Case

Reports

Late-Stage
Neuropsychiatric
Lyme Borreliosis
Differential
A.

BRIAN

M.D.,

FALLON,

M.P.H.,

ROBERT
ANGELO

yme

Borrelia

known

that

by

M.D.,
CHARLES

MICHAEL

R.

is a multi-

the

Although

spirochete

dermatologic,

ophthalmologic,
and neuroare well known,
it is less
psychiatric

disorders

may

arise as a result of borrelial

infection.
sion,2 panic
attacks,3
schizophrenia-like

also

Deprespsy-

chotic
states,4
bipolar
disorder,3
and dementia5
have been attributed
to Lyme borreliosis.
In this
report,
we present
two patients
in whom psychiatric symptoms
represented
tation
of their
late-stage
Specific
dilemmas
will be discussed.

of diagnosis

Case
Case

1.

healthy

Mrs. A. was
married
woman

headaches,
tigue,
and

slurred
memory

diplopia.

magnetic

loss,

a 34-year-old,

speech,
and

and

treatment

Reports

intermittent
exam

imaging

visual
was

normal.

revealed

(MRI)

blurring
Brain
multi-

ceftriaxone.

VOLUME

36 NUMBER

Within

3 MAY

2 weeks,

-JUNE

1995

Mrs.

A. s

F.A.C.P.,

M.D.,

M.D.,

WEBER,

F.A.R.A.

D.O.

ZIMMERMAN,

A.

F.A.R.A.

M.D.

LIEBOWITZ,

became
pressured
and her mood became irritable. She refused further treatment.
Over the following months, Mrs. A.s mood
fluctuated
from marked
agitation
to severe depression accompanied
by suicidal
threats. Auditory hallucinations
and paranoid delusions
emerged along
with a full manic syndrome.
She also became
violent-slapping
her son repeatedly
and breaking
speech

furniture.

At this time, a spinal tap revealed

11 white
cells (86% lymphocytes
and 14% monocytes)
with
an elevated
cerebrospinal
fluid (CSF) immunoglobulin G (IgG) index of 1.17. There were no oligoclonal bands. A Lyme Ab test was negative in the
CSF but positive in the serum. Other labs were all
normal (including
TFTs, RPR, ANA, ESR). A neurologist diagnosed
probable MS, although Lyme borreliosis as a cause of these symptoms
could not be
ruled out. She was then promptly
admitted to a psychiatric hospital. A sleep-deprived
EEG was normal.
She was treated with lithium, perphenazine,
and valblood

proic

previously

ple white matter

lesions
on T2-weighted
scanning.
The differential
diagnosis
included
multiple sclerosis
(MS), multi-infarct
syndrome,
or Lyme encephalitis.
Blood tests were unremarkable
except for a reactive
antibody test for Lyme borreliosis.
Because of the
prominent
headaches
(uncommon
in MS), treatment
for presumed
Lyme borreliosis
was begun using intravenous

BARRY

who presented
with frontal
distal
paresthesias,
fa-

A neurologic
resonance

the primary
manifesLyme
borreliosis.

and Treatment

SCHWARTZBERG,

M.D.,

disease)

caused

burgdoiferi.

articular,
cardiac,
logic manifestations
well

(Lyme

illness

M0RI

BRANSFIELD,
SCOTTI,

borreliosis

system

Diagnosis

cepted

acid.

Her

thoughts

Received

June

April

11, 1994.

became

18,

1993;
From

less

revised

paranoid

April

the Department

11,

and

1994;

ac-

of Psychiatry,

College
of Physicians
and Surgeons
of Columbia
University;
Division
of Therapeutics,
New York State Psychiatric
Institute;
Department
of Medicine,
Section
of Rheumatology,
Jersey
Shore
Medical
Center,
Neptune,
NJ; Department
Neurology,
Paul Kimball
Medical
Center,
Lakewood,
Departments

of Psychiatry

Center,
Redbank,
New York State
New

York,

New

Copyright
Medicine.

and Medicine,

NJ. Address
reprint
Psychiatric
Institute,
York

Riverview

of
NJ;

Medical

requests
to Dr. Fallon,
722 West 168th Street,

10032.

1995

The

Academy

of

Psychosomatic

295

Case

Reports

her behavior

less impulsive,

thinking

poor

she

and

was

discharged

disorder,

but intermittent

insight

remained.

with

manic,

with

the

illogical

After

diagnoses

2 months,

of bipolar

psychosis-improved

the following

During
illogical

thesias,

migratory

lancinating

Lyme

antibody

mildly

elevated

flu-like

test.

