Lyme disease (patient information)

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 * Assistant Editor(s)-in-Chief: Meagan E. Doherty

Overview
Lyme disease is a bacterial infection that features a skin rash, swollen joints and flu-like symptoms. You get the disease from the bite of an infected tick. Sometimes it is hard to know if you have Lyme disease because you may not have noticed a tick bite. Also, many of its symptoms are like those of other diseases. Symptoms may include: In the early stages, doctors look at your symptoms and medical history to figure out whether you have Lyme disease. In the later stages of the disease, lab tests can confirm whether you have it. Antibiotics usually cure early stage Lyme disease. If not treated, the disease can cause problems with the joints, heart and nervous system.
 * A skin rash, often resembling a bulls-eye
 * Fever
 * Headache
 * Muscle pain
 * Stiff neck
 * Swelling of knees and other large joints

Stages of Lyme disease

 * Stage 1 is called early localized Lyme disease. The infection is not yet widespread throughout the body.
 * Stage 2 is called early disseminated Lyme disease. The bacteria have begun to spread throughout the body.
 * Stage 3 is called late disseminated Lyme disease. The bacteria have spread throughout the body.

What are the symptoms of Lyme disease?
The Lyme disease bacterium can infect several parts of the body, producing different symptoms at different times. Not all patients with Lyme disease will have all symptoms, and many of the symptoms can occur with other diseases as well. If you believe you may have Lyme disease, it is important that you consult your health care provider for proper diagnosis. The first sign of infection is usually a circular rash called erythema migrans or EM. This rash occurs in approximately 70-80% of infected persons and begins at the site of a tick bite after a delay of 3-30 days. A distinctive feature of the rash is that it gradually expands over a period of several days, reaching up to 12 inches (30 cm) across. The center of the rash may clear as it enlarges, resulting in a bull's-eye appearance. It may be warm but is not usually painful. Some patients develop additional EM lesions in other areas of the body after several days. Patients also experience symptoms of fatigue, chills, fever, headache, and muscle and joint aches, and swollen lymph nodes. In some cases, these may be the only symptoms of infection. Untreated, the infection may spread to other parts of the body within a few days to weeks, producing an array of discrete symptoms. These include loss of muscle tone on one or both sides of the face (called facial or "Bell's palsy), severe headaches and neck stiffness due to meningitis, shooting pains that may interfere with sleep, heart palpitations and dizziness due to changes in heartbeat, and pain that moves from joint to joint. Many of these symptoms will resolve, even without treatment. After several months, approximately 60% of patients with untreated infection will begin to have intermittent bouts of arthritis, with severe joint pain and swelling.  Large joints are most often affected, particularly the knees. In addition, up to 5% of untreated patients may develop chronic neurological complaints months to years after infection.  These include shooting pains, numbness or tingling in the hands or feet, and problems with concentration and short term memory. Most cases of Lyme disease can be cured with antibiotics, especially if treatment is begun early in the course of illness. However, a small percentage of patients with Lyme disease have symptoms that last months to years after treatment with antibiotics. These symptoms can include muscle and joint pains, arthritis, cognitive defects, sleep disturbance, or fatigue. The cause of these symptoms is not known. There is some evidence that they result from an autoimmune response, in which a person's immune system continues to respond even after the infection has been cleared.

What causes Lyme disease?

 * Lyme disease is caused by bacteria called Borrelia burgdorferi (B. burgdorferi). Blacklegged ticks carry these bacteria. The ticks pick up the bacteria when they bite mice or deer that are infected with Lyme disease. You can get the disease if you are bitten by an infected tick.


 * Lyme disease was first reported in the United States in the town of Old Lyme, Connecticut, in 1975. In the United States, most Lyme disease infections occur in the following areas:
 * Northeastern states, from Virginia to Maine
 * North-central states, mostly in Wisconsin and Minnesota
 * West Coast, particularly northern California


 * Important facts about tick bites and Lyme disease
 * In most cases, a tick must be attached to your body for 24 - 36 hours to spread the bacteria to your blood.
 * Blacklegged ticks can be so small that they are almost impossible to see. Many people with Lyme disease never even saw a tick on their body.
 * Most people who are bitten by a tick do not get Lyme disease.

