Evolution in the Diagnosis and Treatment of Lyme Disease.

What to know in 2018 on the black legged thick responsible of Lyme disease? Believe it, this little animal is on the move. The disease it carries with it bite, was first diagnosed in the North East, at Lyme CT but now can be found in most of western and southern USA as well as into Canada, Mexico and Florida. Lyme’ disease is not exclusive to the North East of the United States anymore.

The last CDC study has reported more than 80% increase in cases of Lyme disease between 2004 and 2016, from 19,804 to 36,429 cases, although more than 300,000 cases may be unreported. Many researchers like John Aucott MD at John Hopkins believe the worse is yet to come.

The black-legged tick (Ixodes Scapularis), also known as the deer tick, carries the bacteria responsible of Lyme infection. The same tick may also spread other diseases, including babesiosis, anaplasmosis, and Powassan virus or other diseases, on the rise in the U.S.

Lyme disease is caused by a bacterium, Borrelia burgdorferi, transmitted to humans through a bite from an infected black-legged or deer tick. Symptoms can occur anywhere from 3 to 30 days after the bite and can be wide-ranging, depending on the stage of the infection. In some cases, symptoms can appear months after the bite. The longer the tick stays attached to you, the more you can attract the disease.

In general, the disease occurs in 36 to 48 hours after the bite. But if the tick is removed within 48 hours, you are not likely to get infected, says Cleveland Clinic infectious disease specialist Alan Taege, MD.

The early signs and symptoms of Lyme’s disease include fever, chills, headache, fatigue, muscle and joint pain, and swollen lymph nodes, all common in the flu. Up to 80% of Lyme infections will reveal a rash as one of the first symptoms.

If left untreated other symptoms may manifest:

Severe headache or neck stiffness, Rashes on other areas of the body
Arthritis with severe joint pain and swelling, particularly in the knees
Loss of muscle tone or “drooping” on one or both sides of the face.
Heart palpitation or an irregular heartbeat
Inflammation of the brain and spinal cord
Shooting pains, numbness, or tingling in the hands or feet
About 20% to 30% of Lyme rashes have a “bull’s-eye” appearance — concentric circles around a center point, round and uniformly red and at least 5 centimeters (about 2 inches) across like the Target logo.”

The rash expands gradually over a period of days and can grow to about 12 inches across. It rarely itches but may feel warm to the touch or occasionally painful.

The diagnosis of Lyme Disease is based on symptoms related to a history of tick exposure. Two-step blood tests are helpful if used correctly. In the first few weeks of infection, the test may be negative, as antibodies take a few weeks to develop. Tests are not recommended for patients who do not have Lyme disease symptoms. Clinicians hope to be able to count on a test showing accuracy in the first week after exposure. The earlier the treatment, the less likely you will note a progression in the symptoms.

It may be difficult for a physician not practicing in an area where this disease is prevalent to recognize the symptoms especially when there is no history of rash.

Keep in mind that there are three stages in the Lyme infestation:

1- Early localized Lyme: Flu-like symptoms such as fever, chills, headache, swollen lymph nodes, sore throat, and typically a “bull’s-eye” appearance rash, red at least 5 centimeters in size.

2-Early disseminated Lyme: Flu-like symptoms that now include pain, weakness or numbness in the arms and legs, vision changes, heart palpitations and chest pain, a rash, and facial paralysis (Bell’s palsy).

3-Late disseminated Lyme: Occur weeks, months, or years after the tick bite. Symptoms might include arthritis, severe fatigue and headaches, vertigo, sleep disturbances, and mental confusion.

It is believed that roughly 10% of people treated for Lyme infection do not heal from the disease. They may present with a triad of symptoms notably joint or muscle pain, fatigue, and short-term memory loss or mental confusion. This is called “post-treatment Lyme disease syndrome”, but unfortunately, there is no blood test to confirm it.