Ab

A.

was

borreliosis

articular

CSF
Lyme

(meningoencephalitis),

of intravenous
atric

of therapy,

and

week.

All

ones,

were

tained

for
Four

another

she

years

hospitalization.

toms

positive

given

physical

asymptomatic
the

This

15 weeks

and

by

psychi-

the

5th

week

by the 12th
psychiatric

remission

was

suggestive

MRI

showed

were

of active

Lyme

10 lymphocytes.

one

sus-

new

no physical

symp-

borreliosis.

A spinal

Although

conventional

habited

at a level

0.067).

The serum

der

assumption

the

related
given
and

to active
psychiatric

followed

improved
tapered

296

that

rapidly.

episode,

oral

psychiatric
Twelve

Mrs.

A.

valpmic

illness

months
remains

after
completely

She
were

the

she
rash,

area
she

headaches,

and

At times,
Physical

she
and

to a

previously

followed

joints,

stuttering,

aches.

in-

moved

recurrences
of Lyme distick bite or reexposure
to

known

and painful

she

heavily

low-grade

more

had

fevers,

severe

and

exams

by

severe

occipital

hyperacusis

neurologic

a flulater

headphotopho-

were

normal.

Blood tests revealed an indeterminate

Western
blot for Lyme borreliosis
(41 kDa, 83 kDa bands),
a positive
cytomegalovirus
(CMV)
IgG titer (1:16),
and

a positive

was

normal

on

Herpes

There

was

two

IgG

titer

Brain

(2.60).

MRI

occasions.

no known

history

of a tick

bite

She did however live in a Lyme-endemic

and 4 months prior to the onset of symptoms
worked in a veterinarians
office.

or

rash.

months

after

onset

of illness,

area

she

a diagnosis

of probable Lyme borreliosis

was made based on the
physical symptoms
and the two reactive bands on
the Western blot. Four weeks of oral antibiotics
were
of no help. A subsequent
8-week course of intravenous ceftriaxone
led to marked improvement
in her
headaches
and joint pain. Several months later, because of extreme fatigue and the possibility
of a systemic CMV infection
(IgG titer 1:64), Ms. B. was
treated with acyclovir.
The fatigue persisted,
and
headaches

and

painful

joints

returned.

Fifteen

months after illness

onset,
given
the possibility
persistent
Lyme borreliosis,
Ms. B. was treated
with a second course of intravenous
ceftriaxone
This

led

to a resolution

of the

fatigue

of

and

symptoms.

Twenty-one
irritability,

months

after illness

a spontaneous

onset,
panic

Ms. B.
attack,

obsessional
thoughts with checking,
and depression.
She was treated with clomipramine.
This
syndrome
then developed
into mania with rapid
mood swings (from grandiosity
to sudden tearfulness), suicidal thoughts,
paranoid delusions,
and
auditory
hallucinations.
Serologic
and routine
CSF
tests for Lyme
borreliosis
were negative.
She was

trusive

anti-

medications

and

swollen

developed

acid,

antibiotics.

no

When

months

Un-

was

of intravenous

Between

fam-

prob-

like

physical

Mrs. A. was

(lithium,

12 weeks

Her

episode

disease,

by maintenance

at 10 months.
manic

manic

medication
and

com-

(cutoff

IgG was also reactive.

this

CNS Lyme

perphenazine)

biotics

ond

Lyme

IgG

of 0.120

area.

the

migrans

thereafter,

her,

infectious

developed

(7 weeks).

Borrelia-specific

CSF

the

rural

Mrs.

left

a wooded area.
Case 2. Ms. B. was a 22-year-old,
healthy woman who in late summer

revealed
in the

Once

erythema

Shortly

was

upon

children

of mania.

presumed

by deer.

there

University)
plexes

for

history

in a Lyme-endemic

living

of normal),
mune complex

unremarkable

tests

family

was

the

antibody

shelter.

the

CNS Lyme disease were

(CSF Lyme ELISA at the upper limits
more sensitive ELISA tests using imdissociation
methods6
(Stony Brook

indirect

no

Nine

after the initial rash, Mrs. A. had

of manic psychosis
that required
There

Mrs.

and

strain

and

episode was explained,

A. had no prior psychiatric

developed

of a probable
A. was

including

lesion.

revealed

largein

Her

A repeat

matter

sugges-

neuropathies,

years.

episode

white

of symptoms

markedly

was

lems

a marked

husband

in a homeless

reunited.

bia.
Lyme

lymphocytosis

Mrs.

discontinued.

