Skin Examinations And Ecgs
Thorough dermatological examination can clarify difficult cases. This happened in my clinic recently, when a nurse practitioner decided to run a full skin examination and discovered typical bulls-eye rashes on the patients back.
Once the diagnosis is suspected, cardiovascular symptoms such as dizziness, palpitations, fainting or near fainting, chest pain and shortness of breath should be investigated. If the patient reports any of these symptoms, along with any other factors suggesting Lyme disease, a 12-lead ECG should be performed.
Quite recently, a team from the United States did 12-lead ECG to a large series of pediatric patients presenting to the emergency department with high-suspicion of Lyme disease, and discovered that nearly 30 per cent of them had some conduction disturbance. Any evidence of electrical disturbance should prompt admission in hospital for a course of intravenous antibiotics while waiting the results of serological tests.
From the other perspective, any patient presenting with unexpected high-degree atrioventricular block , the way to test for Lyme carditis is by running a risk score called SILC , which was developed at Queens University and is now used worldwide.
SILC score is based on the risk factor acronym COSTAR , which may help in determining the likelihood of early Lyme carditis.
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.
How Lyme Carditis Affects The Heart
Lyme carditis most commonly manifests as high-degree atrioventricular block: a complete shut-down of the electrical system of the heart that can evolve rapidly over minutes, hours or days, producing severe symptoms like fainting, extreme dizziness or sudden death.
- sinus node disease, marked by alterations to the hearts motor or natural pacemaker,
- atrial fibrillation, which is a disorganization of the cardiac rhythm that increases the risk of stroke,
- bundle branch blocks, or lesions in the distal cables of the heart that can interrupt electrical impulses, and
- myocarditis, pericarditis or endocarditis, which are different degrees of inflammation of the layers of the cardiac walls.
Some of these manifestations can be so severe that total cardiac dysfunction may rapidly occur, and the patient may die despite medical efforts. Sometimes a heart transplant is the only option.
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What Are The Symptoms Of Lyme Disease
Symptoms can start anywhere from 3 to 30 days after the bite. They may look different depending on the stage of your infection. In some cases, you wonât notice any symptoms until months after the bite.
Early symptoms include:
All of those symptoms are also common in the flu. In most Lyme infections, one of the first symptoms youâll notice is a rash.
Without treatment, symptoms can get worse. They might include:
- Severe headache or neck stiffness
- Rashes on other areas of your body
- Arthritis with joint pain and swelling, particularly in your knees
- âDroopingâ on one or both sides of your face
- Inflammation in your brain and spinal cord
- Shooting pains, numbness, or tingling in your hands or feet
What does the rash look like?
Some Lyme rashes look like a bull’s-eye with circles around the middle. But most are round, red, and at least 2 inches across.
The rash slowly gets bigger over several days. It can grow to about 12 inches across. It may feel warm to the touch, but itâs usually not itchy or painful. It can show up on any part of your body.
How small are ticks?
Ticks come in three sizes, depending on their life stage. They can be the size of a grain of sand, a poppy seed, or an apple seed.
Key Points For Healthcare Providers
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How To Avoid Tick Bites
To reduce the chance of being bitten:
- cover your skin while walking outdoors and tuck your trousers into your socks
- use insect repellent on your clothes and skin products containing DEET are best
- stay on clear paths whenever possible
- wear light-coloured clothing so ticks are easier to see and brush off
Lyme Sci: 12 Ways You Can Help Yourself Manage Chronic Pain
Chronic paindefined as ongoing pain that continues for longer than six monthsis a common complaint of patients with persistent Lyme disease.
The CDC estimates that 20% of Americanscurrently live with chronic pain. Estimates range from 10% to 36% of Lyme patients who are diagnosed and treated early are left with chronic symptoms.
For the past 40 years, the medical definition of chronic pain was more narrowly defined, including only those patients with actual or potential tissue damage.
Recently, with the help of researchers at Johns Hopkins Medicine, the International Association for the Study of Pain has made a subtle but important change to the medical definition of pain.
The new definition, An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damages, is important as it includes the pain caused by an overstimulated nervous system, commonly associated with chronic pain.
This new more inclusive definition, if adopted by insurance providers, could have a positive impact on access to health care for disempowered and neglected populations.
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What Happens At Your Appointment
The GP will ask about your symptoms and consider any rash or recent tick bites you know about.
Lyme disease can be difficult to diagnose. It has similar symptoms to other conditions and there’s not always an obvious rash.
2 types of blood test are available to help confirm or rule out Lyme disease. But these tests are not always accurate in the early stages of the disease.
You may need to be retested if you still have Lyme disease symptoms after a negative result.
When Lyme Disease Enters The Picture
Like many other Lyme experts and patients, Dr. Bill Rawls, Medical Director of Vital Plan, believes many more than one in 10 people with Lyme disease may have some degree of heart issues. The symptomatology can vary from person to person, and exist on a spectrum of mild to severe.
