Misconceptions Regarding Lyme Disease and Fatigue?

Gregory W. Rutecki, MD 

Fatigue is a common primary care symptom. It has become standard practice to ascribe debilitating fatigue to Lyme disease, even after recommended treatment and a presumed cure of any underlying Borrelia burgdorferi infection. But, is such an approach evidence-based? This month’s Top Paper1 may change this popular belief.

The Research

In this study, 100 participants were followed for as long as 20 years (mean follow-up was 15.4 years). The cohort had culture-confirmed Lyme disease. All the individuals presented with erythema migrans as further proof of disease. They were evaluated for fatigue with an 11-item Fatigue Severity Scale (FSS), which was previously validated in studies that scored post-treatment Lyme disease syndrome. 

At baseline:

• With a positive score on the FSS, 52 members of the cohort had fatigue at the baseline visit and 82/100 on at least 1 follow-up visit

• 24 of these individuals experienced an additional episode of early Lyme disease (eg, erythema migrans) during the study period 

• 9 patients had a FSS score of ≥4, which is consistent with severe fatigue 

An enzyme-linked immunosorbent assay test called the C6, which identifies the presence of B burgdorferi, was obtained on all of the cohort when the FSS was administered.

The results:

• In 4 of the 9 persons with severe fatigue, the fatigue actually antedated the Lyme infection. 

• In 7 of the 9 persons in the severe fatigue group, a second cause of fatigue was identified. These included heart failure, restless leg syndrome, insomnia, or thyroid disease. 

• Only 2 in this group were positive on the C6 test 

• In the remaining 91 subjects without a severe fatigue FSS score, there were no reports of fatigue lasting for as long as 6 months

Patients and physicians have to be aware that fatigue is a long-term consequence of Lyme disease. However, fatigue is unusual as a sequel to Lyme disease that has been treated. 

This Top Paper1 suggests that fatigue is an unusual consequence of a previous Lyme infection. If fatigue is an issue, it is probably limited to 3% of patients who have had Lyme disease.

Rethinking Your Approach

It is time to change 2 fallacies in contemporary clinical thinking. First, break the habit of ordering Lyme titers in everyone with fatigue, especially when there is no contributing history consistent with a prior infection (eg, ticks, erythema migrans, endemic area). Second, attributing fatigue to previously-treated Lyme disease is not tenable. By blaming Lyme, you are ignoring something else.

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.


1.Wormser GP, Weitzner E, McKenna D, et al. Long-term assessment of fatigue in patients with culture-confirmed Lyme disease. Am J Med. 2015;128(2):181-184.