Health Information

Lyme disease and related tick-borne infections

Lyme disease and related tick-borne infections

Highlights

Causes

Lyme disease is caused by the bacterium Borrelia burgdorferi, which is transmitted through the bite of a blacklegged tick, also known as a deer tick.

Risk Factors

  • Anyone exposed to deer ticks is at risk for Lyme disease. These ticks thrive in grassy areas that have low sunlight and high humidity.
  • Nymph ticks are the main transmitters of Lyme disease. Their small size makes them harder to spot than adult ticks. Nymph ticks are most active during the spring and summer months. Consequently, the risk for acquiring Lyme disease tends to be higher during these seasons.
  • According to the latest statistics from the U.S. Centers for Disease Control and Prevention (CDC), 96% of Lyme disease cases occur in 13 states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Vermont, Virginia, and Wisconsin.

Prevention

  • Avoid tick-infested areas such as tall grass, woods, and bushes.
  • Wear long pants and long sleeves when you walk through these areas.
  • Wear light-colored clothes to make spotting ticks easier.
  • Use an insect repellent on your exposed skin and clothes, such as DEET or picaridin. Spray your clothes and not your skin if you are using permethrin.
  • Check for ticks when you return home. Removing infected ticks within 48 hours of attachment significantly reduces the risk of developing Lyme disease.

Symptoms

  • A bull's-eye rash (erythema migrans) is the most definitive sign of Lyme disease infection. This rash usually develops 1 - 2 weeks after a tick bite.
  • Other symptoms may accompany the rash, such as joint pain, fever, chills, or fatigue.
  • If Lyme disease is not treated, more severe symptoms and complications can occur. These include arthritis, neurologic symptoms, or heart problems.

Treatment

Most cases of Lyme disease can be prevented or cured with prompt antibiotic treatment. Because most tick bites do not result in Lyme disease, doctors do not recommend antibiotics for every tick bite. If a preventive antibiotic is needed, a single dose of doxycycline will suffice. To treat active disease, antibiotics are usually given for 2 - 4 weeks. Current guidelines do not recommend longer courses of antibiotic treatment for any stage or complication of Lyme disease.

Introduction

Lyme disease is the most commonly reported tick-borne disease in the United States. Lyme disease is caused by the bacterium Borrelia burgdorferi, which is transmitted through the bite of a blacklegged tick.

Borrelia Burgdorferi and White-Footed Mice

Borrelia (B.) burgdorferi is technically a spirochete, which is a bacteria-like organism. In the United States, B. burgdorferi commonly infects rodents and other small mammals, birds, snakes, lizards, and frogs. White-footed mice are the main reservoir for this Lyme disease-causing organism. In epidemiology terms, reservoir refers to the habitat where an infectious organism lives and multiplies.

Blacklegged (Ixodes) Ticks

Blacklegged ticks pick up B. burgdorferi when they bite and feed on an infected white-footed mouse or other animal. The spirochete lodges in the tick and is transmitted when the tick bites and feeds on a new host.

Ticks are the vectors for Lyme disease transmission. In epidemiology, a vector is an insect that carries the infectious organism from the reservoir and transmits it to a host (such as a human or deer). Hosts provide the blood meal for ticks. In the case of Lyme disease, white-footed mice are considered reservoir hosts since they function as both reservoir and host.

In the United States, there are two species of ticks associated with Lyme disease. In the U.S. Northeast and North Central states, it is the blacklegged tick, Ixodes scapularis, also known as the deer tick. In the U.S. Northwest states, it is the blacklegged tick Ixodes pacificus

The Cycle of Infection

The blacklegged tick has a 2-year life cycle in which it goes through three stages:

