Lyme Disease
By Lisa Glickstein, Ph.D, Triplet Mom
Originally printed in June 2004

In the early spring, nymphal ticks search for a host to feed on so that they can
molt into adult ticks and feed and breed in the fall.  In the Northeast, among other
areas of the country, these ticks can carry tiny spiral-shaped bacteria (spirochetes)
that cause Lyme disease.  If they feed on a person, rather than the field mouse 
that is their natural host, this bacterium can be transmitted and lead to disease.

1. The only way to prevent Lyme disease is to avoid tick bites.  For a short time,
there was a marketed vaccine that prevented Lyme disease.  However, it failed to
make enough money for the drug company and was removed from the market.  Wearing
long pants and sleeves on hikes, trimming long grass near yards, and careful use
of tick repellents containing DEET or IR3535, can prevent ticks from attaching and
feeding on you or your children.

2. Do daily tick checks if you spend time outdoors, especially in long grass or 
woods, or if you have been on Martha's Vineyard, Nantucket, or the Cape.  The ticks
that transmit Lyme disease are not the large dog ticks, but the smaller deer tick.
The tiny unfed tick is about the size of the period at the end of this sentence.
Common attachment sites are the arms, legs, groin, and nape of the neck.  The tick
attaches and feeds for several days, and the spirochete takes more than 24 hours
to transmit from the tick to its human host.  If you remove a tick within 24 hours
of attachment, the chance of infection is very low, and you should just watch the
site for the next week or two and report any rash or flu-like symptoms to your doctor.

3. If you find an engorged (fully fed) tick, remove it carefully (with tweezers,
by pulling, not twisting).  Ask your doctor about a single dose treatment of doxycycline
(amoxicillin for children), which has been shown to be curative.  If you do not 
choose to take antibiotics immediately, report any rash or flu-like symptoms that
develop to your doctor.

4.	Early Lyme disease usually (in 8/10 cases) begins with a characteristic "bull's
eye" rash at the site of the tick bite.  The rash is red, and may be slightly
raised and warm, but doesn't itch.  It slowly grows as the spirochete migrates outward
through the skin - to greater than the size of your palm (about 5 centimeters). 
This rash, if present, is highly specific to Lyme disease and requires antibiotic
therapy; if you get it, report it to your doctor right away.

5. Flu-like symptoms are common in Lyme disease (fever, chills, muscle and joint
aches, headache and stiff neck).  In up to 2/10 cases, these are the first symptoms
of the disease.  If you develop flu-like symptoms in the summer, especially without
a sore throat, runny nose, congestion, or stomach symptoms like vomiting or diarrhea,
your doctor should consider Lyme disease.

6. Many cases of facial palsy (paralysis, usually of one half of the face) are caused
by Lyme disease.  This can occur without any other typical symptoms of the disease,
and requires antibiotic therapy.

7. These symptoms often go away after one to several weeks even without medical 
treatment.  Some people may not notice the rash (it can occur on the back, in the
scalp, or armpit and not be obvious), or attribute the flu-like symptoms to a summer
viral illness, and not get treated.  Or they may have no initial symptoms of infection.
If no further symptoms develop, no medical treatment is required.  In some patients,
the immune system can't clear the infection on its own, and the spirochetes may 
localize to specific sites, often the joints, but sometimes the heart, brain, nerves
of the eye or limbs, or skin, and cause localized disease symptoms, such as arthritis.
Late manifestations of Lyme disease also require antibiotic therapy.

8. Lyme disease diagnosed by the presence of the characteristic rash (called erythema
migrans) does not require any further diagnostic tests.  In patients without the
rash, in whom Lyme disease is suspected (because of a history of recent tick bite,
or flu during vacation to the Cape, facial palsy, or arthritis, to give a few examples),
diagnosis is by a blood test.  In patients with early symptoms, the test may not
be positive.  However, the tests will be positive in most people within four weeks
of the tick bite, including all or nearly all people with late symptoms.  The blood
test looks for evidence that your immune system has made antibodies to the spirochete.
Current blood tests administered by a good doctor are very reliable.  A negative
test after weeks or months of symptoms indicates that a diagnosis other than Lyme
disease should be considered.  Testing on urine or other bodily fluids (or ticks)
is not recommended.

9. Currently, there are two diagnostic tests for Lyme disease.  In the first, called
the "two-test" approach, an antibody titer is measured against small parts
(proteins) of the bacteria.  If this test is positive, a second test is done that
measures the reaction between your blood antibodies and a series of specific proteins
from the spirochete.  Some of these "bands" can be positive even in patients
who have never had Lyme disease, because they are similar to proteins from other
bacteria that you might have been infected with in the past.  Therefore, you need
to have at least five or more of ten specific "bands" in your IgG test
to be considered positive.  A newer test looks for a response to one protein of 
the spirochete, called VlsE.  This single test gives results that compare well with
the two-test method in terms of specificity (not giving false positive results) 
and sensitivity (not giving false-negative results).

10. Lyme disease can be cured with appropriate antibiotic therapy.  It usually requires
at least two to four weeks of oral antibiotics.  Patients with evidence of neurologic
(brain or nerve) involvement need several weeks of intravenous antibiotics.  Not
all antibiotics are effective against Lyme disease.  Doxycycline (oral) is usually
prescribed for adults and other choices for children or expectant mothers.  As with
all antibiotic prescriptions, it is important to finish the course even if you feel
better right away.  A second course may be needed if symptoms persist.  However,
extended antibiotic therapy for greater than two months has not been shown to be
effective, and can lead to significant side effects.

11. There are usually no long-term complications of Lyme disease, particularly if
it is caught early, at the time of the initial rash or flu-like illness.  Some symptoms,
like facial palsy, may take months to resolve, even after the infection is cured
with antibiotics.  In a small number of patients, Lyme disease seems to trigger 
a chronic pain and fatigue syndrome.  This syndrome is not caused by ongoing infection,
and patients suffering with it should be under the care of a doctor specializing
in similar diseases (a rheumatologist).

12. Patients who are diagnosed and treated early may not develop protective antibodies
against the spirochete and can be reinfected.  This is uncommon in patients who 
have late manifestations.  Antibodies against the spirochete in your blood may persist
for years, or even a lifetime.  There is a risk that a subsequent illness could 
be misdiagnosed as Lyme disease based on a positive Lyme disease blood test.  Therefore,
any doctors you visit should be informed of your Lyme disease history.