Lyme Disease Diagnosis

  • Diagnosis

    Lyme disease is a bacterial infection that causes a rash and flu symptoms, and can affect the joints, heart, and nervous system Figure 01. Lyme disease was first recognized in 1975 after a cluster of arthritis cases appeared in rural communities surrounding Lyme, Connecticut. Cases have now been diagnosed throughout the US and Europe, with particular concentrations in New England and the Middle Atlantic states, Wisconsin, Minnesota, and coastal and wooded areas of California and Oregon.

    Click to enlarge: Distribution of Lyme Disease Cases in the United States

    Figure 01. Distribution of Lyme Disease Cases in the United States

    Lyme disease can usually be cured with antibiotics, especially in the early stages. A vaccine is also available, and is recommended for people who live in areas endemic for Lyme disease, and who spend time out of doors in woody or grassy environments.

    Lyme disease is transmitted from bacteria carried by ticks Figure 02. Lyme disease is caused by Borrelia burgdorferi, the spiral-shaped bacteria that are carried by Ixodes ticks. Humans can be infected when bitten by infected Ixodes ticks, which are associated with white-tailed deer and the white-footed mouse.

    Click to enlarge: Deer Ticks

    Figure 02. Deer Ticks

    Lyme disease starts with flulike symptoms and a circular rash at the site of the tick bite Table 01 Figure 03. A red, circular rash (erythema migrans) develops anywhere from 1 to 30 days after the tick bite (most commonly within 7 to 10 days). While redness, pain, and swelling may develop within hours at the site of any insect bite or sting, erythema migrans (EM) will appear around the bite as an expanding red, painless area with a central clearing. Sometimes the rash will appear as multiple concentric rings, as in a bull’s-eye pattern. About 10% of patients with EM will have multiple lesions that occur when B. burgdorferi spreads from a single tick bite. Although bites can appear anywhere, particularly common sites include the groin, thighs, and armpits, presumably because ticks prefer warm, moist areas. Some people experience flulike symptoms (fever, fatigue, malaise, headache, and muscle and joint aches) without a rash, and others have neither a rash nor other symptoms. If a rash appears, however, it will generally clear within a few weeks to a month, even without treatment.

    Click to enlarge: Lyme Disease Rash

    Figure 03. Lyme Disease Rash

    Other common viral symptoms, including rhinitis and upset stomach, are relatively uncommon in Lyme disease. If you experience these symptoms, or have severe fever or fatigue, your doctor will likely suspect that you have something other than Lyme disease.

    You may experience joint pain and stiffness if your disease progresses without treatment. More than half of untreated patients with Lyme disease experience joint pain and stiffness. Usually one or two joints are affected at a time, the knee being the most common site, followed by the shoulder, ankle, elbow, and hip. Simultaneous involvement of many joints, or involvement of small joints is unusual, and should prompt investigation into other arthritic disorders. Initially, joint discomfort may be transitory, coming and going within hours or days. After months of infection, more typical symptoms of arthritis occur, with swelling, redness, and pain in the affected joint that may last for months.

    Without treatment, a number of neurological symptoms can develop. Some patients have no symptoms, despite evidence in the spinal fluid of the bacteria that cause Lyme disease. Others develop typical symptoms of meningitis, which include headache, stiff neck, and light avoidance. Nerve inflammation can manifest as facial muscle paralysis, often with just one side affected, causing a distorted appearance and drooling, or as pain or paralysis in the arms or legs. Seizures, eye inflammation, emotional changes, depression, and poor memory and concentration can also develop. Children tend to develop irregular, jerky movements of the arms, legs, or face. Neurological symptoms usually resolve within a few months.

    Temporary heart symptoms occur in up to 10% of patients with untreated Lyme disease. Heart symptoms manifest as abnormal rhythms, which may be noticeable as palpitations, or as confusion, fatigue, dizziness, or fainting. Sometimes patients are not aware of symptoms, but have detectable changes on their EKG. Cardiac problems tend to resolve within weeks.

    People with Lyme disease may develop chronic disease, which is characterized by continuing joint problems and, less commonly, neurological deficits. Lyme disease can continue to cause intermittent joint pain and swelling. As in the earlier stage, usually one weight-bearing joint such as the knee or hip is affected at a time. This chronic arthritis can be severe, with breakdown of cartilage and bone, and sometimes requires removing the lining of the joint (synovectomy) to relieve the pain.

    Neurological changes can also persist, with memory and concentration deficits, sleep disturbances, fatigue, and personality changes. Specific nerve disorders may also persist, causing partial paralysis in affected muscles.

    Sometimes musculoskeletal problems become chronic, even after Lyme disease treatment has been apparently successful. It is sometimes difficult to determine whether problems that persist despite adequate antibiotic therapy should be attributed to persisting Lyme disease, or to other conditions. Lyme disease has symptoms similar to those of chronic fatigue syndrome, including chronic pain, headache, fatigue, joint stiffness, and sleep disturbances. All are difficult to diagnose with certainty. Fibromyalgia, which can occur after Lyme disease, is also characterized by similar symptoms.