  • Larva Stage. In spring and summer of year one, larvae hatch from eggs. They take their first meal from a mouse, bird, or other small animal. This is when they can first pick up the B. burgdorferi spirochete but they do not transmit it at this stage. After feeding, the larvae become dormant for the fall and winter.
  • Nymph Stage. In spring and summer of year two, the nymph ticks wake up and begin to feed on wild animals (mice, chipmunks, and birds), domestic animals (dogs), or humans. Peak activity is usually from late May through July, although this can vary depending on climate. Most cases of Lyme disease are transmitted by nymphs.
  • Adult Stage. In the fall of year two, the nymphs become adults. Only the adult female takes a blood meal. For their third and final meal, female ticks seek a larger animal. After feeding, they mate with males, lay eggs, and then die. White-tailed deer are the main hosts (and transportation) for adult ticks. Female ticks feed on deer, while male ticks attach themselves to deer to wait for the females.

The nymph stage (May-July) is the most critical time for Lyme disease infection:

  • Nymph ticks are only about the size of a poppy seed. They are very difficult to spot and are estimated to be responsible for the majority of Lyme disease cases.
  • Adult ticks can be as large as a raisin after feeding, so they are easier to see. In addition, they usually prefer to dine on the blood of white-tailed deer rather than humans.
  • A tick can feed for several days while being embedded in the skin. After this time, it falls off. The tick's bite is painless. Only about half of people with Lyme disease recall being bitten.
  • Once a tick is attached, it takes about 36 – 48 hours for the spirochete to be transmitted to the host. If you can find and remove the tick while it is still attached but before it has become engorged with blood, you can reduce your risk for Lyme disease.

Lyme disease is only transmitted through ticks. You cannot catch Lyme disease from a person who has the condition. Lyme disease can also infect dogs (and cats), but it cannot be directly transmitted from a dog to a human, unless an infected tick crawls off a dog and bites a person.

Not all ticks are blacklegged ticks, and not all blacklegged ticks are infected. Most people who are bitten by a tick do not get Lyme disease. Still, Lyme disease and other tick-borne infections should not be taken lightly. It is important to take precautions to avoid tick bites.

Other Infections Carried by the Ixodes Tick

Human granulocytic anaplasmosis (HGA) and babesiosis are also transmitted by the deer tick Ixodes scapularis. Although HGA, babesiosis, and Lyme disease are borne by the same kind of tick, these infections are entirely different diseases.

Deer ticks can also transmit deer tick virus, a disease related to the deadly tick-borne Powassan virus. In very rare cases, deer tick virus, like Powassan virus, may cause serious brain infection (encephalitis).

New  tick-borne diseases, carried by Ixodes ticks as well as other tick species, continue to emerge.

Risk Factors

Lyme disease is the most commonly reported insect-borne illness in the United States. About 30,000 cases of Lyme disease are reported to the U.S. Centers for Disease Control and Prevention (CDC) each year. However, the CDC estimates that about 90% of cases go unreported. The total number of Americans diagnosed annually with Lyme disease is most likely closer to 300,000.

General Risk Factors

If you spend time outdoors in tick-infested areas, avoid wooded and bushy areas. Other factors that can increase your risk for tick bites include:

  • Exposed skin (don’t wear sandals, shorts, or short sleeved shirts)
  • Wearing dark-colored clothing (choose light-colored clothing so you can spot ticks more easily)
  • Not wearing insect repellant (DEET insect repellant is very effective against ticks)
  • Not doing tick checks (check your skin and clothes while outside, and do a complete body check for ticks when you come back inside)

Not every tick bite will cause Lyme disease. In general, there is only a small risk for developing Lyme disease after a blacklegged tick bite. The risk depends on several factors.

  • The longer the tick has fed, the greater the risk. It takes about 36 – 48 hours for an attached tick to transmit the Lyme disease organism to your blood.
  • Nymph ticks carry a greater risk than adult ticks, because they are often too small to be detected (about the size of a pinhead). Nymph ticks are active from May – July.
  • Only nymph ticks that are at least partially swollen when removed pose any significant risk. The swelling suggests that they have been feeding for a prolonged period.

