In Reply Mr Tuttle and Mr Santarella and Dr Sellati cite data from passive surveillance systems as evidence that our statement that erythema migrans develops in 90% or more of patients with Lyme disease was inaccurate.1 However, multiple large clinical studies2,3 have estimated the proportions of pediatric and adult patients with Lyme disease with erythema migrans. These estimates, which are much more reliable because patients were carefully assessed for the presence of erythema migrans, have consistently equaled or exceeded 90%. Lower proportions (eg, 70%) among cases reported to the CDC likely reflect reporting bias toward clinical manifestations associated with seropositivity.4 The CDC also estimates that 90% of cases of Lyme disease go unreported. Among cases reported to the CDC, 30% had Lyme arthritis, in contrast to the 6% or lower frequency of this manifestation in prospective clinical studies.2,3
Shapiro ED, Wormser GP. Controversies About Lyme Disease—Reply. JAMA. 2018;320(23):2482–2483. doi:10.1001/jama.2018.17207
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