Who is at highest risk?

 * people who spend a lot of time outside in wooded areas
 * people with outdoor occupations
 * people who live in the Northwest and Midwest USA (ex. Oregon and Washington)
 * Working outside with bare or exposed skin
 * 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.)

When to seek urgent medical care?
Call your health care provider if you have:
 * A large, red, expanding rash that may look like a bull's eye
 * Had a tick bite and develop weakness, numbness, or tingling, or heart problems
 * Symptoms of Lyme disease, especially if you may have been exposed to ticks

Diagnosis
Lyme disease is diagnosed based on symptoms, objective physical findings (such as erythema migrans, facial palsy, or arthritis), and a history of possible exposure to infected ticks. Validated laboratory tests can be very helpful but are not generally recommended when a patient has erythema migrans. For detailed recommendations on serologic testing, click here. When making a diagnosis of Lyme disease, health care providers should consider other diseases that may cause similar illness. Not all patients with Lyme disease will develop the characteristic bulls-eye rash, and many may not recall a tick bite. Laboratory testing is not recommended for persons who do not have symptoms of Lyme disease.

Laboratory Testing
Several forms of laboratory testing for Lyme disease are available, some of which have not been adequately validated. Most recommended tests are blood tests that measure antibodies made in response to the infection. These tests may be falsely negative in patients with early disease, but they are quite reliable for diagnosing later stages of disease. CDC recommends a two-step process when testing blood for evidence of Lyme disease. Both steps can be done using the same blood sample. 1) The first step uses an ELISA or IFA test. These tests are designed to be very "sensitive," meaning that almost everyone with Lyme disease, and some people who don't have Lyme disease, will test positive. If the ELISA or IFA is negative, it is highly unlikely that the person has Lyme disease, and no further testing is recommended.  If the ELISA or IFA is positive or indeterminate (sometimes called "equivocal"), a second step should be performed to confirm the results. 2) The second step uses a Western blot test. Used appropriately, this test is designed to be "specific," meaning that it will usually be positive only if a person has been truly infected. If the Western blot is negative, it suggests that the first test was a false positive, which can occur for several reasons. Sometimes two types of Western blot are performed, "IgM" and "IgG." Patients who are positive by IgM but not IgG should have the test repeated a few weeks later if they remain ill. If they are still positive only by IgM and have been ill longer than one month, this is likely a false positive. CDC does not recommend testing blood by Western blot without first testing it by ELISA or IFA. Doing so increases the potential for false positive results. Such results may lead to patients being treated for Lyme disease when they don't have it and not getting appropriate treatment for the true cause of their illness. For detailed recommendations for test performance and interpretation of serologic tests for Lyme disease, click here.

Other Types of Laboratory Testing
Some laboratories offer Lyme disease testing using assays whose accuracy and clinical usefulness have not been adequately established. These tests include urine antigen tests, immunofluorescent staining for cell wall-deficient forms of Borrelia burgdorferi, and lymphocyte transformation tests. In general, CDC does not recommend these tests. Click here for more information. Patients are encouraged to ask their physicians whether their testing for Lyme disease was performed using validated methods and whether results were interpreted using appropriate guidelines.

Testing Ticks
Patients who have removed a tick often wonder if they should have it tested. In general, the identification and testing of individual ticks is not useful for deciding if a person should get antibiotics following a tick bite. Nevertheless, some state or local health departments offer tick identification and testing as a community service or for research purposes. Check with your health department; the phone number is usually found in the government pages of the telephone book.

Treatment options
The National Institutes of Health (NIH) has funded several studies on the treatment of Lyme disease. These studies have shown that most patients can be cured with a few weeks of antibiotics taken by mouth. Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or cefuroxime axetil. Patients with certain neurological or cardiac forms of illness may require intravenous treatment with drugs such as ceftriaxone or penicillin. Studies of women infected during pregnancy have found that there are no negative effects on the fetus if the mother receives appropriate antibiotic treatment for her Lyme disease. In general, treatment for pregnant women is similar to that for non-pregnant persons, although certain antibiotics are not used because they may affect the fetus. If in doubt, discuss treatment options with your health care provider.