Geographic Locations

Locations in the U.S. Lyme disease was named for a town in Connecticut where the first American cases of the disease were described. Lyme disease has been reported in nearly all U.S. states. However, nowadays 96% of Lyme disease cases are concentrated in 13 Northeastern and Midwestern states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Vermont, Virginia, and Wisconsin.

Worldwide Locations. Pockets of Lyme disease exist around the world. The disease is common in Europe, particularly in forested areas of middle Europe and Scandinavia. The Borrelia family is also responsible for tick infections in Europe but different subspecies (B. garinii and B. afzelii) are more common there and cause slightly different symptoms than the B. burgdorferi spirochete. The infection has also been reported in Russia, China, and Japan.

High-Risk Landscapes

Blacklegged ticks thrive in grassy areas that have low sunlight and high humidity. Woodlands and fields are prime habitats, but these ticks can also be found in the long grasses adjacent to beaches. The ticks are not confined to rural settings. In suburban areas, they can live in overgrown lawns, ground cover plants, and leaf litter.

Time of Year

The exact time of year for risk depends on a geographic region's seasons and how they affect the tick's breeding cycle. In general, the highest risk for contracting Lyme disease is from late May through July when nymph ticks are active. The lowest risk is from December through March.

Symptoms

Symptoms of Lyme disease are diverse, can vary from person to person, and can appear and disappear at different times. Symptoms tend to follow the course of Lyme disease, which typically occurs in three stages:

  • Stage 1 is called early localized Lyme disease. It occurs 3 – 30 days after the tick bite when the infection has not yet spread throughout the body.
  • Stage 2 is called early disseminated Lyme disease. It occurs weeks to months after the tick bite when the bacteria have begun to spread throughout the body.
  • Stage 3 is called late Lyme disease. It occurs months to years after the tick bite when the bacteria have spread throughout the body.

Early Localized Lyme Disease

In the majority of cases, the first sign of Lyme disease is the appearance of a bull's-eye skin rash called erythema migrans (EM). It usually develops about 1 - 2 weeks after the bite, but can appear as soon as 3 days or as late as 1 month after. In some cases, it is never detected. The rash is often accompanied by flu-like symptoms such as low-grade fever, headache,  fatigue, neck pain and stiffness, and body aches.

The bull's-eye skin rash is considered the classic sign of Lyme disease. It usually appears on the thigh, buttock, or trunk in older children and adults, and on the head or neck in younger children.

The bull's-eye rash may take the following course:

  • It can first appear as a pimple-like spot that expands over the next few days into a purplish circle. The circle may reach up to 6 inches in diameter with a deeper red rim. In some cases the ring is incomplete, forming an arc rather than a full circle.
  • The center of the rash often clears or may turn bluish. Or secondary concentric rings may develop within the original ring, creating the bull's-eye pattern. Over the next several weeks, the circular rash may grow to as large as 20 inches across
  • Patients often describe the sensation of the rash as burning rather than itching. On darker-skinned people, the rash may resemble a bruise. In most patients, the rash fades completely after 3 - 4 weeks. Secondary rashes may appear during the later stages of disease.

Early Disseminated Lyme Disease

If left untreated, the infection can spread through the bloodstream and lymph nodes within weeks to months where it may affect the joints, nervous system, or heart. Symptoms of early disseminated Lyme disease include:

  • Multiple small bull’s eye rashes on various parts of the body.
  • Severe fatigue
  • Flu-like symptoms
  • Joint pain
  • Numbness or nerve pain
  • Weakness or paralysis in the muscles of the face (Bell’s palsy)
  • Stiff and painful neck, which may be sign of Lyme meningitis
  • Heart problems (Lyme carditis); symptoms include light-headedness, heart palpitations, shortness of breath, chest pain, and fainting

Late Lyme Disease

If patients are not treated with antibiotics, infection can spread throughout the body. Symptoms of late Lyme disease can develop months or years after the initial infection and may include:

