Lyme disease and liver dysfunction may be connected in some patients as the Lyme disease bacteria like to congregate in tissues such as the heart, the joints, and the liver leading to jaundice and hepatitis. Elevated liver enzymes may be found during tests when diagnosing Lyme disease but many patients suffer no symptoms of liver dysfunction and enzymes return to normal after successful Lyme disease treatment. An unfortunate few will develop serious liver problems related to Lyme disease infection, however, requiring immediate intervention to avoid long-term liver damage. In a case study published this month a 78 year old man with polymyalgia rheumatica suffered from Lyme disease and hepatitis complicated by treatment for PMR with corticosteroids. This case alone highlights the difficulties faced by patients with systemic immune system disorders when facing acute infection such as Lyme disease.
Liver Problems with Undiagnosed Lyme Disease
Early Lyme disease symptoms such as fatigue, joint pain, fever, and headaches are often mistaken for summer flu or simply tiredness from a camping weekend or hike. Many do not develop the Lyme disease rash and so can easily miss the fact that they have been bitten one or more times by an infected tick. As the symptoms may dissipate quickly and then arise intermittently and to varying degrees it is easy to see how a Lyme disease diagnosis can be a protracted affair allowing lots of tissue damage to occur in the liver and other organs over the weeks and months of untreated infection.
Lyme Disease: A Cause of Liver Dysfunction?
Many physicians will dismiss the idea of Lyme disease as a cause of liver disease but a quick look through the medical literature throws up a number of cases in which severe Lyme disease infection and liver disease have occurred together in children and adults. This does not necessarily imply causation as liver disease and hepatitis (inflammation of the liver) can occur for a variety of reasons, including infection by another organism (such as Lyme disease coinfections), by gallstones, and even by medications used to treat Lyme disease infection.
Liver Enzymes Elevated in Around a Third of Lyme Disease Patients
Although liver disease from Lyme disease is considered rare there are reported cases published in the journal Gastroentérologie Clinique et Biologique (2001), which involved jaundice and abnormal liver function tests in Lyme disease patients. Children and the elderly may be more susceptible to liver damage from Lyme disease as the tick borne infection can present as acute hepatitis with fever and jaundice in those with compromised or underdeveloped immune systems. The author W. Allan Walker also noted in his book ‘Pediatric Gastrointestinal Disease’ that some 40% of adults diagnosed with Lyme disease had one or more liver abnormalities when tested. Such abnormalities then resolved either completely or considerably after antibiotic treatment eradicated the Lyme disease infection.
Why Lyme Disease Affects the Liver
Looking at the issue of Lyme disease and liver dysfunction holistically it is easy to see how one could assume that this infection could compromise the liver. Not only do the spirochaetes infect various tissues and cause cellular damage they also cause systemic inflammation and possibly even confusion in the body’s immune system. As the liver processes toxins circulating through the body the presence of Lyme disease bacteria and the waste materials created in their wake would add an extra burden to the regular processes. Antibiotics, and other medications, employed to treat Lyme disease and its symptoms would also be processed by the liver, thus adding extra work to the organ. As with any systemic disease it can help to optimize liver function, by reducing toxicity and such things as alcohol consumption, during the healing process in order to avoid bacterial toxins accumulating and circulating to cause further damage and symptoms of herxing.
Asymptomatic Liver Disease in Lyme Infection
The first case reported by Dadamessi, et al (2001), involved a seventy-one year old man who experienced febrile jaundice, while a slightly younger man had cytolytic and cholestatic abnormalities and fever. The authors of this paper concluded that symptoms of Lyme disease involving the liver were rare although there may be functional abnormalities that remain asymptomatic but show up on blood tests for Lyme disease.
Liver Abnormalities in Forty Percent of Lyme Patients
More evidence to support the involvement of the liver in Lyme disease comes from a study carried out in 1996 by Horowitz, et al. These researchers looked at patients with erythema migrans but no other identifiable cause for liver abnormalities (hepatitis A, B, and C, along with other common causes of hepatitis were ruled out in this study). Out of 115 patients with Lyme disease, forty six (40%) had at least one liver test abnormality, with 31 (27%) having more than one abnormal liver test result. A control group had a 19% and a 4% incidence of at least one and more than one liver abnormality, respectively.
Which Liver Enzymes are Affected by Lyme Disease?
The abnormal liver test results found in the Lyme disease patients included gamma-Glutamyl transpeptidase elevations in 28% of the cases, and alanine transaminase (ALT) elevations in 27% of cases. There were symptoms such as anorexia, nausea, and vomiting in 30% of the Lyme disease patients but the incidence of these did not appear connected to the liver abnormalities found in the study. Elevated liver enzymes in Lyme disease were more likely in the early stages of disseminated infection (66%), with just over a third (34%) of patients with localized, early stage Lyme disease having abnormal liver enzyme levels. Some patients had persistent abnormalities in liver enzymes even after treatment for Lyme disease, although most patients’ enzymes returned to normal following three weeks of antibiotics for the infection.
