Family Circle Lyme Article-Lyme Disease on the Rise May 2003

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By A. Edlow, M.D., F.A.C.E.P.

Lyme Disease on the Rise

How to Protect Your Family

Lyme disease was not in medical dictionaries in 1975, the year that two

Connecticut housewives notified the state of strange goings-on in the Lyme,

Connecticut, area. Family members and neighbors were being diagnosed at an

alarming rate with arthritis, often associated with bizarre rashes and odd

neurological symptoms. Doctors from Yale University investigated, and " Lyme

disease " was born. But in fact, European doctors had known of the disease

since the turn of the last century.

Whatever its history, its present and future seem certain. Officially

reported cases of Lyme disease have skyrocketed in the past decade. In 2000,

the last year for which complete figures are available, 17,730 cases were

documented. Since Lyme disease statistics were first compiled in 1982, the

cases have increased nearly 25-fold. But this number is thought to represent

only 10 percent of the actual number of cases. Underreporting is likely

because although Lyme disease is a problem, it is not contagious and is

almost never life threatening. Also, in some areas Lyme is so common that

doctors simply do not take the time required to inform the public health

department about cases.

And Lyme is no longer just a Connecticut curiosity. The disease has been

found in nearly every state; the majority of cases occur along the East

Coast and in the north central states. The reasons for the geographical

expansion: increased deer herds and the spread of ticks by birds. (Lyme is

caused by a bite from a bug, commonly known as the " deer tick, " that is

infected with a bacterium called a spirochete.) These factors, plus greater

recognition of the disease (both by the public and physicians), likely play

a role in the recent rise in cases of Lyme disease.

Spot the Symptoms

Lyme disease can affect anyone-including children, who account for 25

percent of cases. Infection typically occurs in spring and summer, peaking

in May, June and July, when the tick population is high. Because the deer

tick is so small (ranging from the size of a poppy seed to a sesame seed),

only 25 percent of patients recall being bitten. The disease occurs in three

stages; the symptoms of one stage often disappear without treatment before

the next stage begins.

The typical Stage 1 phase starts a week or two following the tick bite, with

a flat red rash that sometimes looks like a bull's-eye and can grow to a

large size-sometimes as big as a dinner plate. Patients may have a mild

fever, chills, a sore neck and achy muscles. Often the rash is so

characteristic that a doctor can definitively diagnose Lyme disease by

examination alone; no blood tests are needed. Untreated, the rash can last a

few weeks but may disappear sooner. If you cannot be seen by your doctor

soon after discovering the rash, take a photograph to document it to show

your physician. A photo is also helpful in observing the rash's evolution.

Unfortunately, this distinctive rash is absent in 15 to 20 percent of cases,

making diagnosis more difficult. Patients with Stage 1 Lyme disease and no

rash will often have other symptoms--fevers, chills and sore muscles-all the

symptoms of a summer flu. It is important to be aware that what seems like

flu could be Lyme disease if the sufferer has been exposed to ticks during

any outdoor activities.

When Lyme disease is not diagnosed early, the spirochete can invade the

brain, heart and joints. This is called Stage 2 Lyme disease, and occurs

weeks to months following the tick bite. Symptoms can include paralysis of

half the face (known as Bell's palsy), headache from a mild form of

meningitis, or severe pains in the back, arms or legs. Some patients may

have heart palpitations or a dangerously slow pulse. Fortunately, the

infection is still treatable with antibiotics at this stage, although

medicine may need to be given intravenously to increase its effectiveness.

Stage 3 Lyme disease develops months to years later, and generally affects

the joints and nervous system. Arthritis is the most notorious Stage 3

manifestation of the disease. When Stage 3 Lyme affects the nervous system,

it may cause numbness, tingling or weakness in the arms and legs, memory

problems, irritability and an increased need for sleep. These later

manifestations still may be helped by courses of antibiotics, but the

improvement is slower and the outcome less certain.