  • Joint pain and swelling (Lyme arthritis)
  • Nerve damage resulting in weakness, pain, numbness, and tingling in hands and feet (peripheral neuropathy)
  • Neurological problems (confusion, memory loss, difficulty concentrating, speech problems)

Post-Lyme Disease Syndrome

Lyme disease is a curable condition. Most patients improve after a short course of antibiotics. In rare cases, patients continue to complain of persistent non-specific symptoms, such as fatigue, muscle aches, cognitive problems, and headache lasting years after completing antibiotic treatment for the initial infection. This syndrome is referred to as post-Lyme disease syndrome, which can resemble fibromyalgia or chronic fatigue syndrome (CFS).

In the past, post-Lyme disease syndrome has been called “chronic Lyme disease.” However, based on many reviews of scientific literature, researchers and doctors strongly believe that Lyme disease does not have a chronic state. According to guidelines from the Infectious Diseases Association of America, post-Lyme disease syndrome is the preferred name for this condition.

Patients are considered to have this syndrome if they still have symptoms 6 months after treatment. There must also be definitive evidence that the patient was originally infected by the  B. burgdorferi spirochete. If there is no documented evidence of infection, it is likely that the patient never had Lyme disease and is experiencing a new or different type of illness. If the patient did have Lyme disease, symptoms should eventually resolve without additional antibiotic treatments. Antibiotics are not helpful for post-Lyme disease syndrome.

In some rare cases, patients may experience a new onset of symptoms after antibiotic treatment, such as the bull’s-eye rash. Research suggests that repeat symptoms are most likely caused by new infections, not relapses from a previous infection.

Complications

Prompt treatment with antibiotics is very effective in curing Lyme disease in nearly all people. While rare, untreated Lyme disease can spread through the body and lead to complications. People at highest risk for complications are those who go the longest without treatment.

Joint Complications (Lyme Arthritis)

Joint pain is common in all stages of Lyme disease. In early stages of Lyme disease, patients may experience migratory pain in joints, muscles, and tendons. In the later stages of the disease, arthritis may develop in one or two large joints such as the knee, elbow, shoulder, wrist, ankle, or hip. Knees are usually affected most.

Patients with Lyme arthritis usually experience sporadic episodes that last anywhere from a few weeks to several months. Fewer than 10% of patients develop chronic arthritis, which usually affects a single joint.

Lyme arthritis usually resolves with a month of antibiotic treatment. If it does not, doctors recommend several years of drug therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) or the anti-malaria drug hydroxychloroquine (Plaquenil, generic). Patients with difficult to treat cases should also seek the advice of a rheumatologist who has experience treating rheumatoid arthritis and similar conditions.

Neurologic Complications (Neuroborreliosis)

The medical term for neurological problems caused by the Borrelia burgdorferi organism is neuroborreliosis. These complications are associated with late Lyme disease.

Peripheral Nervous System. The nerves in the peripheral nervous system (PNS) provide the critical connection between the brain and spinal cord and its limbs and organs. Lyme disease causes various types of nerve damage (neuropathies):

  • Peripheral neuropathy is nerve damage that disrupts CNS signals to the limbs and other parts of the body. It includes numbness, weakness, pain, and tingling in the hands and feet.
  • Cranial neuropathy affects the facial muscles, which results in Bell's palsy. This is a sudden weakness and drooping of the facial muscles and eyelid on one side of the face. Affected nerves around the facial area may also cause numbness, dizziness, double vision, or hearing changes.
  • Radiculoneuropathy occurs when Lyme disease affects the nerve roots as they leave the spinal cord. Symptoms include stabbing or burning pains that shoot across the limbs or the torso. Muscle weakness can also occur.