Where to find medical care for Lyme disease?
Directions to Hospitals Treating Lyme disease

What to expect (Outlook/Prognosis)?
If diagnosed in the early stages, Lyme disease can be cured with antibiotics. Without treatment, complications involving the joints, heart, and nervous system can occur. However, these symptoms are still treatable.

Rarely, a person will continue having symptoms that can interfere with daily life even after they have been treated with antibiotics. Some people call this post-Lyme disease syndrome. The cause is unknown.

Possible complications
Stage 3, or late disseminated, 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 disorders
 * Nerve damage
 * Numbness
 * Pain
 * Paralysis of the face muscles
 * Sleep disorders
 * Vision problems

Diseases with similar symptoms

 * Babesiosis
 * Human granulocytic anaplasmosis (HGA)
 * Leptospirosis
 * Tick-borne diseases
 * Allergic Reaction to the Tick
 * Other Insect Bites
 * Systemic lupus erythematosus (SLE)
 * Rheumatoid arthritis
 * Reiter syndrome
 * Scleroderma
 * Mononucleosis
 * Chronic fatigue syndrome (CFS)
 * Fibromyalgia
 * Depression
 * Viral meningitis

Protect Yourself from Tick Bites

 * Know where to expect ticks. Ticks live in moist and humid environments, particularly in or near wooded or grassy areas. You may come into contact with ticks during outdoor activities around your home or when walking through vegetation such as leaf litter or shrubs. Always walk in the center of trails, in order to avoid ticks.
 * Use a repellent with DEET (on skin or clothing) or permethrin (on clothing) and wear long sleeves, long pants and socks. Products containing permethrin can be used to treat boots, clothing and camping gear which can remain protective through several washings. Repellents containing 20% or more DEET (N, N-diethyl-m-toluamide) can be applied to the skin, and they can protect up to several hours. Always follow product instructions! Parents should apply this product to their children, avoiding the hands, eyes, and mouth.
 * Wear light-colored clothing, which allows you to see ticks crawling on your clothing.
 * Tuck your pant legs into your socks so that ticks cannot crawl up inside of your pant legs. Some ticks can crawl down into shoes and are small enough to crawl through most socks. When traveling in areas with lone star ticks (which are associated with Southern tick-associated rash illness, ehrlichiosis, and possibly Rocky Mountain spotted fever) you should examine your feet and ankles to ensure that ticks are not attached.

Perform Daily Tick Checks

 * Check your body for ticks after being outdoors, even in your own yard. Conduct a body check upon return from potentially tick-infested areas by searching your entire body for ticks. Use a hand-held or full-length mirror to view all parts of your body and remove any tick you find.
 * Check your children for ticks, especially in the hair, when returning from potentially tick-infested areas. See the list above for the places on your child's body to check for ticks. Remove any tick you find on your child's body.
 * Check your clothing and pets for ticks. Ticks may be carried into the house on clothing and pets. Both should be examined carefully, and any ticks that are found should be removed. Placing clothes into a dryer on high heat effectively kills ticks.

Reduce Ticks In Your Yard

 * Modify your landscape to create Tick-Safe Zones. To do this, keep play areas and playground equipment away from shrubs, bushes, and other vegetation. Also, regularly remove leaf litter and clear tall grasses and brush around homes, and place wood chips or gravel between lawns and wooded areas to keep ticks away from recreational areas.
 * Provide a vegetation-free play area. Keep play areas and playground equipment away from away from shrubs, bushes, and other vegetation.
 * Use a chemical control agent. Effective tick control chemicals are available for use by the homeowner, or they can be applied by a professional pest control expert, and even limited applications can greatly reduce the number of ticks. A single springtime application of acaricide can reduce the population of ticks that cause Lyme disease by 68–100%.
 * Discourage deer. Removing plants that attract deer and constructing physical barriers may help discourage deer from entering your yard and bringing ticks with them.