1.5

CSF,

her

of the manic

fatigue,
basic

persistent

continued

medications,

cell

myelin

normal

past

improved

immunosorbent

as having

ceftriaxone.

than

[including

and

apparently

rash.

symptoms

other

normal

and a history

migrans

clearneck.

imposed

After

suburban

positive

tests,

bands,

symptoms,

serologies,

erythema

were

MS) because
and cranial

(not

joint

tap

lived

ease,

a stiff

enzyme-linked

the

peripheral

of

CSF

re-diagnosed

fatigue.

central

and

revealed

oligoclonal

Despite

Mrs.

severe

neck,

elicited a history 2

Repeat

by

pares-

a stiff

persistent

symptoms

protein,

Lyme

protein].

arthralgias,

tests again

(ELISA),

assay

diffuse

a circular red rash with

by

serologic

count,

developed

and

pain,

of

earlier

Repeat

she

a rheumatologist

followed

Mrs. A.s poor

and headaches

irritability,

large-joint

spine

At this point,
years

8 months,

thinking,

In addition,

continued.

tive

she

ily

insight,

illness

family.

cause

and

MS.

ing

This
As

sec-

well.

PSYCHOSOMATICS

in-

Case

and diagnosed

hospitalized
lar disorder
der.

and

Her

possible

manic

lithium.

state

After

was

she

depression

to

of the following
and culminated

worsened
suicide

attempt

for

which

and panic attacks

Mania

paranoia,

verbal

ritability,

and

auditory

year, Ms. B.s

she

was

violent

hip
and

and

with

knee

courses

pain,

were

and ocborre-

tried

Electroshock

success.

killing others and excessive

bathing,

returned.

After

2 weeks, Ms. B.s symptoms

markedly diminished
and she was discharged
shortly thereafter.
After
12 weeks of intravenous
antibiotics,
Ms. B.s psychiatric and cognitive
symptoms
were nearly completely resolved. The arthralgias
and headaches
were
less severe.
On 5 month follow-up,
Ms. B. remains
stable. She continues
on lithium and an oral antibiotic. Although
tests for Lyme borreliosis
were negative throughout
the hospitalization
(2 Western blots
and 1 ELISA), Lyme tests after the hospitalization
revealed
a Western
blot that was equivocal
for IgG
(41 kDa band) but positive
for 1gM (25,41,
and
83

kDa
Ms.

bands).
Bs

past

psychiatric

history

able. Her family

history
is positive
maternal aunt was hospitalized
twice
breakdowns.

is unremarkfor

migraines.
for

nervous

Discussion
Mrs. A. and
disseminated,

36

Ms. B. were diagnosed

as having
late-stage
Lyme
borreliosis.
In

NUMBER

3 MAY

and

JUNE

1995

The

Prevention

Centers

for

(CDC)

Disease

Control

epidemiologic

surveil-

criteria
for the diagnosis
of Lyme disease
require
a history of exposure
to a Lyme-endemic
area

and

following:
ripheral

either

1)

a physician-diagnosed

arthritis,
neuropathy,

neurologic
meningitis,

meningoencephalitis),
fects.

These

or cardiac

criteria

are

unduly

symptoms
(peencephalitis,
conduction

de-

restrictive

for

clinical
purposes
because
about one-third
of patients do not recall an erythema
migrans
rash and
because
serologic
testing
may be unreliable,7
with both false positive
and false negative
results.
The

serologic

tests

most

ELISA
and the Western
are being
standardized
chain reaction8
and
Further
complicating
tients

with

CNS

parently
normal
studies.#{176}In these
on the patients
ing the diagnosis.

commonly
blot,
such

the antigen
diagnosis

Lyme

used

are the

but newer methods

as the polymerase
capture
is that

borreliosis

assays.9
some pa-

may

have

ap-

EEG,
MRI,
and CSF
Lyme
situations,
physicians
must rely
full clinical

presentation

in mak-

Lyme borreliosis
is known
to have protean
manifestations,
some of which do not include
any
of the typical
features
outlined
by the CDC. Some
of these presentations
are listed in Table
1.
Because
of Lyme
borreliosiss
ability
to
mimic
other known
diseases,
it has been dubbed
the new
lis-the

both cases, psychiatric

presentations
were prominent and profoundly
disruptive.
In both cases,
initially
no relationship
was thought
to exist between
the history
of Lyme
borreliosis
and the

VOLUME

and man-

will be presented
two patients.

erythema
migrans
rash, or 2) serologic
evidence
of exposure
to B. burgdorferi
and one of the

therapy was considered.

