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Lyme Disease

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Appendix E: Decontamination Procedures
Appendix F: Glossary


Table of Contents

Trauma Pictures

After reviewing the following article, be sure to visit our Trauma section to view our pictures of a Lyme Disease Rash.

Introduction

Lyme Disease is one of only a few tick-transmitted infectious agents. Lyme Disease has received a lot of attention over the last 10-15 years, and was first recognized in 1975 in Lyme, Connecticut. Other tick-borne illnesses that are very similar to Lyme Disease include Babesiosis and Ehrlichiosis. In 1996, there were approximately 16,000 cases reported, in approximately 45 states. This is most likely an underreported number, and this number is likely to increase over the years as more cases are reported. This is in part due to greater media attention regarding Lyme Disease.

Areas with the highest incidence of Lyme Disease include Connecticut, Rhode Island, New Jersey, Delaware, New York State, Pennsylvania, Maryland, and there is an area in northwest Wisconsin which also has a fairly high incidence of Lyme Disease.

The lifecycle of a tick is approximately two years, and includes three blood meals in the spring. The adult female tick releases her eggs, which hatch six-legged larvae during the summer, and the larvae stage lasts approximately two days. They enter a dormant phase in the fall weather. The ticks molt in the spring, and they enter their second phase as an eight-legged nymph, which is approximately the size of a numeral of the year on a penny. They also take a blood meal, which lasts 2-3 days, and then they molt. In the fall, you have the adult tick. Hence you have the lifecycle of the tick.

Lyme disease has been detected in 45 states. Survive Outdoors has had one case of Lyme Disease from Jackson County in Southern Illinois. Please refer to pictures of the typical Lyme Disease rash on the Survive Outdoors website. The Lyme Disease rash is called erythema migrans. This rash is usually around 5 cm. or greater in diameter. The rash in the photo measures approximately 7 cm., has the typical bulls eye appearance with a central clearing pale area in the middle, surrounded by a pale to bright red rash. This area may or may not be itchy or tender to touch. Only about 70% of individuals who do have Lyme Disease actually experience the rash. Allergic reactions can also be confused with erythema migrans. Only about 70% of all Lyme Disease cases will have the rash.

A common myth is that when a tick bites, it burrows underneath the skin. When a tick bites, the head of the tick is just barely under the epidermis, and the rest of the tick’s body extrudes out of the skin. It has been studied that a female and a nymph tick usually has to be attached greater than 72 hours, greater than 3 days at which point they were much more likely to induce Lyme Disease than a tick attached less than 72 hours. The nymph tick is primarily the culprit in inducing Lyme Disease. This may be in part because the nymph tick is so tiny, and cannot be detected until they have already transmitted Lyme Disease.

Recent Lyme statistical reports

There were 17 reported cases of Lyme disease in Illinois in 1999. There has been a slow increase since 1996. In 1996 there were 10 reported cases, in 1997 13 cases, 1998 14 cases, and in 1999 17 cases. This is actually down from 1990, where there were 30 cases reported in Illinois. The decline may be due to individuals utilizing proper precautions, public awareness of Lyme disease, as well as awareness of the symptomatology to look for.

Lyme Disease Symptoms

Lyme Disease can be divided into 3 stages

  1. The first stage is the early stage, and this is the stage that the Lyme rash, or the erythema migrans is most typically seen. It takes approximately 7-10 days after the tick bites for this rash to appear. It can occur as long as 28-30 days later. At this time you can also experience swollen lymph nodes. Fever is usually low-grade, around 102-103 degrees, and the fever is more common in children than adults. After 3-4 weeks, the rash does fade without any treatment. If antibiotics are given, the rash resolves much more quickly.
    IT IS VERY IMPORTANT NOT TO PANIC IF YOU HAVE A RASH, AND YOU HAVE BEEN IN THE OUTDOORS. Please go to the photo section on Survive Outdoors, and you will see common allergic reactions from tick bites which are not the Lyme Disease rash.
  2. Stage 2 usually occurs within weeks after infection. About 50% of patients will encounter numerous rashes throughout the body that are similar to the erythema migrans. Sometimes there is blistering that occurs. Fever, swollen lymph nodes, and nausea and vomiting may occur, as well as an enlarged spleen. Severe headaches are not uncommon. Some dizziness, as well as emotional changes, perhaps insomnia, may occur, as well as muscle aches and pains, and joint pain. During this phase, it is not uncommon for Lyme Disease to be confused with a generalized virus. Heart problems develop in only about 4-7% of patients with untreated Lyme, and the onset of that usually ranges from 3-21 weeks. In approximately 60% of untreated individuals with Lyme Disease, arthritis develops after approximately 4 weeks, and can be delayed up to 2 years. It is very common to have pain and enlarged joints. This may be one, or multiple joints. In this stage, antibiotics have been successfully used in treatment.
  3. The late stage, Stage 3, usually begins a year or more later, after the Lyme rash has first appeared. Chronic arthritis is common in about half of the patients. Although rare, strokes, seizures, and severe dementia may occur. This phase can persist for many years, even decades.

Lyme Disease Treatment

Healthcare Provider - Medical Treatment
With Lyme disease, it is important to ascertain some important historical information before implementing treatment.

  1. It is helpful to know where this person acquired the tick, what geographic range. Certain areas are more endemic to Lyme than others.
  2. It has been shown that although a Lyme infected tick can transmit Lyme in less than 72 hours, it is much more likely that the individual could contract Lyme disease if the tick has been attached for 72 hours or greater. I always ask the patient if they have any idea now long the tick has been attached before removing it. That does sway me towards treatment.
  3. Please be advised that after being bitten by a tick, red areas is not necessarily Erythema Migrans. Many individuals have hypersensitive reactions to the tick bite. A healthcare provider needs to be aware of the difference.

Labs
One should note that the IgM antibody titers usually peak around the 4th to 6th week after the onset of illness. If there was early treatment by another healthcare provider or yourself prior to this, this could suppress antibodies. It is also important to note that IgM and IGG antibodies can persist for quite a few years.

Treatment
For this website, we will target early localized disease. For late disseminated neurological and arthritic conditions, as well as carditis from Lyme disease, we will refer you to Wilderness Medicine by Paul Auerbach, since this is beyond the scope of Survive Outdoors.

Treatment for early, isolated Lyme disease as recommended by Dr. Auerbach, go with Tetracycline, 250 mg., 4x/day for 14-28 days, Doxycycline, 100 mg. 2x/day for 14-28 days, Amoxicillin, 500 mg., 3x/day for 14-28 days, Cefuroxime, 500 mg., 3x/day for 14-28 days. For children, they recommend Amoxicillin, 50 mg./kilo 3x/day for 14-28 days. However, this author has seen recommendations of going up to 80 mg./kilo. Over 8 years old, Doxycycline, 100 mg. bid for 14-28 days, Erythromycin, 30-50 mg./kilo qid 14-28 days. It is important to note that Zithromax has also been recommended by Sanford. It is not the optimal treatment. However, if you have a pregnant female who is allergic to Amoxicillin, this may be one of the routes you may want to go, and prescribe Zithromax.

It has been recommended and shown to be clinically appropriate if in an endemic area and the tick has been on for 72 hours, it is recommended to prescribe Doxycycline, 200 mg., one dose, and has been shown to be beneficial for prophylaxis, if caught early enough. This is somewhat controversial. Some clinicians do not recommend the prophylactic dose, and others do. Survive Outdoors will let you be the judge.




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