Reply to Greenberg

TO THE EDITOR—We thank Dr Greenberg for her interest in our study on the health-related quality of life (HRQOL) of US patients with culture-confirmed er-ythema migrans, that is, early Lyme disease [1]. We assessed 100 patients using the 36-item short-form general health survey (SF-36), version 2, at 11–20 years after diagnosis and treatment. Our findings demonstrated that, on average, the HRQOL of our patients was similar to that of the general population [2]. This result was found despite the fact that at least 24% of our patients were reinfected and experienced a second episode of early Lyme disease with erythema migrans before the HRQOL assessment was performed. Moreover, our findings closely resembled those from a prior study that assessed the long-term HRQOL of 25 patients with erythema migrans [3]. Dr Greenberg is concerned that those who underwent the SF-36 testing had fewer symptoms (approximately 1 less symptom on average) on study entry than those who did not participate in this assessment ; a point that we had clearly acknowledged. However, in addition, she states that our 100 study participants were also otherwise healthier; we are unaware of the basis for this statement. Subsequent additional analysis of our study data should allay some of Dr Green-berg's concerns. The most relevant factor in regard to the long-term HRQOL outcome of Lyme disease patients is how many of such patients have post-treatment Lyme disease symptoms (PTLDS) and how severe are these symptoms. In 8 US studies of patients with erythema migrans, the