    Table 1.  Symptoms of Lyme Disease

    Early localized stage Early disseminated stage Late stage
    Redness around the bite with central clearing (EM)HeadacheFeverMalaiseAchy joints and muscles Multiple EMTransitory joint painHeadacheStiff neckPhotophobiaParalysis of muscles in face, arms, or legsSeizuresMoodinessMemory and concentration deficitsHeart rhythm changesDizzinessFaintingConfusionFatigue Swelling and pain in jointsMemory and concentration deficits Personality changesInsomnia and fatiguePartial or transitory paralysis in various muscles

    People who spend time in natural settings in endemic areas have the greatest risk of acquiring Lyme disease. People who live or work in areas surrounded by woods or overgrown brush, and those who visit natural areas for recreational purposes are at greatest risk for acquiring Lyme disease.

    Lyme disease persists with greater frequency in localized regions throughout the United States, Europe, the former Soviet Union, South Africa, Australia, and Asia. In 1996, more than 90% of reported cases of Lyme disease in the U.S. were from Connecticut, Rhode Island, New York, New Jersey, Delaware, Pennsylvania, Maryland, and Wisconsin. In each state, high-risk areas are usually concentrated in specific localities. Focal endemic areas also exist in Europe, the former Soviet Union, South Africa, Australia, Japan, Korea, and China.

    Being outside during warm-weather months increases your risk of acquiring Lyme disease. In the U.S., ticks thrive during the warm-weather months of April through September (except in the western U.S., where the high-risk season is January through May). Ticks favor the moist, shaded environment provided in leaf litter or low-lying vegetation in wooded, brushy, or overgrown grassy habitats.

    Lyme disease is most easily diagnosed if the characteristic rash appears after a known tick exposure. Your doctor will look for a characteristic rash of at least 5 cm, especially if you know that you were exposed to a tick. Unfortunately, sometimes the rash does not appear, or may pass unnoticed.

    Laboratory tests can be helpful in confirming a diagnosis. It may be necessary for a doctor to examine bacteria from your rash to make a diagnosis. Unfortunately, making a definitive diagnosis in this way is problematic in later stages after the rash has cleared, or for those who never develop a rash.

    General blood tests can help to help make a diagnosis. Common blood tests used to detect antibodies against B. burgdorferi include enzyme-linked immunosorbent assay (ELISA), or an indirect fluorescent antibody test. A positive or ambiguous result from either of these tests will require another verifying blood test called a Western blot. These tests do not determine whether or not you have an active infection, but merely determine if your immune system has ever come in contact with B. burgdorferi.

    Sometimes it takes time for the body to launch an immune response large enough to be detected by these tests. If this is the case, early blood tests may come back falsely negative.

    Avoid tick habitat in endemic areas, and take special precautions when outdoors Table 02. Avoid entering areas of low-lying vegetation in wooded, brushy, or overgrown grassy habitat in regions where Lyme disease is known to occur (especially in spring or summer). People who live in such areas should clear their property of leaf litter, brush, and woodpiles where ticks are apt to hide.

    Dress appropriately when visiting natural areas. Wear long sleeves with tight cuffs, tuck your shirt into your pants, and tuck your pants into your boots or socks to decrease ticks’ access to the skin. Also, wear light-colored fabrics to make it easier to spot a tick on yourself.

    Spray your skin or clothes with tick repellant Table 02. Repellants containing diethyltoluamide (DEET) may be applied to the skin. They must, however, be applied sparingly to infants, children, and pregnant women because of potential toxic effects such as blistering, and in some cases, neurologic side effects. Wash the repellant off with soap and water after returning indoors. Repellents containing permethrin should only be applied to clothing.

    After being outdoors, inspect yourself for ticks. Adult ticks that transmit Lyme disease are not much larger than a pinhead. Biting ticks in the nymphal stage are even smaller. They tend to hide in protected areas, such as the scalp, groin, or armpits.

    If you find a tick, remove it properly Table 02. Take a shower, and use a washcloth to dislodge unattached ticks from your skin (it takes several hours for the tick to attach once it lands on the skin).

    If you find an attached tick, try to grasp its head with fine tweezers, and remove the entire tick without crushing it. Wash the affected area and your hands afterwards. If there are parts of the mouth remaining in the skin, leave them alone, disinfect the skin, and wait for the parts to be expelled naturally.

    You may wish to save the tick in a sealed container and bring it to your local health department for identification.

    A vaccine is available for individuals between the ages of 15 to 70 who are at high risk. A safe and effective vaccine has been approved for people between 15 and 70 years of age. It is recommended for those who are considered to be at high risk for infection; for example, for individuals in endemic regions who live, work, or enjoy recreational activities in wooded, brushy, or grassy areas. The vaccine should not, however, be used if you have had a previous bout with Lyme disease accompanied by chronic joint or neurological problems, or for those who have had cardiac manifestations that required hospitalization. It is also not recommended for pregnant women, persons with immunodeficiency, or those with musculoskeletal disease such as arthritis.