The likely bacterial and viral culprits causing cardiovascular symptoms include Borrelia , Bartonella, Mycoplasma, cytomegalovirus , and probably many others. These stealth microbes enter the body and spread throughout the tissues by various mechanisms. They have one goal: Survival, notes Dr. Rawls. And they migrate or set up camp anywhere they can in the body, including the heart.
Theres a growing body of evidence showing that we have microbes throughout our body and brain, including on heart valves, says Dr. Rawls. Often, I think these microbes are present without causing harm. They stay dormant in tissues until a disruption in the immune system occurs and depresses it, allowing the microbes to flourish.
When stealth pathogens thrive, they can alter the electrical signaling to the heart, affecting the heartbeat or causing irritation to the heart itself.
Additionally, an abnormal heart rate isnt the only way microbes can affect the heart. As the pathogens disseminate throughout the organ and further irritate the heart muscle, the heart can become oxygen-deprived, leading to angina , heart attack, shortness of breath, and more.
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What Is Lyme Disease
Lyme disease is a bacterial infection. You get it when the blacklegged tick, also known as a deer tick, bites you and stays attached for 36 to 48 hours. If you remove the tick within 48 hours, you probably wonât get infected.
When you do get infected, the bacteria travel through your bloodstream and affect various tissues in your body. If you donât treat Lyme disease early on, it can turn into an inflammatory condition that affects multiple systems, starting with your skin, joints, and nervous system and moving to organs later on.
The chances you might get Lyme disease from a tick bite depend on the kind of tick, where you were when it bit you, and how long the tick was attached to you. Youâre most likely to get Lyme disease if you live in the Northeastern United States. The upper Midwest is also a hot spot. But the disease now affects people in all 50 states and the District of Columbia.
How Do We Approach The Patient With Chronic Lyme Disease
A lot of confusion surrounds the diagnosis of Chronic Lyme Disease. When we say Chronic Lyme Disease we do not mean untreated Lyme with progression to late disseminated disease, or undiagnosed Lyme with chronic arthritis or neurological manifestations. Rather, CLD is one of two broad categories:
- Physical manifestations of the disease after successful treatment. More correctly this diagnosis should be Post-Lyme syndrome . PLS defined by fatigue, weakness, arthralgias and other symptoms of Lyme for a prolonged period after successful treatment with antibiotics. In fact, many patients require 12-24 months for all symptoms to clear. This period may even longer for those with disseminated disease.
- Vague complaints in a patient with no true diagnosis of Lyme. The patient may have positive PCR testing but is likely false positive or positive due to a previous Lyme infection. Alternatively, he or she may have had negative PCR results but he or she may still believe that Lyme is responsible. Both of these patient groups have an alternative diagnosis causing their symptoms.
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Lyme Disease Vs Rheumatoid Arthritis
Lyme disease can sometimes be confused for other conditions, and its not uncommon for patients presenting with Lyme disease-related joint pain to be misdiagnosed with rheumatoid arthritis . Both Lyme and RA cause joint pain and can be debilitating when left untreated, but there are differences.
- Lyme arthritis tends to manifest in larger joints , on one side of the body. Lyme joint pain tends to come and go.
- Rheumatoid arthritis occurs more often in the hands, feet, fingers, and toes, and shows up on both sides of the body. RA joint pain and stiffness occurs every day, and is usually chronic.
- Lyme disease usually goes away when treated, and most patients make a full recovery.
- Rheumatoid arthritis treatment can manage symptoms and show the progression of the disease, but there is no cure.
Lyme pain can often migrate throughout the body, and patients may have pain in their knee one week, and in their wrists the following week, says Chicago-based integrative medicine specialist Casey Kelley, MD. With rheumatoid arthritis, the pain often stays where it begins and does not migrate.
Getting Lyme puts you at greater risk for later developing RA and other types of inflammatory arthritis. One study found that nearly one-third of participants who had Lyme-arthritis later developed an inflammatory arthritis.
Lyme disease symptoms typically begin 3-30 days after youve been bitten by a tick. Early symptoms of Lyme disease include:
- Bulls eye rash
Ongoing Symptoms Of Lyme Disease
A few people who are diagnosed and treated for Lyme disease continue to have symptoms, like tiredness, aches and loss of energy, that can last for years.
These symptoms are often compared to fibromyalgia and chronic fatigue syndrome.
It’s not clear why this happens to some people and not others. This means there’s also no agreed treatment.
Speak to a doctor if your symptoms come back, or do not improve, after treatment with antibiotics.
The doctor may be able to offer you further support if needed, such as:
- referral for a care needs assessment
- telling your employer, school or higher education institution that you require a gradual return to activities
- communicating with children and families’ social care
Page last reviewed: 05 July 2021 Next review due: 05 July 2024
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Signs That Lyme Is At Play In The Heart
For most people with Lyme disease and other chronic illnesses like fibromyalgia and chronic fatigue syndrome, we become accustomed to symptoms that fluctuate from one day to the next. Were so used to it, in fact, that we often adopt a wait-and-see approach to the newest symptom du jour.
