Diagnosis And Management Of Lyme Disease
WILLIAM F. WRIGHT, DO, MPH DAVID J. RIEDEL, MD ROHIT TALWANI, MD and BRUCE L. GILLIAM, MD, University of Maryland, Baltimore, Maryland
Am Fam Physician. 2012 Jun 1 85:1086-1093.
Patient information: See related handout on Lyme disease, written by the authors of this article.
Lyme disease is the most common tick-borne illness in the United States. It is caused by the bacterium Borrelia burgdorferi, and is transmitted primarily by the deer tick . Following its discovery in children and adults in Lyme, Conn., in 1977,1 its incidence has increased steadily in the United States.2
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Erythema migrans rash following a tick bite is the only clinical manifestation sufficient to make the diagnosis of Lyme disease in the absence of laboratory confirmation.
A = consistent, good-quality patient-oriented evidence B = inconsistent or limited-quality patient-oriented evidence C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to .
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Erythema migrans rash following a tick bite is the only clinical manifestation sufficient to make the diagnosis of Lyme disease in the absence of laboratory confirmation.
Complications Of Untreated Lyme Disease
If unchecked, the Lyme disease infection can spread to other bodily systems, causing significant damage. Untreated, complications of this condition can be very severe:
- Arthritis:Prolonged infection with Lyme disease leads to chronic joint inflammation and swelling, usually in the knees . These symptoms tend to arise within two years of infection, with periods of flare-ups and remissions. This arthritis is relatively difficult to manage, though antibiotics and steroids may be attempted.
- Lyme carditis:If the bacteria reach the heart tissues, they can cause inflammation and lead to heart block. The electrical signals being sent between the upper and lower chambers of the heart are interrupted, impairing the coordination of the heartbeat. Though disruptive, this is rarely fatal.
- Lyme neuroborreliosis:Inflammation of multiple nerves, including those in the spine and brain, is the chief characteristic of this condition. This can also affect the meningesthe layer of tissue surrounding the brain and spineleading to meningitis, among other conditions. Antibiotic therapy, if applied promptly, tends to be effective as a treatment.
Even in cases where Lyme disease has progressed, antibiotic regimensespecially drugs like doxycyclineare generally successful in resolving problems.
What Are The Second Stage Signs And Symptoms Of Lyme Disease
The symptoms of second stage, early disseminated, Lyme disease can be difficult to attribute. Symptoms include severe fatigue, fever, pain, intermittent weakness and achiness of the muscles and joints, numbness in arms and legs, vision changes, and cognitive dysfunction such as short-term memory difficulties and problems multitasking. These symptoms are not specific for Lyme disease and can make the diagnosis of second stage Lyme disease very challenging.
More recognizable Lyme disease nervous system manifestations include facial paralysis , or meningitis with severe headache and stiff neck. Notable cardiac manifestations include passing out or feeling faint from an abnormally slow heart rate, irregular heart palpitations, or unexplained difficulty tolerating exercise. Meningitis and carditis are both potentially serious Lyme disease conditions and warrant immediate medical attention.
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Lyme Disease: Symptoms Diagnosis And Treatment
Lyme disease is the most common disease transmitted by ticks in the United States with an estimated 300,000 people infected each year. It can cause symptoms including headache, fever, fatigue, and a characteristic bullseye skin rash. Promisingly, most cases of Lyme disease can be treated effectively with antibiotics, especially when caught early.
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How Can I Tell If Treatment Is Working
If joint lameness is the presenting sign, improvement may be noted after 3-5 days starting antibiotics. A dog’s response to therapy can be assessed by repeating the QC6 test six months after treatment is complete. Dogs that start with a moderate to high QC6 value typically show a 50% reduction or more in the QC6 at six months, indicating that treatment has been successful. Dogs that have a lower initial QC6 value may not show such dramatic reductions in the QC6 at six months, although the value should still be lower than the starting point if treatment has been successful.
A persistently high QC6 suggests treatment may not have been complete or that the dog became reinfected after treatment was stopped.
What Are Signs And Symptoms Of The Third Stage Of Lyme Disease
Late stage Lyme disease can result when treatment is unsuccessful or started too late due to unrecognized symptoms or misdiagnosis. The late disseminated stage occurs months or years after initial infection and can have a major impact on a patients health and quality of life. Late Lyme arthritis is a third stage Lyme disease manifestation that involves fluid accumulation and pain in joints, particularly in the knee joints. Late neurologic disease is a 3rd stage condition that can also be debilitating and difficult to diagnose. Late disseminated Lyme disease symptoms include a variety of symptoms that are often neurologic in origin including: numbness in extremities, mental fogginess and concentration problems, and difficulty following conversations or processing information.
