Lyme disease
(līm 
)
[ Lyme, CT, where a cluster of cases was reported in 1975]
ABBR: LD
A multisystem disorder caused by the spirochete Borrelia burgdorferi and the most common tick-borne disease in the U.S.
Incidence: The disease is endemic in New England , but cases have been reported in all 50 states and in 20 other countries, including Germany, Switzerland , France, and Australia. It occurs most often in the spring and summer, when its deer tick vectors (genus Ixodes) are most active. An estimated 300,000 cases of Lyme disease occur each year in the U.S.
Causes: The infected tick injects its spirochete-laden saliva into the bloodstream, where they incubate for 3 to 32 days and then migrate to the skin, causing the characteristic erythema migrans (EM) rash.
Symptoms and Signs: The course of Lyme disease is divided into three stages: 1) localized infection, which begins with the tick bite and proceeds as above; 2) disseminated infection, which begins weeks to months later. The spirochetes spread to the rest of the body through the blood, in some cases causing arthritis (esp. of the knee joints), muscle pain, cardiac dysrhythmias, pericarditis, lymphadenopathy, or meningoencephalitis. Nonprotective antibodies develop during this stage; and 3) chronic infection, which begins weeks to years after the initial bite. Patients develop mild to severe arthritis, encephalitis, or both, which are rarely fatal.
Diagnosis: The disease is best diagnosed by the presence of EM, which begins as a red macule or papule at the site of the tick bite and expand s in a red ring, leaving a clear center like a target or bull’s eye. The lesion usually feels hot and itchy and may grow to over 20 in (50.8 cm) as more lesions erupt. The lesion is later replaced by red blotches or diffuse urticaria. Conjunctivitis, malaise, fatigue, and flulike symptoms and lymphadenopathy may occur. Positive blood cultures, or cultures of joint fluid or skin biopsy specimens are also diagnostic. Antibody tests for B. burgdorferi with an enzyme-linked immunosorbent assay (ELISA) test are also used for diagnosis in patients with a history of exposure and signs and symptoms of Lyme disease but with no evidence of rash. The antibodies are developed against flagellar and outer surface proteins on the spirochete.
Prevention: The CDC recommends that people should discuss with their health care providers the possibility of getting a Lyme disease vaccination if they are between 15 and 70 years old; live, work, or vacation in endemic areas; or frequently go into wooded or grassy areas. The vaccine is not recommended for children, pregnant women, and those who do not live in or visit endemic areas.
When planning to spend time in places where there may be ticks, people should wear clothing impregnated with insect repellents, hats, long sleeves, pants tucked into socks, heavy shoes, and a tick repellent containing DEET (N,N-diethyltoluamide). Tick repellent should not be directly applied to an infant or toddler’s skin because of the danger of neurotoxicity. If possible, people should stay on paths and away from high grass or brush. They should check clothing carefully for ticks when leaving those areas although tick nymphs, which are smaller than 1 mm in length, may not be easily seen. Once back at home, people should remove and wash clothing and check their entire body, esp. the hairline and ankles, for ticks or nymphs. If a tick or nymph is found, it should be carefully removed with tweezers, esp. the head and mouth parts, but the body of the tick or nymph must not be squeezed. The site may then be cleansed with an antiseptic, but should be observed for signs of infection (redness, swelling, pain, rash), and the primary health care provider contacted if infection is suspected. Some people make the mistake of trying to remove ticks or nymphs with alcohol, a lighted match, or petroleum jelly. These measures are ineffective and may increase the risk of transmission of tick-borne diseases. Prophylactic antibiotics generally should not be requested (or given). Although pet dogs may receive Lyme vaccine, they should still be checked to prevent them from bringing ticks into the house.
Prompt removal of visible ticks from the skin before they become attached or gain access to the bloodstream (in the first 24 to 48 hr) decreases the risk of transmission.
Treatment: Oral doxycycline should be used to treat patients with a tick bite who have an erythema migrans rash. Patients with Lyme-related joint disease need 28 days of treatment with antibiotics. Intravenous treatments, for example with ceftriaxone, cefoxtaxime, or penicillins, can be used to treat neurological infection, although oral doxycycline is also effective.
Impact on Health: When the disease is treated early, results are good. If treated late, convalescence is prolonged, but complete recovery is the usual outcome in most patients.
About 15% of patients who suffer an episode of erythema migrans experience the rash again within five years. However, the recurrence of the rash is secondary to re-infection, rather than to relapse of persistent disease.
Patient Care: The patient is checked for any drug allergies. Prescribed pharmacologic therapy is explained to the patient, including dosing schedule, the importance of completing the course of therapy even if he feels better, and adverse effects. Patients being treated for Lyme disease often require antibiotics for a prolonged period, esp. in advanced stages, which increases their risk for developing adverse effects, e.g., diarrhea. Methods for dealing with these problems are explained. Patients with chronic Lyme disease often require assistance to deal with changes in lifestyle, family interactions, and ability to perform daily activities. Available local and national support groups can assist with such problems. Patients should be made aware that one occurrence of Lyme disease does not prevent recurrences. The U.S. Department of Health and Human Services has made Lyme disease prevention a priority under its program “Healthy People 2010.” Patients can be referred to the Lyme Disease Foundation (860-870-0070; http://www.lyme.org) or the American Lyme Disease Foundation (http://www.aldf.com) for information and support.