But there are times when our bodies give us warning signs red-flag symptoms that we should get checked out as soon as possible, even if going to the doctor seems uneventful or inconvenient. The primary symptoms to seek medical attention for include irregular heartbeats that arent going away, persistent chest pain, or shortness of breath associated with exertion, says Dr. Rawls.
However, cardiac issues may not always be so apparent, because the symptoms can range from mild to more severe, or they can be easily confused with other causes. Other signs to be aware of include:
- Dizziness
- Pressure or tightness in the chest
- Pain radiating to the neck or down the arm
- Heart palpitations
- Fatigue
- Nausea or vomiting
Lets look at three conditions that can be caused when Lyme, coinfections, or other stealth pathogens affect the heart, including the most well-known one called Lyme carditis.
Advanced Lyme Disease Options
Hyperthermia utilizes your bodys temperature to fight infection. When you have fevers, that is when your body goes to work fighting off bacteria that can make you ill. Uncontrolled fevers can be risky if the temperature rises too high. However, controlled hyperthermia is medically supervised to help your body reach a high temperature slowly and boost your immune system.
Chelation is a detoxifying process that removes toxins from the body.
Oxygen therapies use extra oxygen as a medical process to treat over 100 diseases, including Lyme disease.
Apheresis can be used to replace your infected blood and plasma with clean, healthy, and usually donated blood and plasma.
Nutraceuticals are products created from foods and herbs that offer antioxidants, vitamins, and minerals that can help boost your immune system so you can fight off infections.
Biofilm eradication protocols, parasite inactivation, and immune modulation are additional treatments. You may even opt for IV therapies in which your doctor can give your immune system great strength by sending Vitamin C, Silver, and other antioxidant properties straight into your bloodstream.
The apheresis process is based on a simple theory: remove the bad, replace the bad with the good.
When treating neurologic Lyme disease, this means removing your infected blood and replacing it with donated, healthy blood that is free of infection.
Believe it or not, these processes can happen in just a few hours at your Lyme doctors office.
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The Pain Changes And Moves Around The Body
Another classic trait of Lyme disease is the migratory nature of the pain. The muscle and joint pain, as well as the tingling, numbness and burning sensations often tend to come and go and move around the body. For example, one day the joint pain might be in the knees and a few days later it may be affecting another nerve. Especially when untreated, research says Lyme disease can spread to the joints, heart, and nervous system.
When Should You See A Doctor If You Think You Have Lyme
The rash is a pretty good indication that you may have been bitten. Take a photo of the rash and see your doctor. At this stage, treatment with antibiotics will probably work.
If you don’t have the rash but have symptoms like fatigue, fever, and headache but no respiratory symptoms like a cough, you may want to talk to your doctor.
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Laughter Is The Best Medicine
Last but not least I do believe the key to happiness is laughter. Laughter reduces stress hormones like cortisol and releases endorphins, the bodys natural pain reliever. My simple advice is to avoid things that cause you stress, fear or anger.
Watch comedy or movies with happy endings. Stay connected with someone you can be honest with, one who listens and can make you laugh. Above all else, never give up hope.
LymeSci is written by Lonnie Marcum, a Licensed Physical Therapist and mother of a daughter with Lyme. In 2019-2020, she served on a subcommittee of the federal Tick-Borne Disease Working Group. Follow her on Twitter: Email her at: lmarcum@lymedisease.org .
Getting The Right Diagnosis
If you have Lyme disease, you must find a doctor specializing in successfully treating Lyme disease. General practitioners are limited in their knowledge about Lyme disease and the advanced diagnostic and treatment methods.
A Lyme literate doctor has other ways to test and confirm a Lyme disease diagnosis. They have the tools and equipment not only to test you but treat your symptoms in their office.
Most importantly, Lyme literate doctors can develop the right treatment plan with your input to ease your symptoms.
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If I Suspect Lyme Meningitis How Should I Tailor Ed Management And Antibiotic Choices
Management for Lyme meningitis in the ED is identical to management for any other suspected bacterial meningitis. Antibiotic therapy should not be delayed in order to obtain a lumbar puncture since a delay in antibiotic therapy leads to worse patient outcomes. Antibiotics should be ordered immediately while the LP is being performed. If Lyme is the causative agent for meningitis, the patient will already be covered appropriately if IDSA guidelines are followed for antibiotic choices. Every patient greater than one month old should receive either ceftriaxone or cefepime, either of which will adequately treat Borrelia burgdorferi.
Case 4:
32 -year-old male presents to the ED for shortness of breath and chest pain. He reports a recent illness after which he started to have chest pain and shortness of breath. He is bradycardic on examination and his EKG demonstrates a 2nd degree AV block.