Because
case reports
have linked Lyme borreliosis with psychiatric disorders, an empiric
trial of
intravenous
ceftriaxone
was initiated. During the
first 2 weeks, Ms. B.s psychiatric
symptoms
worsened
with a marked
increase
in agitation.
Obsessivecompulsive
symptoms,
such as horrific
images
of
without

of the diagnosis

lance

blurred

problems,

of antidepressants

ir-

symp-

cipital headaches.
Serologic
studies for Lyme
liosis were negative. An EEG was normal.
Additional

aspects

Diagnosis.

impulses,
Other

memory

different

agement
of Lyme borreliosis
with illustrations
from these

hospital-

along

hallucinations.

stuttering,

concentration

psychiatric
disorders.
In both cases, treatment
for
Lyme borreliosis
led to a marked
improvement
in both the psychiatric
and systemic
symptoms.
In both cases,
a return
of symptoms
occurred
despite
prior antibiotic
treatment.
In this discus-

dys-

in a life-threat-

emerged,

aggressiveness,

returned:

vision,

with
be severe-

controlled

continued

disor-

sion,

fluency.
Over the course

toms

bipo-

and she had evidence

of cognitive
in spelling, writing, and verbal

function-trouble

ized.

atypical
compulsive

partially

discharge,

ly depressed,

ening

as having
obsessive

Reports

Lyme
pear

great imitator.
former
great

borreliosis

As was true for syphiimitator-in

late-stage

psychiatric

as the predominant

disorders
symptom.

may

When

ap-

Lyme

borreliosis
is suspected
but not proven,
either
because
the clinical
profile
is not typical
or because the diagnostic
tests are negative,
some physicians

opt to use a trial

of antibiotics

as both

297

Case

Reports

TABLE

1.

Common

Disorders
associated
Lyme borreliosis

with

TABLE

neurologic

Bacterial
Acute:

or Typical

Aseptic

2.

meningitis

Group
A Beta
Streptococcus,
Haemophilus,

Meningoencephalomyelitis
nerve

palsies

(e.g.,

Bells

palsy,

Leptospira,

Subacute:

optic neuritis)

fatigue-like

syndrome

Depression
Viral

Insomnia
Mood
Less

lability

and behavioral

disorders

paraparesis
myelitis

Cerebellar

syndromes

Extrapyramidal
Seizure

burgdorferi,

Cytomegalovirus,
Epstein-Barr
virus,

Herpes
simplex
virus, Human
immunodeficiency
virus,
Influenza
virus, Measles
virus,
Papovavirus,
Poliovirus,
Rabies
virus, Toga virus

syndromes

Protozoal

Infection

Toxoplasmosis

disorders
Fungal

Dementia
Pseudo-tumor-like
Tullio

syndrome

Parasitic

disorders

diagnostic
improves,
With

(e.g.,
(e.g.,

ALS-like,

Cysticercosis

prior

to the onset

be considered

In the case

disorder.
are raised

by the

here.

of Mrs.

A., doctors

uncertain
whether
Lyme
borreliosis

the correct
or MS. These

similar

fluctuating

features:

not commonly
2 lists a variety
infectious
disin the differential

diagnosis
of any new psychotic
Different
diagnostic
issues
presented

of illness,

MRI lesions,
symptoms,

positive

central
prominent

and pehead-

aches,
migratory
arthralgias,
repeated
CSF
lymphocytosis,
and the remission
of articular
and
psychiatric
symptoms
after an extended
course of

disorders

and therapeutic
tool. If the patient
the diagnosis
is supported.
the exception
of AIDS,
infectious

that should

rash

Lyme
serologies,
ripheral
neurologic

syndrome

or anxiety

causes
of psychopathology
are
recognized
in this country.
Table
of medical
disorders,
including

cases

Infection

Coccidiomycosis,

multiple

grans

horn cell-like
disease
motor neuropathy)

