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Lyme Disease: a patient's guide.

An article written by Dr A G Baird.

Lyme disease is endemic in the South West of Scotland and is spread by ticks, which feed indiscriminately on mammalian blood. They feed on sheep, deer, cattle and humans as well as other mammals. High levels of positive serology have been discovered in Wigtownshire dairy farmers and the disease almost killed a patient in the Garrick hospital who remained undiagnosed by no less than 3 major hospitals, including an internationally acclaimed neurological unit. His survival and later complete recovery depended on a lucky combination of circumstances of which the most significant was his GP taking a simple blood test.

Diagnosis
Lyme disease diagnosis is based on the patient's symptoms (signs of illness), history, and blood test results. There are three stages of Lyme disease: early, early disseminated and late Lyme disease.

Symptoms-First Stage
Early Lyme disease usually causes one or more of the following symptoms that occur days to weeks after infection:

  • Fatigue
  • Chills and fever
  • Headache
  • Muscle and joint pain
  • Swollen lymph nodes
  • Erythema migrans

Erythema migrans, the skin rash associated with Lyme disease, occurs as a circular rash that gradually spreads. It may appear anywhere from 1 day to 1 month after the infected tick's bite. It usually appears in about 7 days. The centre of the rash may clear as it grows, giving it the appearance of a bulls-eye. The rash may be warm, but is not usually painful. Sometimes, the rash includes many red patches that appear in different shapes and sizes around the body. The erythema migrans type of skin rash is different from a rash that appears as an allergic reaction to a tick or insect bite. Such reactions to a bite usually appear as redness within hours to 1 day after a bite, do not grow, and disappear within a day or two. Erythema migrans does not always occur in Lyme disease.

Symptoms-Second Stage
The second stage of Lyme disease occurs weeks to months after the bite of an infected tick. Problems can include:

  • Numbness and pain in arms or legs
  • Paralysis of facial muscles (usually on one side of the face)
  • Meningitis-fever, stiff neck, and severe headaches
  • Abnormal heart beat (rare)

Symptoms-Third Stage
The third stage of Lyme disease is called late (or chronic) Lyme disease. This stage can occur weeks, months, or even years after infection in patients who either never received antibiotic treatment for early Lyme disease or whose treatment did not kill all of the bacteria that cause Lyme disease. Patients with late Lyme disease may get:

  • Chronic Lyme arthritis-brief bouts of pain and swelling usually occurring in one or more of the large joints, especially the knees
  • Nervous system problems, including memory loss and difficulty concentrating
  • Chronic pain in muscles and/or unrestful sleep

History
A history of a known tick bite will help the doctor to know if Lyme disease caused the current symptoms. However, many people with Lyme disease do not remember being bitten by a tick. For example, nymph ticks, the most common transmitters of Lyme disease, are often about 2mm, or the size of a full stop.

Blood Tests
Blood tests cannot diagnose Lyme disease alone, but they may confirm a diagnosis. These anti-Borrelia burgdorferi antibodies may take up to 2 to 6 weeks after infection to appear in the blood. Therefore, a blood test immediately following a tick bite will not be able to determine whether or not a person has been infected since not enough time has passed for antibodies to develop.

Other bacterial infections and diseases may cause an ELISA to be positive when, in fact, the patient does not have Lyme disease. However, if symptoms and history strongly suggest Lyme disease, a doctor may begin treatment without blood test confirmation. Note that frequent testing without symptoms that suggest infection, even in endemic areas, increases the chance of a test result being positive when a person is not actually infected with Lyme disease.

Prevention
The best way to avoid Lyme disease is to avoid ticks. Most cases of Lyme disease occur in the spring and summer months, when ticks in the nymph stage are feeding. Symptoms tend to appear in spring and autumn. Avoiding areas where ticks live reduces the chance of infection.

While outdoors, a few simple precautions can reduce your chance of being bitten:

  • Wear long trousers and long-sleeved shirts.
  • Tuck your trousers into your socks .
  • Wear light-colored clothing (makes ticks more visible).
  • Check for ticks, (may look like nothing more than a new freckle or speck of dirt).
  • Using insect repellents helps to protect against Lyme disease. Follow label instructions carefully.

Lyme Disease in Pets
Household pets can get Lyme disease.

If You Are Bitten
Early removal of an attached tick is important because it reduces the risk of infection.

To remove a tick, use fine-tipped tweezers. Grasp the tick as close as possible to the skin and slowly pull it straight out. The mouth parts may stay attached, but do not be alarmed, as these will not cause Lyme disease. After removal, apply antiseptic or alcohol to the bite area. Do not apply mineral oil, Vaseline, heat, or other agents to remove the tick. These practices do not remove ticks and may actually increase your chance of infection by causing the tick to excrete bacteria.

If you remove a tick as soon as you find it, it is very likely that the tick did not transmit the bacteria Borrelia burgdorferi to you because it was not attached long enough for transmission to occur. Your doctor may suggest watching the bite and waiting to see if any symptoms occur instead of beginning treatment immediately. If you begin to develop symptoms or a rash at the site of a tick bite, contact your doctor within the next day or two.

References
Baird, A.G., et al., Prevalence of antibody indicating Lyme disease in farmers in Wigtownshire [published erratum appears in BMJ 1989 Nov 11;299(6709):1206] [see comments]. Bmj, 1989. 299(6703): p. 836-7.

Baird, A.G., et al., Lyme disease [letter; comment]. British Journal of General Practice, 1990. 40(333): p. 168.

Bourke, S.J., et al., Lyme disease with acute purulent meningitis [published erratum appears in BMJ 1988 Oct 15;297(6654):950]. Bmj, 1988. 297(6646): p. 460.