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How Do Patients Test Negative For Lyme Disease In Ireland But Test Positive For Lyme Disease In Another Country
Laboratories in Ireland generally follow the laboratory testing recommendations of the US Centres for Disease Control and Prevention , the Infectious Disease Society of America , the European Federation of Neurological Societies and the British Infection Association .
The antibody tests used in Ireland are made by commercial companies and meet strict quality criteria. Irish laboratories have their own quality assurance methods to make sure the tests are working correctly as well as being accredited by the Irish National Accreditation Body to perform the test correctly.
Testing which is performed abroad may be performed in laboratories which have not met National or International Accreditation . In some cases they may use tests which are made in the laboratory rather than purchased from commercial companies. These tests may not have the same or consistent levels of quality as commercial tests which must meet specific European criteria called CE marking. These tests may be more likely to give a false positive result for those reasons.
Some laboratories abroad do not use antibody tests like the EIA and western blot and instead will use other types of tests. For example, testing for levels of a specific white blood cell or lymphocyte transformation tests . These types of tests are not currently recommended by international groups such as the CDC, IDSA or BIA for a number of reasons:
Hhs Federal Research Updates On Lyme Disease Diagnostics
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The Blood Tests Can Have False Positives
The blood tests can trigger false positives, suggesting that you have the disease when you really dont. This can happen in up to one out of four tests.
This can lead to unnecessary treatment with antibiotics. These drugs are usually safe, but they sometimes cause side effects, such as nausea, vomiting, diarrhea, and increased sensitivity of the skin to sunlight. In rare cases, they can even cause dangerous allergic reactions.
Using too many antibiotics can also lead to the growth of drug-resistant bacteria. This means that bacteria in your body may get stronger and more difficult to treat with antibiotics in the future.
A false positive can also lead to more unneeded blood tests, urine tests, X-rays, and doctor visits.
If you have a false positive, you may not get treated for the real cause of your pain. For example, rheumatoid arthritis is a disease that causes joint pain. It can lead to permanent and severe joint damage if you do not start taking the right medicines as early as possible.
Early Localized Lyme Disease
Early localized Lyme disease usually presents as an acute illness characterized by:
- fever
- headache
- the presence of a single, localized skin lesion known as erythema migrans
Not all patients will present with an EM. Therefore, diagnosis should not be based solely on the presence of EM.
Most patients will present with EMs within 7 days of the initial tick bite. However, the incubation period can vary between 3 and 30 days.
The skin lesion is characteristically an annular erythematous lesion greater than 5 cm in diameter that:
- slowly increases in size
- is usually painless and non-pruritic
The lesion sometimes develops central clearing, but it can be more homogenously erythematous. In dark-skinned patients, the rash may appear more as a bruise.
Variations of an EM are highly suggestive of Lyme disease and can take the following forms:
- blistering
- blue-purple hues
- a bull’s-eye appearance
A skin lesion called erythema migrans can develop into a bull’s-eye at the site of a tick bite. It is shown here on a patient’s upper arm.Footnote 1
A typical sign of early non-disseminated Lyme disease is an expanding rash called erythema migrans. This can take on the appearance of a bull’s eye.Footnote 1
Some Lyme disease skin lesions are uniformly red and do not appear with the classic ring.Footnote 1
Some patients present with a central blistering lesion, commonly mistaken as a spider bite. This is likely due to an inflammatory reaction to the pathogen induced by the tick.Footnote 1
- fatigue
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What Do The Results Mean
The Centers for Disease Control and Prevention recommends a two-test process of your sample:
- If your first test result is negative for Lyme disease, you don’t need any more testing.
- If your first result is positive for Lyme disease, your blood will get a second test.
- If both results are positive for Lyme disease and you also have symptoms of infection, you probably have Lyme disease.
Positive results don’t always mean a Lyme disease diagnosis. In some cases, you can have a positive result but not have an infection. Positive results may also mean you have an autoimmune disease, such as lupus or rheumatoid arthritis.
If your lumbar puncture results are positive, it may mean you have Lyme disease, but you might need more tests to confirm a diagnosis.
If your health care provider thinks you have Lyme disease, he or she will prescribe antibiotic treatment. Most people who are treated with antibiotics in the early stage of disease will make a complete recovery.
Can I Be Assured That The Type Of Lyme Disease Testing Carried Out In Ireland Is Accurate
Yes. Irish laboratories operate to a very high standard of quality. Laboratories in Ireland follow the testing guidelines of the US Centres for Disease Control and prevention , Infectious Disease Society of America , European Federation of Neurological Societies and British Infection Association . These guidelines provide information on which of the currently available laboratory tests have enough evidence to accurately diagnose Lyme disease.