Guillain-Barr#{233}-like
Psychotic

Cryptococcosis,
Histoplasmosis

disease

Demyelinating-like
sclerosis-like)
Anterior
diffuse

Infections

in children

phenomenon

Cerebrovascular

eases,

Borrelia

Coxsackievirus,
Enterovirus,

or hemiparesis

Transverse

two

Infections

in children

Common

Spastic

Hemolytic
Pneumococcus,
Meningococcus

Treponema
pallidum,
Mycobacterium
tuberculosis,
Whipples
disease

Radiculoneuropathy

Chronic

of psychiat-

Infections

Encephalopathy
Cranial

causes

Selected
infectious
nc disorders

were

initially

diagnosis
disorders

was
share

neurologic

symp-

antibiotics.
volvement

Confirmation
of B. burgdoiferis
inin the CNS came when more sensitive

techniques

were

used

to isolate

Borrelia-specific

antibodies.
Although
there is significant
in the clinical
phenomenology
between
borreliosis

and

MS,

Lyme

borreliosis

overlap
Lyme

is the most

parsimonious
diagnosis
when
extraneural
disease is present
(e.g.,
dermatologic,
articular),
when there is a history
of an erythema
migrans
rash and/or
positive
serologic
tests, and when
CSF oligoclonal
tein are absent.

bands

and/or

myelin

basic

pro-

The diagnosis
of Lyme borreliosis
in Ms. B.
was made based on the presence
of a multisystem

toms, demyelinating-like
lesions
on MRI scans,
and CSFlymphocytosis.
The diagnosis
was made
more difficult
by the fact that routine CSF testing

illness
that included
severe
headaches,
fatigue,
joint swelling
and pain, insomnia,
and memory
problems.
Ms. B.s initial Lyme tests were nega-

for

tive

Lyme

antibody

tologist
linked
and aggressive
B. burgdorferi
ratory

298

was

negative.

The

rheuma-

patients
mania,
psychosis,
behavior
to infection
with
because
of the clinical
and labo-

constellation:

this

a probable

erythema

mi-

except

positive
positive;
response
reinfection.

for a Western

blot

IgG

that

had

two

bands.
A more
recent
Lyme
test was
this may represent
a late-appearing
1gM
as has been described2
Ms. B.s psychiatric

or,

possibly,
symptoms

PSYCHOSOMATICS

Case

started
2 1 months
after the presumed
onset of
infection.
These symptoms
included
depression,

chiatric
disorder,
Lyme
psychiatric
disorder
that

paranoid
delusions,
bipolar
disorder,
panic
attacks, and obsessive-compulsive
disorder.
Worth
noting is that the influenza
epidemic
of the 1920s
was also associated
with obsessive-compulsive
disorder
in some patients.3
More recently,
a theory has been proposed
that links new-onset
ob-

going
ability
courses

sessive
compulsive
disorder
in children
to
neuroimmunological
dysfunction;
cross-reactive
antineuronal
antibodies
in some children
with

gered a psychiatric
mously
occurring.

obsessive-compulsive

to

antibodies

in her

with Group
A
Ms. B.s psyto psychiatric

infection.

However,

disorder

are

have been triggered

by infection
Beta Hemolytic
Streptococcus.4
chiatric
disorder
was unresponsive

thought

medications.
instituted,

When intravenous
antibiotics
the psychiatric
disorders
resolved

idly.

presence

The

suggestive

of typical

serologies,

travenous

antibiotic

to a Lyme-endemic
of Lyme

Lyme

excellent

tained

for the treatment

of
been changing
rapidly.

Until recently,
a 4-week
course
of intravenous
antibiotics
was considered
curative
for patients
with symptoms
of CNS Lyme borreliosis.
Now it
is recognized
that some
patients
relapse
after
an initial
good response
and require
additional
courses
of intravenous
antibiotics.5
Patients
who are not treated
until later in the course
of
chronic,
with

to be more

relapsing

these

two

disorder.
patients.

likely

to develop

Such

Mrs.

A.s

was

the

Lyme
that
A.

thus

borreliosis

trig-

is now autonohad
borrelial

suggesting

ongoing

psychiatric

medica-

because

antibiotics
were administo treat her second
manic
be certain
that the psychiatric
would not have been sufficient

a
case

first antibiotic

treatments.

on lithium

dramatic

are thought

CSF,

and intravenous
simultaneously

psychiatric

the diagnosis

borreliosis.

