A case study published earlier this year in the British Medical Journal detailed the symptoms of a 66-year-old woman with a history of cancer who was thought to be suffering a relapse when, in fact, she had Lyme disease. How can Lyme disease masquerade as cancer? What diagnostic signs might be confusing your physician if you are immunocompromised? And why might it be dangerous to make assumptions based on medical history without thoroughly checking a patient’s current status?
Symptoms of Cancer or Lyme Disease?
In the case in question, the woman sought medical attention due to severe shooting pains in her back and legs. These could have been taken as signs of wear and tear in the spine and simply dismissed as old age but the pain was followed by progressive deafness, weight loss and headache. As she had a history of marginal zone B-cell lymphoma, for which she had been treated with immunochemotherapy and a maintenance regime of rituximab, it was suspected that her symptoms signalled a return of the cancer.
Causes of Unusual Symptom Clusters
However, on further investigation it was found that there was no sign of recurring malignancy and so the woman was not given another round of chemotherapy. The variety of the symptoms are not immediately suggestive of a single illness or condition and it may have been that a combination of things were going on, leading to overlapping symptoms. For example, chronic pain can lead to headaches and even to weight loss due to curbed appetite. Degneration in the spine may demonstrate an underlying bone or connective tissue disorder that could also be affecting the jaw and causing headaches and difficulties eating, leading to weight loss. Nerve damage from cervical spinal stenosis or jaw problems may also lead to damage to structures in the ear and progressive deafness.
Lyme Disease Tests in Immunocompromised Patients
Luckily, though, the doctors took notice of a history of tick bites and so the woman, who was living in the Netherlands, was tested for Lyme disease. Cerebrospinal fluid and blood were taken and analyzed to detect antibodies to Borrelia burgdorferi. These, however, came back negative. To be sure that the woman did not have the bacteria in her system, even if her body was not mounting a significant response to the infection due to a suppressed immune system, the physicians ran a polymerase chain reaction (PCR) test on the cerebrospinal fluid and that returned positive. PCR tests look for signs of bacteria themselves, rather than for the antibodies we produce to bacteria.
Seronegative Lyme Disease wih Rituximab
The patient was diagnosed with seronegative Lyme disease and treated with intravenous ceftriaxone. This led to dramatic improvements. Had the physicians simply relied on the initial round of Lyme disease testing and ruled out such an infection on that basis there would have been a more protracted and painful process of diagnosis for the woman, perhaps leading to many years of unnecessary suffering as Lyme disease ran rampant and unchecked. Late-stage diagnosis of Lyme disease can cause permanent tissue damage to a number of different organs, including the heart and the brain, and may even contribute to premature death in some.
This case highlights the particular need to explore alternative testing methods for Lyme disease in cancer patients who are immunocompromised. Any patient suspected of infection and whose immune system is known to be compromised, whether through medication or other condition, requires careful management as reliance on antibody testing can prove unhelpful and costly and delay diagnosis.
van Dop WA, Kersten MJ, de Wever B, Hovius JW. Seronegative lyme neuroborreliosis in a patient using rituximab. BMJ Case Rep. 2013 Feb 14;2013.