The treatment of Lyme disease at the early stage is based on the use of Doxycycline for 10 days to 3 weeks or with Amoxicillin and Cefuroxime for 2 to 3 weeks. In 90% of cases, the antibiotic cures the infection.

For early disseminated Lyme disease, which may happen when a Lyme infection goes untreated, oral antibiotics are recommended for symptoms such as facial palsy and abnormal heart rhythm. Intravenous antibiotics are recommended if a person has meningitis, inflammation of the lining of the brain and spinal cord, or more severe heart problems. The term “Neurolyme” became popular in the mid 90’s in the Northern States and irritability and hyperactivity were seen in families with such symptoms.

Recent studies using four antibiotics produced similarly good outcomes for the treatment of neurological Lyme disease, in Europe. A second treatment with amoxicillin does not appear to provide any added benefit to ceftriaxone. There are no known trials of antibiotics for the treatment of neurological Lyme disease in the United States.

In late-stage Lyme, a patient may receive oral or intravenous antibiotics. Patients with lingering arthritis would receive standard arthritis treatment.

“Ten percent of people (30000) don’t get better after antibiotics but will live in New England, and the Mid-Atlantic States. These numbers will increase all over the USA.

Infection is more common in males up to age 15 and between the ages of 40 and 60. Because perhaps, they are more likely to play outside, and go camping, hunting, and hiking. Reforestation in the North East and climate changes may favor the black legged thick facilitating exposure to the white tail deer and the white-footed mice, responsible of the transmission of the disease to the ticks. These vectors are moving closer to humans as their habitats disappear.  

More, with the changes in climate, we have longer and warmer summers exposing more to tick-bites and increasing the chances in developing Lyme Disease.

Ticks can’t fly but jump. They live in shrubs and bushes, and grab onto someone clothes when they pass by.

Recommendations to avoid getting bitten by a tick:

Wear pants and white socks in the woods,
Wear a tick repellent on your skin and clothing with lemon oil, or eucalyptus, camping gear, chemical permethrin.
Shower within 2 hours after coming inside, if possible.
Look at your skin and wash ticks out of your hair.

How do you know if you’ve been bitten?

Given that the ticks are the size of a poppy seed, you’ve got to have pretty good eyes. The CDC recommends that if you’ve been walking in the woods, in tall grass, or working in the garden, check your skin afterward, ideally in the shower or bath. That way, you’ve removed your clothes, which may carry ticks, too. 

How do you remove a tick under the skin?
Use a pair of fine-tipped tweezers as soon as possible, pulling upward with steady pressure. If parts of the tick remain in the skin, also try to remove it with the tweezers, then clean the bite area with rubbing alcohol or soap and water.

To dispose of a tick? Place it in soapy water or alcohol, stick it to a piece of tape, or flush it down the toilet.

When should you see a doctor if you suspect you may have Lyme?
The rash is a pretty good indication that you may have been bitten. It is recommended to take a photo of the rash prior to see a doctor.

If you don’t have the telltale rash but have a summer flu, fatigue, fever, headache but no respiratory symptoms like a cough, you may want to visit a physician.

The FDA in July 2017 gave “fast-track” approval to French biotech company Valneva to test a potential Lyme disease vaccine “VLA15” on adults in the U.S. and Europe. Data from the first phase will be released soon, and then the second phase will begin.

A dog owner needs to look for ticks on his pet because they are more likely than humans to get bitten. In the area where Lyme disease is prevalent, 25% of dogs have evidence of past infection. About 10% of dogs with Lyme disease will become ill. Common symptoms may show up 7-21 days after a tick bite. Your dog may appear to be walking on eggshells with fever, lethargy, and enlarged lymph nodes. Dogs also get antibiotics. A Lyme vaccine is also available for dogs.

Maxime Coles MD



CDC Lyme Disease Home Page

NIOSH Fast Facts Card: Protecting Yourself from Ticks and Mosquitoes
DHHS (NIOSH) Publication No. 2010-119

CDC Lyme disease communications tool kit

OSHA Logging eTool: Tick-borne Disease

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