Treatment.
Guidelines
Lyme
borreliosis
have

illness

tions
tered

that
disorder
Mrs.

to treat the psychiatric

disorder.
In the case
B., the psychiatric
disorder
was refractory

to in-

and the exposure

all support

As already
discussed,
in
Lyme borreliosis
was redisorder.
In the case of

A., it is unlikely

episode,
we cannot
medications
alone

symptoms,

response

treatment,
area

were
rap-

borreliosis
triggered
a
is now unrelated
to on-

infection;
the spirochete
has an unusual
to resist antibiotic
treatment
much longer
of antibiotic
treatment
are needed;
or the

patient
was reinfected.
both cases we believe
lated to the psychiatric
Mrs.

Reports

Although

throughout

response

treatment

supports

infection.

Could

the
these

she was

her hospital

to the

main-

stay,

intravenous

the

antibiotic

assumption
patients

of Ms.
to all

of ongoing
have

been

rein-

fected?
Mrs. A. had moved
out of the Lyme-endemic
area where
she contracted
her initial
infection,
making
reinfection
unlikely.
Ms. B.
continued
to reside in an endemic
area and therefore

may have been reinfected.

That B. burgdoiferi
is capable
of resisting
routine
courses
of antibiotic
treatment
has long
been suspected
on clinical
grounds.
and clinical
evidence
is now emerging
the

need

tients.5

for
How

long-term
does

treatment

B. burgdoiferi

Preclinical
to support
in some

evade

both

pathe

course was begun 1 year after the presumed

onset
of infection
(rash), and Ms. B.s first course
was
begun
9 months
after the onset
of symptoms.
Despite
extensive
courses
of oral and intravenous
antibiotics
(17 weeks),
Mrs. A. experienced
a

patients
immune
system and antibiotics?
Recent
studies
have identified
B. burgdo,feri
intracellularly
in human
fibroblasts6
and endothelial
cells.7 Because
organisms
with intracellular
localizations
are difficult
to cure, these
in vitro

second

observations
may explain
how B. burgdoferi
can
persist
in the human
host. Patients
symptoms,

manic

episode

with evidence

CNS infection.
Similarly,
psychiatric
illness
began
15 weeks

of intravenous

of oral antibiotics.
The persistence
otic treatment
Lyme borreliosis

VOLUME

of persistent

Ms. B.s first signs of

after having
received
antibiotics

of symptoms

and 4 weeks
despite

antibi-

suggests
several
possibilities:
has nothing
to do with the psy-

36 NUMBER

3 MAY

JUNE

1995

including

psychiatric

ones,

may

the first few weeks of antibiotic

phenomenon
has been compared
Herxheimer
reaction
that occurs

worsen

during

treatment.
This
to the Jarischwhen antibiotic

treatment
for syphilis
is initiated.
Mrs. A. s first
manic
episode
may actually
have been precipi-

299

Case

Reports

tated or hastened
by the intravenous
antibiotic
treatment.
Ms. B.s clinical
condition
deteriorated dramatically
during
the first 2 weeks
of

may not be considered

in the
cially if the patient
has moved
endemic

area.

intravenous
thereafter.
of tertiary

borreliosis
perhaps

can allow the infection

allowing
a treatable
acute

become

a relapsing

tion

antibiotic
treatment
only to improve
It is worth noting that, in the treatment
syphilis,
the Jarisch-Herxheimer
reac-

has included

less responsive

new-onset

Conclusions.

The

Lyme
tating

may be as diverse
with neurosyphilis.

borreliosis
as occur

vention

and

control

of

neurologic
years

psychiatric

early
this

presentations

treatment

keys

onset

M.D.,

because

emerge

infection,2

months

Lyme

trists need
borreliosis

to the

However,
may

the initial

of

and as debiliPrimary
pre-

are

epidemic.

symptoms

after

Failure

to

borreliosis

diagnosis-espeout of the Lyme-

to recognize

chronic

active

Lyme

to progress,
infection
to

one that is ultimately

to antibiotics.

Therefore,

to keep in mind
when evaluating

psychia-

the diagnosis
of Lyme
a patient
with a new

or treatment-refractory

psychiatric

illness.

The authors
express
gratitude
to P. K. Coyle,
of the State University
of New Yorkat Stony

Brook,

who

conducted

the

immunologic

CSF

analyses.

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PSYCHOSOMATICS

New