Lyme Disease in the Joints, Heart, and Liver
Adding further to the evidence supporting liver complications from Lyme disease infection, German researchers looking at severe combined immunodeficient (SCID) mice purposefully infected with Lyme borreliosis describe how symptoms reflect concentration of the bacteria in the joints, heart, and liver. Schaible, et al (1990), describe how the mice suffered swelling and reddening of the joints in the leg, diagnosed as Lyme arthritis, and, later in the infection, similar arthritic symptoms in other joints such as the feet and hands.
Liver Fibrosis (Scarring) in Lyme Disease
Progressive inflammation occurred throughout the body, including the heart, liver, and other joints as synovial linings became inflamed and signs of cartilage and bone breakdown began to arise. Lyme carditis was noted, as was hepatitis with mononuclear cell infiltrations in the portal field and central vein. Liver fibrosis arose later after granulomatous reactions. As well as signs of liver disease from Lyme disease the mice had lesions in the kidneys, lungs, brain, and striated muscles. Normal mice, without compromised immune systems, had minimal signs of lesions and few spirochaetes able to be identified from their tissues.
ELISA Fails to Find Lyme Disease in Most Cases
Yet another study describes the incidence of subclinical hepatitis in Lyme disease, putting the rate at 27% in their study of seventy three patients. These patients had erythema migrans and lived in a Lyme endemic area in the lower Connecticut River valley. ELISA tests for Lyme disease proved positive in only 9% of cases, once again demonstrating the problems with reliance on this method to determine Lyme disease in the absence of the rash (which can confirm diagnosis alone). Kazakoff, et al (1993), concluded that liver abnormalities and subclinical hepatitis are common in early Lyme disease, with gamma-glutamyltransferase the most commonly elevated liver enzyme.
Ceftriaxone for Hepatitis in Lyme Disease
A case of hepatitis from Lyme disease was described by Bendix, et al (2007), perhaps constituting the only directly related case of hepatitis, rather than simply Lyme disease and elevated liver enzymes. In this case the sixty nine year old man presented with multiple erythema migrans and hepatitis which resolved after a course of antibiotics. The man had elevated liver enzymes and multiple infiltrated urticarial plaques and livid maculae. He underwent PCR testing of a skin biopsy, which proved positive for Lyme disease bacteria, and was diagnosed with a Borrelia afzelii infection and subclinical hepatitis. Ceftriaxone was given intravenously and the skin lesions disappeared almost entirely while the liver enzymes returned to normal levels within two weeks.
Recognizing Lyme Disease Liver Dysfunction
The authors of the previously mentioned study suggest that dermatologists be on the lookout for multiple erythema migrans and signs of hepatitis and Lyme disease in patients who may have experienced tick bites in recent weeks or months. Contrary to popular belief, Lyme disease appears connected to liver dysfunction in many cases with around two thirds of patients found in a number of studies to have elevated liver enzymes. Compromised liver function may alter metabolism of various drugs and medications for Lyme disease and associated symptoms as well as creating atypical symptoms of Lyme disease infection and potential confusion around differential diagnoses of Lyme disease. Patients may be asymptomatic or could present with jaundice or general malaise due to liver irregularities in Lyme disease and doctors should be alert to such signs so as to optimize treatment.
Dadamessi I; Brazier F; Smail A; Delcenserie R; Dupas JL; Capron JP [Find, [Hepatic disorders related to Lyme disease. Study of two cases and a review of the literature]., Gastroenterol Clin Biol 2001 Feb;25(2):193-6 (ISSN: 0399-8320)
Muslmani M, Gilson M, Sudre A, Juvin R, Gaudin P., Lyme disease with hepatitis and corticosteroids: A case report, Rev Med Interne. 2012 Jun;33(6):339-42. Epub 2012 Feb 24.
Benedix F, Weide B, Broekaert S, Metzler G, Frick JS, Burgdorf WH, Röcken M, Schaller M., Early disseminated borreliosis with multiple erythema migrans and elevated liver enzymes: case report and literature review, Acta Derm Venereol. 2007;87(5):418-21.
Kazakoff MA, Sinusas K, Macchia C., Liver function test abnormalities in early Lyme disease, Arch Fam Med. 1993 Apr;2(4):409-13.
Schaible UE, Gay S, Museteanu C, Kramer MD, Zimmer G, Eichmann K, Museteanu U, Simon MM., Lyme borreliosis in the severe combined immunodeficiency (scid) mouse manifests predominantly in the joints, heart, and liver, Am J Pathol. 1990 Oct;137(4):811-20.
Horowitz HW, Dworkin B, Forseter G, Nadelman RB, Connolly C, Luciano BB, Nowakowski J, O’Brien TA, Calmann M, Wormser GP., Liver function in early Lyme disease. Hepatology. 1996 Jun;23(6):1412-7.