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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

• Lyme disease is a condition commonly caused by bite of a tick infected with Borrelia burgdorferi.

What are the symptoms of Lyme disease?

It's important to know the symptoms of Lyme disease and to seek medical help if you think have Lyme disease. Early signs and symptoms (3 to 30 days after tick bite): The first symptom is usually a red rash at the site of tick bite, which may look like a bull's eye. But not all people with Lyme disease have a rash. The rash is called erythema chronicum migrans or erythema migrans (EM). EM occurs in approximately 70 to 80 percent of infected persons. EM begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days). Em expands gradually over a period of days reaching up to 12 inches or more (30 cm) across. EM may feel warm to the touch but is rarely itchy or painful. Sometimes, EM clears as it enlarges, resulting in a target or “bull’s-eye” appearance. EM may appear on any area of the body but majority of times present in areas including axilla, inguinal region, popliteal fossa, or along belt line. The rash may or may not be associated with flu-like symptoms including: Fever and/or chills Headache Body aches Joint aches Headaches Stiff neck Fatigue

Classic Lyme disease rash - Source: CDC.gov

• Late Signs and Symptoms (days to months after tick bite):
  • Severe headaches and neck stiffness
    • Multiple erythema migrans rashes on other areas of the body.
    • Arthritis with severe joint pain and swelling, particularly the knees and other large joints.
    • Facial palsy (loss of muscle tone or droop on one or both sides of the face).
    • Intermittent pain in tendons, muscles, joints, and bones.
    • Heart palpitations or an irregular heart beat (Lyme carditis).
    • Episodes of dizziness or shortness of breath.
    • Inflammation of the brain and spinal cord.
    • Nerve pain.
    • Shooting pains, numbness, or tingling in the hands or feet.
    • Problems with short-term memory.

Notes Fever and other flu-like symptoms may occur in the absence of rash. A small bump or redness at the site of a tick bite that occurs immediately and resembles a mosquito bite, is common. This irritation generally goes away in 1-2 days and is not a sign of Lyme disease. A rash with a very similar appearance to EM occurs with Southern Tick-associated Rash Illness (STARI), but is not Lyme disease. Ticks can spread other organisms that may cause a different type of rash. What causes Lyme disease? Lyme disease is caused by a bacterial infection you get from bite of an infected tick. The majority of Lyme disease in North America is caused by bite of black-legged tick, or deer tick (Ixodes scapularis). Other ticks that transmit Lyme disease are sheep tick, castor bean tick, or European castor bean tick (Ixodes ricinus) in the Europe; Western black legged tick (Ixodes pacificus) in the Pacific region of North America; taiga tick (Ixodes persulactus) Europe, Central and Northern Asia, China, and Japan. Only 20% of individuals infected with Lyme disease by the deer tick are aware of having had any tick bite.

I. scapularis, the primary vector of Lyme disease in Eastern North America - Source: Gross L (2006) A New View on Lyme Disease: Rodents Hold the Key to Annual Risk. PLoS Biol 4(6): e182. https://doi.org/10.1371/journal.pbio.0040182

Who is at highest risk?

Individuals who spend time outdoors and/or have pets that go outdoors in endemic regions are at risk for tick-borne disease.

Exposure to ticks

• Individuals with frequent exposure to dogs and who reside near wooded areas or areas with high grass may also be at increased risk of tick-borne infection.
• Individuals with outdoor occupations and who work outside with bare or exposed skin are at a high risk of contracting Lyme disease.
• Failing to remove a tick as soon as you see it on your skin (the longer a tick is attached to your skin, the greater your risk of developing Lyme disease) also increases risk of developing Lyme disease.

Endemic Regions

• About 95% of all reported cases are confined to 14 states including Connecticut, Delaware, Maine, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.
• Any individual traveling or living within these five geographic areas including New England, Mid-Atlantic, East-North Central, South Atlantic, and West North-Central is at a heightened risk of exposure to Lyme disease.

Seasonal Variation

• The majority of Lyme disease cases are reported during the summer months of May to August.
• Case incidence increases in May, peaks in June and July, and tapers off in August.

Rarer forms of Transmission

• Cases of blood transfusion and organ transplantation have been recorded as methods of transmission but this is a rare mode of transmission.

Diagnosis

• Following points should be taken into consideration in order to make a diagnosis of Lyme disease:
  • A history of exposure to potentially infected ticks, especially in areas of the country known to have Lyme disease.
  • Symptoms, including physical findings such as the characteristic rash (erythema migrans).
  • Results of blood tests that check for antibodies to the bacterium that causes Lyme disease.

When to seek urgent medical care?

• Lyme disease is rarely fatal.

Treatment options

• According to CDC, patients treated with antibiotics in the early stages of the infection usually recover rapidly and completely.
• Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or cefuroxime axetil (Ceftin).
• Patients with certain neurological or cardiac forms of illness may require intravenous treatment with drugs such as ceftriaxone or penicillin.

Where to find medical care for Lyme disease?

• In this section you can provide links for reputable places that the patient can find good treatment for there condition.

Prevention

• Educate yourself about Lyme disease, and try not to get bitten by ticks.
• More specifically:
  • Avoid wooded, brushy, and grassy areas, especially in May, June, and July. (Contact the local health department or park/extension service for information on the prevalence of ticks in specific areas.)
  • Wear light-colored clothing so that you can see ticks that get on you.
  • Wear long pants and long-sleeved shirts.
  • Wear shoes that cover the entire foot. Tuck pant legs into socks or shoes, and tuck shirts into pants.
  • Wear a hat for extra protection.
  • Spray insect repellent containing DEET on clothes and exposed skin other than the face, or treat clothes with permethrin, which kills ticks on contact.
  • Walk in the center of trails to avoid brush and grass.
  • Remove your clothing, and wash and dry them at high temperatures after being outdoors.
  • Do a careful body check for ticks after outdoor activities.
• If a tick is attached to you, remove it!
  • Using tweezers, grasp the tick close to the skin, pull straight back, and avoid crushing the tick's body.
  • Save the tick for possible identification by a doctor or the local health department.

What to expect (Outlook/Prognosis)?

• For early cases, prompt treatment is usually curative.
• However, the severity and treatment of Lyme disease may be complicated due to:
  • Late diagnosis
  • Failure of antibiotic treatment
  • Coinfection with other tick-borne diseases including Ehrlichiosis and Babesiosis
  • Immune suppression in the patient
• Some patients with Lyme disease have fatigue, joint and/or muscle pain, and neurocognitive symptoms persisting for years despite antibiotic treatment.
• Patients with late stage Lyme disease have been shown to experience a level of physical disability similar to that seen in congestive heart failure.
• Though rare, Lyme disease can be fatal.

Possible complications

• Late Lyme disease can cause long-term joint inflammation (Lyme arthritis) and heart rhythm problems. Brain and nervous system problems are also possible, and may include:
  • Decreased concentration
  • Memory disturbances
  • Nerve damage
  • Numbness
  • Pain
  • Paralysis of the face muscles
  • Sleep disorders
  • Vision problems

Sources

• https://medlineplus.gov/lymedisease.html
• https://www.cdc.gov/lyme/index.html
• https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm049298.htm

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