicians like Sigal who were content to leave them there.
There have been more than 12,000 articles written about Lyme disease since it was discovered by an "empiricist" housewife named Polly Murray in 1975 (2). It has been estimated that Lyme disease is underreported by a factor of twelve in the United States (3). Current testing for the disease is non-standardized and often inadequate, and the diagnostic criteria for Lyme disease remain controversial (4). On a cellular level, it has recently been shown that B. burgdorferi infection may persist in macrophages (5), suggesting that long-term tuberculosis-type antibiotic regimens may be necessary for eradication of the spirochete. In this setting of epidemiologic, clinical and diagnostic uncertainty, care for patients suffering from Lyme disease remains abysmal, and advocacy of inadequate treatment regimens for the disease is both irrational and unconscionable. Significant improvement in the diagnosis, characterization and treatment of Lyme and other tickborne diseases needs to be accomplished before we can embrace Sigal's "rationalism" as dogma.
In Table 2 of his article, Sigal suggests a list of Lyme disease terms that should be "deleted from use" in describing this complex, ill-defined and potentially devastating infectious disease. Can witch-hunts and book-burning be far behind?
References
1. Sigal LH. Misconceptions about Lyme disease: Confusions hiding behind ill-chosen terminology. Ann Intern Med 2002;136:413-19.
2. Doherty A. Lots of links on Lyme 2002; www.geocities.com/HotSprings/Oasis/6455/lyme-links.html.
3. Meek JI, Roberts CL, Smith EV, Cartter ML. Underreporting of Lyme disease by Connecticut physicians, 1992. J Public Health Management Practice 1996;2:61-5.
4. Stricker RB, Winger EE. Decreased CD57 lymphocyte subset in patients with chronic Lyme disease. Immunol Letters 2001;76:43-8.
5. Linder S, Heimerl C, Fingerle V, Aepfelbacher M, Wilske B. Coiling phagocytosis of Borrelia burgdorferi by primary human macrophages is controlled by CDC42Hs and Rac1 and involves recruitment of Wiskott-Aldrich syndrome protein and Arp2/3 complex. Infect Immun 2001;69:1739-46.
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