In the U.S., “chronic Lyme disease” is a term used by a relatively small group of physicians to describe the chronic symptoms (fatigue, muscle pain) experienced by patients caused by Borrelia burgdorferi infection that is resistant to antibiotics. While substantial evidence to validate the disease is lacking, some clinicians have strongly advocated for this diagnosis and treatment often times consists of long courses of antibiotics. The diagnosis typically comes after long-term complaints of fatigue and pain go undiagnosed by other clinicians; it is also sometimes given based on the results of unproven Lyme tests.  

For this patient, a diagnosis of chronic Lyme disease, led to a potentially fatal drug reaction. While DRESS is commonly associated with agents such as carbamazepine and allopurinol, antibiotics, specifically doxycycline, minocycline, and sulfamethoxazole, can also cause this reaction. Symptoms often include widespread maculopapular or erythematous rash and liver involvement and usually begin 2 to 6 weeks after starting the offending agent. Though rare, DRESS can be a life-threatening complication of antibiotic use, which is why these agents should be avoided if there is no clear reason to use them.

While there have been reports of patients who have suffered post-Lyme disease syndrome (fatigue and pain following true Lyme disease), studies have shown that antibiotics are no more effective in treating these symptoms than placebo. “Perhaps the most important factor is the inadequate recognition of the functional somatic syndromes often mislabeled, and mistreated, as chronic Lyme,” the authors note. These functional somatic syndromes can include fibromyalgia and chronic fatigue syndrome, both difficult to treat. 

For clinicians treating patients who present with similar symptoms, it is important to include functional somatic syndromes in the differential diagnosis. “Some patients respond to psychotherapy, cognitive behavioral therapy, graded exercise regimens, or antidepressants, and clinicians should advocate these safe and evidence-based treatments,” the authors conclude.