It is important that patients who are concerned about Lyme disease seek help and receive a firm diagnosis in Ireland to ensure continued medical care. It is important to ensure that your symptoms and lab results are considered together to make sure your diagnosis is as correct as possible.
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If My Dog Tests Positive Does He Need To Be Treated
The decision to treat Lyme disease is somewhat controversial since many infected dogs show no signs of illness. Factors that would support treatment include:
a moderate to high value of QC6 signs of illness compatible with Lyme disease at the time of testing a history of illness compatible with Lyme disease within the past year the presence of abnormal levels of protein in the urine.
How Are Dogs Tested For Lyme Disease
Diagnosis is made by a combination of history, physical signs, and diagnostics. For dogs, the two blood tests for diagnosing Lyme disease are called the C6 Test and Quant C6 test. Veterinarians perform both.
The C6 test detects antibodies against a protein called C6. Presence of the antibodies suggests an active Lyme infection. The C6 antibodies can be detected three to five weeks after an infected tick bites a dog and may be found in the bloodstream even before the dog shows signs of illness.
The next step is to do a Quant C6 test. This, along with urinalysis will help determine if antibiotic treatment is necessary.
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Who’s At Risk And Where Are Ticks Found
The risk of getting Lyme disease is higher:
- for people who spend time in woodland or moorland areas
- from March to October because more people take part in outdoor activities
Ticks are found throughout the UK and in other parts of Europe and North America. There are a high number of ticks in the Scottish Highlands.
It’s thought only a small proportion of ticks carry the bacteria that cause Lyme disease. Being bitten doesn’t mean you’ll definitely be infected. However, it’s important to be aware of the risk and speak to a GP if you start to feel unwell.
Late Lyme Disease Symptoms
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If I Am Worried About Lyme Disease Who Can I Talk To
Lyme disease is being increasingly recognised as causing illness and hardship, if the diagnosis is missed. Over the last number of years, there has been a marked increase in awareness of the condition among GPs and hospital doctors in Ireland. Each of the HSEs Hospital Groups have a number of Infectious Disease Consultants who are expert in the diagnosis and management of Lyme disease. If you have been bitten by a tick or have other reasons to strongly suspect you may have Lyme disease, you should visit your GP for advice.
Canadian Public Health Laboratory Network Recommendations
The appearance of a typical EM rash occurring in season and with a history of exposure to ticks should be considered an indication for antibiotic treatment, irrespective of the results of serological testing.
An EM-like rash occurring out of season and/or after exposition in a Lyme nonendemic area where ticks are not known to be established should be investigated with antibody testing.
Initial negative serological tests in patients with skin lesions suggestive of EM should have testing repeated after four weeks.
Patients with symptoms and signs suggestive of early disseminated or late Lyme disease should be tested for antibodies to B burgdorferi.
Initial testing should include an EIA commercially available and approved for use in Canada.
Sera that are positive or indeterminate by an EIA should be subjected to Western blot confirmatory testing.
Sera that are screened negative for antibodies using an EIA should not be subjected to Western blot testing.
Western blot tests should be interpreted using criteria set forth by the CDC Working Group.
Western blot tests that fail to meet all of the criteria set out by the CDC Working Group should be reported as negative testing may be repeated when it is appropriate to do so.
The specific banding patterns seen on Western blots should not be reported.
Culturing for B burgdorferi is a low-yield procedure and is not encouraged if performed, it should be done only on biopsies from EM lesions and synovial or spinal fluid.
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Achy Stiff Or Swollen Joints
Joint pain and stiffness, often intermittent, are early Lyme symptoms. Your joints may be inflamed, warm to the touch, painful, and swollen. You may have stiffness and limited range of motion in some joints .
Pain may move around. Sometimes your knees may hurt, whereas other times its your neck or your heels. You may also have bursitis . Bursae are the thin cushions between bone and surrounding tissue.
The pain may be severe, and it may be transitory. More than one joint may be affected. Most often the large joints are involved .
People often attribute joint problems to age, genetics, or sports. Lyme should be added to that list, as these statistics indicate:
- One study estimates that 80 percent of people with untreated Lyme have muscle and joint symptoms .
- Fifty percent of people with untreated Lyme have intermittent episodes of arthritis .
- Two-thirds of people have their first episode of joint pain within six months of the infection .
- Use of anti-inflammatory drugs may mask the actual number of people with joint swelling .
Summary:
Joint pain that comes and goes, or moves from joint to joint, could be a sign of Lyme.
