Early Localized Lyme Disease
Early localized Lyme disease usually presents as an acute illness characterized by:
- 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:
- 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
If I Take Antibiotics To Prevent Lyme And Then Have A Negative Test Am I Lyme
If you do receive prophylactic treatment, be cautious in in interpreting the results of subsequent testing. Widely-used blood tests look for antibodies to Borrelia burgdorferi, but early treatment can prevent the body from mounting an antibody response. Should you become infected despite prophylactic treatment, subsequent tests results couldbe falsely negative.
Trial Design And Study Characteristics
Table summarizes the study design of the four randomized, double-blind, placebo-controlled trials included for analysis. All four trials were conducted in areas where Lyme disease is endemic and all trials enrolled patients with an Ixodes scapularis tick bite within the preceding 72 h. In all four trials, the blinding of patients was performed by giving them identical-appearing tablets, capsules or liquid suspensions. The success of patient blinding was assessed in only one study. In all four trials, physicians were reported to be blinded to the treatment allocation. However, no trial reported how physician blinding was assessed. Two trials assessed patient compliance: the first measured patient compliance by assessing the antimicrobial activity of patient urine and the other asked subjects to swallow the single-dose regimen under direct observation by study personnel.
All of the four clinical trials used the development of erythema migrans or symptoms of extracutaneous Lyme disease as their primary outcome for statistical analysis. All trials measured serum antibodies against B. burgdorferiat presentation and upon follow-up. Only two trials, confirmed equivocal or positive results with immunoblot assays.
Dosage, duration and types of antibiotics tested varied among trials. In three trials, a 10 day course of treatment was administered. In the other trial, subjects were given two 100 mg capsules of doxycycline as a single dose.
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How Can Ld Be Prevented
Physicians should be aware of the epidemiology of tick-borne LD in their area, and recommend some basic precautions for families living, hiking or camping in rural or wooded areas where they may be exposed to ticks.
- Where play spaces adjoin wooded areas, landscaping can reduce contact with ticks. A pictogram from the Centers for Disease Control and Prevention is available at: www.cdc.gov/lyme/prev/in_the_yard.html
- Apply 20% to 30% DEET or icaridin repellents. Repellents can be applied to clothing as well as to exposed skin. Always read and follow label directions.
- Do a full body check every day for ticks. Promptly remove ticks found on yourself, children and pets. Shower or bathe within two hours of being outdoors to wash off unattached ticks.
For more information on how to prevent tick bites, refer to a recent practice point from the Canadian Paediatric Society at: www.cps.ca/en/documents/position/preventing-mosquito-and-tick-bites.
Awareness Of Lyme Disease
1.1.1 Be aware that:
the bacteria that cause Lyme disease are transmitted by the bite of an infected tick
ticks are mainly found in grassy and wooded areas, including urban gardens and parks
tick bites may not always be noticed
infected ticks are found throughout the UK and Ireland, and although some areas appear to have a higher prevalence of infected ticks, prevalence data are incomplete
particularly high-risk areas are the South of England and Scottish Highlands but infection can occur in many areas
Lyme disease may be more prevalent in parts of central, eastern and northern Europe and parts of Asia, the US and Canada.
1.1.2 Be aware that most tick bites do not transmit Lyme disease and that prompt, correct removal of the tick reduces the risk of transmission.
1.1.3 Give people advice about:
where ticks are commonly found
the importance of prompt, correct tick removal and how to do this
covering exposed skin and using insect repellents that protect against ticks
how to check themselves and their children for ticks on the skin
sources of information on Lyme disease, such as Public Health England’s resources and guidance on Lyme disease and organisations providing information and support, such as patient charities.
For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on awareness of Lyme disease.
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Key Points for Practice
Prophylaxis for Lyme disease is most beneficial for high-risk bites, which include those from an Ixodes tick in an endemic area that was attached for at least 36 hours.
Antibiotic treatment is recommended for classic erythema migrans or a possible Lyme presentation with positive serum antibody testing.
Routine testing for Lyme disease is not beneficial in psychiatric disorders, behavior disorders, or chronic cardiomyopathy.
From the AFP Editors
Lyme disease, a tick-borne spirochete infection caused by Borrelia burgdorferi, is most common in three regions in the United Statesthe northeastern states from Virginia to Maine the upper Midwest, especially Wisconsin and Minnesota and northern California. A multidisciplinary panel representing the Infectious Diseases Society of America , the American Academy of Neurology , and the American College of Rheumatology has published recommendations on the prevention, diagnosis, and treatment of Lyme disease.
Should I Call My Doctor Right Away Or Wait To See If I Develop Symptoms
ILADS recommends immediately contacting your health care provider. There are steps you can take to prevent a Lyme infection, as explained below. The onset of Lyme disease symptoms can be overlooked or mistaken for other illnesses. Once symptoms are more evident, the disease may have already entered the central nervous system, and could be hard to cure. Immediate care may prevent this from happening.