    The vaccine is administered in three doses: the second dose is given one month after the initial dose, and the third is given 12 months after the first dose (a “0, 1, 12” protocol). More recent evidence suggests that giving the last dose after 6 months (“0, 1, 6”), or even after only two months (“0, 1, 2”), may be equally effective. Timing should be planned such that the second and third doses are administered several weeks before the beginning of tick season in both years.

    The vaccine, however, is only about 80% effective against Lyme disease, and offers no protection against other tick-borne illnesses. Therefore, precautions still need to be taken against tick exposure, even if you have been vaccinated.

    Because the vaccine is new, its longevity is still unknown. Experts will probably recommend booster doses as more data become available.

    Table 2.  Preventing Tick Bites When Outside

    Avoid wooded, grassy, or overgrown areas
    Clear outdoor areas of woodpiles, brush, and leafpiles, where ticks may live
    Wear long sleeves with tight cuffs
    Tuck your shirt into your pants
    Tuck your pant legs into your socks or boots
    Wear light-colored clothing
    Spray yourself with tick repellant (sparingly with children and pregnant women)
    Inspect yourself for ticks after a day outdoors
    Remove any ticks you find on yourself with a tweezer, pulling at the head
    Get a Lyme disease vaccine if you are at high risk, and between the ages of 15 and 70
  • Prevention and Screening

    Avoid tick habitat in endemic areas, and take special precautions when outdoors Table 02. Avoid entering areas of low-lying vegetation in wooded, brushy, or overgrown grassy habitat in regions where Lyme disease is known to occur (especially in spring or summer). People who live in such areas should clear their property of leaf litter, brush, and woodpiles where ticks are apt to hide.

    Dress appropriately when visiting natural areas. Wear long sleeves with tight cuffs, tuck your shirt into your pants, and tuck your pants into your boots or socks to decrease ticks’ access to the skin. Also, wear light-colored fabrics to make it easier to spot a tick on yourself.

    Spray your skin or clothes with tick repellant Table 02. Repellants containing diethyltoluamide (DEET) may be applied to the skin. They must, however, be applied sparingly to infants, children, and pregnant women because of potential toxic effects such as blistering, and in some cases, neurologic side effects. Wash the repellant off with soap and water after returning indoors. Repellents containing permethrin should only be applied to clothing.

    After being outdoors, inspect yourself for ticks. Adult ticks that transmit Lyme disease are not much larger than a pinhead. Biting ticks in the nymphal stage are even smaller. They tend to hide in protected areas, such as the scalp, groin, or armpits.

    If you find a tick, remove it properly Table 02. Take a shower, and use a washcloth to dislodge unattached ticks from your skin (it takes several hours for the tick to attach once it lands on the skin).

    If you find an attached tick, try to grasp its head with fine tweezers, and remove the entire tick without crushing it. Wash the affected area and your hands afterwards. If there are parts of the mouth remaining in the skin, leave them alone, disinfect the skin, and wait for the parts to be expelled naturally.

    You may wish to save the tick in a sealed container and bring it to your local health department for identification.

    A vaccine is available for individuals between the ages of 15 to 70 who are at high risk. A safe and effective vaccine has been approved for people between 15 and 70 years of age. It is recommended for those who are considered to be at high risk for infection; for example, for individuals in endemic regions who live, work, or enjoy recreational activities in wooded, brushy, or grassy areas. The vaccine should not, however, be used if you have had a previous bout with Lyme disease accompanied by chronic joint or neurological problems, or for those who have had cardiac manifestations that required hospitalization. It is also not recommended for pregnant women, persons with immunodeficiency, or those with musculoskeletal disease such as arthritis.

    The vaccine is administered in three doses: the second dose is given one month after the initial dose, and the third is given 12 months after the first dose (a “0, 1, 12” protocol). More recent evidence suggests that giving the last dose after 6 months (“0, 1, 6”), or even after only two months (“0, 1, 2”), may be equally effective. Timing should be planned such that the second and third doses are administered several weeks before the beginning of tick season in both years.

    The vaccine, however, is only about 80% effective against Lyme disease, and offers no protection against other tick-borne illnesses. Therefore, precautions still need to be taken against tick exposure, even if you have been vaccinated.

    Because the vaccine is new, its longevity is still unknown. Experts will probably recommend booster doses as more data become available.

    Table 2.  Preventing Tick Bites When Outside

    Avoid wooded, grassy, or overgrown areas
    Clear outdoor areas of woodpiles, brush, and leafpiles, where ticks may live
    Wear long sleeves with tight cuffs
    Tuck your shirt into your pants
    Tuck your pant legs into your socks or boots
    Wear light-colored clothing
    Spray yourself with tick repellant (sparingly with children and pregnant women)
    Inspect yourself for ticks after a day outdoors
    Remove any ticks you find on yourself with a tweezer, pulling at the head
    Get a Lyme disease vaccine if you are at high risk, and between the ages of 15 and 70

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