Get the Right Diagnosis

Over the last few years doctors have discovered that many of the

Lyme-infected ticks also carry germs that cause other diseases, such

as babesiosis and ehrlichiosis. Both of these infections usually cause a

higher fever than Lyme disease alone, along with severe headache and very

sore muscles, and can occasionally be fatal. About 10 to 15 percent of

patients with Lyme disease will contract two diseases from the same tick

bite. Because patients who are co-infected with two tick-borne diseases may

have atypical symptoms, they can be more difficult to diagnose and treat.

In Stage 1 Lyme disease, your doctor may be able to accurately diagnose you

simply by talking with you and examining the rash, if you have one. If the

doctor draws blood at this early stage, results would frequently be negative

(or normal), which is why physicians do not recommend blood testing in

patients with early disease. Such results are called a " false negative, "

meaning you really do have Lyme disease, even though the blood test is

negative. In this situation, your doctor will likely prescribe antibiotics

for presumed (or clinically diagnosed) Lyme disease.

When Lyme affects the heart, nervous system or joints, your doctor will

almost certainly take a blood test. In these later stages of the disease,

the test will usually be positive, allowing the doctor to diagnose Lyme

disease with a high degree of certainty. Controversy exists here too, as a

minority of physicians believe that the currently available Lyme blood tests

are negative in a significant proportion of patients with late disease.

Scientists are examining newer blood tests that may solve some of the

problems with the currently available tests. These newer tests may turn

positive sooner and be a better marker for patients who truly have the

infection. All of these tests share one basic problem-they reveal the

presence not of the bacteria itself, but of our antibodies to it. If

administered too soon, before antibodies to the bacteria develop, these

tests can give a false negative reading.

Fight the Bite

Most patients with Stage 1 or 2 Lyme disease are easily and successfully

treated with antibiotics-oral antibiotics for Stage 1 and, often,

intravenous antibiotics for Stage 2. Some late-stage arthritis patients also

respond to oral antibiotics. Newer antibiotic combinations and dosages are

constantly being tested, and patients who are co-infected by multiple

tick-borne germs may require different medications. Frequently prescribed

oral antibiotics include amoxicillin, doxycycline and cefuroxime. The most

common intravenous antibiotic used for Lyme disease is ceftriaxone.

The best treatment is prevention. Avoid ticks by staying away from low

vegetation and walking along the center of trails. Wearing light-colored

clothing may make it easier to see ticks that do try to attach to you.

Wearing long pants and tucking pant legs into socks can be protective but

may be uncomfortable in hot weather. Applying repellents with DEET to skin

and clothing and/or permethrin to clothing only (not skin) helps. The

combination provides additional protection. Apply DEET solutions only to

exposed skin but avoid the face and hands, especially children's, to lessen

the chance that the repellent will come in contact with their eyes and lips.

Also, do not use DEET products on infants, toddlers, pregnant women or skin

that is sunburned or abraded. Pediatricians recommend 10 percent

concentrations for children. Concentrations of 20 to 30 percent are probably

safe for adults but should be washed off after each use. As with any such

product, carefully follow the manufacturers' labeling advice. Some doctors

recommend Avon's Skin-So-Soft Bug Guard Plus IR3535, which contains no DEET.

As for a vaccine, the manufacturer of the Lyme vaccine (LYMErix) pulled it

from the market in February 2002, and there is currently no substitute.

Scientists are researching other possible vaccines, but none is on the

immediate horizon. Until one becomes available, avoid tick-infested areas,

wear protective tick repellents and spot infection early.

The Best Way to Battle the Bug

Tick removal is an important preventive strategy. After being in

tick-infected areas, check yourself and your family for ticks. Removing

ticks within the first 24 hours drastically decreases your chance of

infection. If a deer tick has been attached to you for more than a day, your

doctor may prescribe antibiotics to prevent infection. The best method to

remove a tick is to grasp it, using very fine-tipped tweezers, as close as

possible to the skin, and then gently pull it out over a period of 30 to 60

seconds. If some of the mouthparts of the tick remain, they will not

transmit Lyme disease and can be disinfected with alcohol.

- A. Edlow, M.D., F.A.C.E.P., is the author of Bull's-Eye:

Unraveling the Medical Mystery of Lyme Disease (Yale University Press, May

2003).