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If Bitten By A Tick Should I Consider Immediate Antibiotics To Prevent Lyme Disease
ILADS recommends that prophylaxis be discussed with all who have had a blacklegged tick bite.An appropriate course of antibiotics has been shown to prevent the onset of infection.
When the decision is made to use antibiotic prophylaxis, ILADS recommends 20 days of doxycycline . The decision to treat a blacklegged tick bite with antibiotics often depends on where in the country the bite occurred, whether there was evidence that the tick had begun feeding, and the age of the person who was bitten. Based on the available evidence, and provided that it is safe to do so, ILADS recommends a 20-day course of doxycycline.
Patients should also know that although doxycycline can prevent cases of Lyme disease, ticks in some areas carry multiple pathogens, some of which, including Babesia, Powassan virus, and Bartonella, are not responsive to doxycycline. This means a person could contract a tick-borne illness despite receiving antibiotic prophylaxis for their known tick bite.
ILADS recommends against single-dose doxycycline. Some doctors prescribe a single 200 mg dose of doxycycline for a known bite. However, as discussed in detail in the guidelines, this practice is based on a flawed study that has never been replicated. Read more in the ILADS treatment guidelines.
The bottom line: If you have been bitten by a blacklegged tick, you should discuss immediate antibiotic treatment with your provider as a possible course of action.
What You Should Know About Blacklegged Tick Bites
When it comes to Lyme and other tick-borne illness, prevention is the best form of medicine. When spending time in areas where ticks may be present, wear long sleeves and pants, tuck your pants into your socks, and wear tick repellent containing DEET, picaridin, IR3535, or oil of lemon eucalyptus. Pretreat outdoor clothing and gear with permethrin, an insecticide that kills ticks on contact. Clothing can be treated at home with sprays or dips that are effective for 2-6 weeks . Always check yourself for ticks after each potential exposure check pets, even those treated with tick repellents, after every trip outside. For more on tick bite prevention, see our Lyme brochure.
If you are bitten by a tick, here is information you should have.
The information below is for educational purposes only. It is not intended to replace or supersede patient care by a healthcare provider. If you suspect the presence of a tick-borne illness, you should consult a healthcare provider who is familiar with the diagnosis and treatment of tick-borne diseases.
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How Prevalent Is Ld In Canada
Black-legged tick populations are well established in parts of British Columbia, Manitoba, Ontario, Quebec, New Brunswick and Nova Scotia, and may be expanding. Migratory birds can bring infected ticks into nonendemic areas, and people may also become infected while travelling to other endemic areas in North America and Europe. In 2009, LD became a nationally reportable disease. The number of reported cases has increased from 128 in 2009 to an estimated 500 in 2013.
What Are The Clinical Manifestations Of Ld
Clinical manifestations are divided into early, localized disease, and later disease.
Early, localized disease: Erythema migrans a rash at the site of a recent tick bite is the most common presentation in children and adults . EM typically develops seven to 14 days after a tick bite. EM is usually > 5 cm and mainly flat. There may be central clearing or some bluish discoloration but a classic bulls eye is uncommon. EM is usually asymptomatic but is not painful to the touch, like a cellulitis. EM can be confused with a localized hypersensitivity reaction from a tick or insect bite, which is usually swollen, smaller in size and pruritic). There can be either a single erythema migrans rash or multiple rashes without extracutaneous manifestations. However, fever, malaise, headache, mild neck stiffness, myalgia and arthralgia often accompany EM.
Without treatment, EM resolves spontaneously over a four-week period, on average.
Later disease: Approximately 20% of children with LD first present to a health care provider with extracutaneous signs or symptoms that are compatible with LD. These cases may also have a recent past history of EM lesions and non-specific low-grade fever, myalgia, and fatigue upon questioning further.
Figure 4) Erythema migrans rash showing the classic bulls eye form. Reproduced from reference 1 © All rights reserved. With permission from the Minister of Health, 2014
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Are Prophylactic Oral Antibiotics Effective Against Lyme Disease
The use of antibiotics as a prophylactic was found to be effective against Lyme disease, according to results of a meta-analysis published in BMC Infectious Diseases.
Investigators searched PubMed, Embase, and the Cochrane Library for studies which enrolled patients who had no clinical evidence of Lyme disease 72 hours after receiving a tick bite and were assigned to either the intervention or control groups. Patients in the intervention groups received either a 10-day course of oral antibiotics, a single 200-mg dose of oral doxycycline, or topical antibiotic treatment with azithromycin. A random-effects model was used to calculate the pooled results and the risk ratio for rates of unfavorable events among patients in both groups.
Overall, the final analysis included 6 randomized controlled trials with a total of 3766 patients, of whom 56 had unfavorable events. Of note, only 1 event was disseminated Lyme disease while 55 were erythema migrans.
Among patients in the intervention groups, the pooled rate of unfavorable events was 0.4% vs 2.2% among those in the control groups. In addition, the pooled risk ratio was 0.38 .
Among patients included in the 5 studies that assessed the effects of oral prophylactic antibiotics, the pooled rate of unfavorable events among those in intervention and control groups was 0.2% and 2.5% , respectively, and the pooled risk ratio was 0.29 .
How Long Does A Tick Need To Be Embedded For It To Transmit Disease
The longer a tick is attached, the higher the risk of transmission. Although Lyme disease is not commonly transmitted when ticks are attached for less than 24 hours, the risk of Lyme disease posed by those bites is not zero. There may be other factors that contribute to disease transmission in short duration attachments. In addition, there are other disease-causing bacteria and viruses carried by blacklegged ticks that are known to be transmitted in less than 24 hours.
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Prevention Of Lyme Disease
The key to preventing Lyme disease is to avoid tick bites and prolonged tick attachment. Basic protection measures include avoiding risky areas, wearing long sleeves and pants, tucking pants into socks, and using clothing treated with permethrin. Unlike permethrin, many effective repellants are safe to apply to skin including N,N-diethyl- m-toluamide , picaridin, ethyl-3- aminopropionate , oil of lemon eucalyptus, p-methane-3,8-diol , and 2-undecanone.
Because spirochete transmission occurs after at least 36 hours of attachment, ticks should be removed promptly after discovery. After exposure to a tick habitat, thorough tick checks of exposed and intertriginous skin, bathing within two hours, and drying clothes for at least one hour on high heat can prevent disease. Ticks can be removed with tweezers and placed in a bag for later identification. To remove ticks, fine-tipped tweezers should be used to grasp the mouth parts as close to the skin as possible and steady traction applied directly away from the skin. Because B. burgdorferi in ticks does not predict infection in humans, testing ticks is not recommended.
When Is Antibiotic Prophylaxis Indicated In The Prevention Of Lyme Disease
Routine prophylaxis after a recognized tick bite is not recommended. A guideline from the Infectious Disease Society of America recommends prophylactic antibiotic therapy for adults and children older than 8 years, using a single 200-mg dose of doxycycline only if all of the following criteria are met :
The attached tick can be reliably recognized as a nymphal or adult Ixodes scapularis
The tick has been attached for at least 36 hours, as determined by the degree of engorgement of the tick or certainty about the time of exposure to the tick
Prophylaxis can be started within 72 hours of the time the tick was removed
The local rate of infection of these ticks with Borrelia burgdorferi is at least 20%
Doxycycline treatment is not contraindicated
The species of tick is important because non-Ixodes ticks , although they can contain the organism, are highly unlikely to cause disease. The one clinically relevant exception may be bites by Amblyomma americanum in the central and southern midwestern United States, but few data exist on treating these tick bites prophylactically.
Feder HM Jr. Lyme disease in children. Infect Dis Clin North Am. 2008 Jun. 22:315-26, vii. .
Centers for Disease Control and Prevention. Lyme Disease: Diagnosis and Testing. CDC. Available at . November 20, 2019 Accessed: March 30, 2021.
Edlow JA. Erythema migrans. Med Clin North Am. 2002 Mar. 86:239-60. .
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Q3 Should Patients With Persistent Manifestations Of Lyme Disease Be Retreated With Antibiotics
The panel placed a high value on reducing the morbidity associated with chronic Lyme disease and improving the patients QoL as well as on the need for individualized risk/benefit assessment and informed shared decision-making. The panel also placed a high value on the ability of the clinician to exercise clinical judgment. In the view of the panel, guidelines should not constrain the treating clinician from exercising clinical judgment in the absence of strong compelling evidence to the contrary.
Clinicians should discuss antibiotic retreatment with all patients who have persistent manifestations of Lyme disease. These discussions should provide patient-specific riskbenefit assessments for each treatment option and include information regarding C. difficile infection and the preventative effect of probiotics . .
Role of patient preferences
Low: The benefits of educating patients about the potential benefits of retreatment and the risks associated with various treatment options, including not treating, clearly outweigh any attendant risks associated with education.
Treatment options are extensive and choices must be individualized. Each of these options would benefit from further study followed by a GRADE assessment of the evidence and consideration of associated risks and benefits, but until this information is available, clinicians may act on the currently available evidence.
Role of patient preferences
Notes On Serological Tests
For patients with illness lasting over a month, only IgG testing should be performed . A positive IgM test alone is not sufficient to diagnose current disease in these patients.
Due to antibody persistence, a positive serological test cannot distinguish between active and past infection.
- should not be done as a test of cure
- cannot be used to measure treatment response
The EIA test:
- may yield false-positive results when used as a stand-alone test
- may cross-react with antibodies to commensal or pathogenic spirochetes
- there may be some viral infections for certain autoimmune diseases
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