Central Nervous System. Lyme disease complications in the central nervous system (CNS) are rare but very serious, since this area includes the brain and spinal cord:

  • Meningitis can occur if the infection spreads to the membranes that surround the brain and spinal cord (the meninges). Symptoms include severe headache, neck stiffness and pain, and sensitivity to light.
  • Encephalomyelitis is inflammation in the brain and spinal cord, which damages the protective sheath that covers nerve fibers (myelin). Symptoms include headache, confusion, and difficulty with words and speech, as well as muscle weakness. It may be misdiagnosed as multiple sclerosis.
  • Lyme encephalopathy refers to cognitive and memory problems. Symptoms include “brain fog,” problems with short-term memory, difficulty with word recall, slow thought processing, and general feelings of mental impairment.

Heart Complications (Lyme Carditis)

When Lyme disease infection spreads to the tissues of the heart it can cause inflammation (carditis). Lyme carditis interferes with the heart’s electrical conduction signals. The result is “heart block,” the stopping of the electrical impulses that keep the heart beating normally. Heart block can occur very suddenly, and can be fatal. Lyme carditis is one of the most serious complications of Lyme disease.

Other Organ Complications

If Lyme disease spreads throughout the body, it can affect other organs. Lyme disease may manifest as hepatitis (liver), hearing loss (ears), or keratitis (eyes).

Pregnancy and Lyme Disease

In rare cases, Lyme disease acquired during pregnancy can lead to infection of the placenta and possible miscarriage or stillbirth. Studies indicate that pregnant women infected with Lyme disease can safely be treated with antibiotics without endangering the fetus.

Diagnosis

Lyme disease is usually diagnosed based on symptoms and evidence of possible exposure to ticks. A diagnosis of Lyme disease is straightforward if the patient meets the following criteria.

  • Lives in a tick infested area
  • Has the tell-tale bull's-eye rash (erythema migrans)
  • Has other symptoms, such as headache, joint aches, malaise, or flu-like symptoms

If the patient meets these criteria, treatment is often started without confirming the diagnosis with laboratory tests.

Blood Tests for Antibodies

Blood tests for detecting antibodies to B. burgdorferi can give false negative results during the first few weeks of infection. During the early stages of disease, a doctor can identify a patient with Lyme disease based on the bull’s-eye rash and other criteria.

  • EIA or IFA Test. The first test used is either an enzyme immunoassay (EIA) or an indirect immunofluorescence assay (IFA). EIA is the immune test used most often for Lyme disease. (The IFA test is less accurate but may be used when EIA isn't available.) ELISA measures IgM and IgG antibodies to the B. burgdorferi spirochete. Positive results from any of these tests still require confirmation with a Western blot test. Negative results do not require further testing.
  • Western Blot. If the EIA or IFA test is positive or uncertain, it is followed by the Western blot test. This test is more accurate and is very helpful in confirming the diagnosis. The Western blot creates a visual graph showing bands of different colors or shading that laboratories use to interpret the immune response.

The CDC recommends only these tests. Other tests do not have enough scientific evidence to support their use.

If the patient does not have any symptoms of Lyme disease, these tests are not recommended. These tests should not be used to make a diagnosis of Lyme disease in patients who do not have obvious symptoms or findings of the disease. This is because both false positive and false negative results are common with these tests.

  • False positive results occur when the test suggests the presence of the disease, but the person does not actually have an active infection.
  • False negative results miss the actual presence of the disease. If the results are negative but Lyme disease is highly suspected, the doctor will probably prescribe antibiotics anyway.

Polymerase Chain Reaction (PCR) Test

The polymerase chain reaction (PCR) test detects the DNA of the bacteria that causes Lyme disease. It is sometimes used for select patients who have neurological symptoms or Lyme arthritis. The PCR test is performed on spinal fluid collected from a lumbar puncture (spinal tap) or synovial fluid (collected from an affected joint.). For most patients, standard blood antibody tests are preferred.

Ruling Out Other Diseases

Many other infections and medical conditions can produce fever, headache, muscle aches, fatigue, and some of the neurologic or cardiac features of early Lyme disease. Some are transmitted by the same tick as Lyme disease.

Co-Infections Transmitted by the Ixodes Tick. Babesiosis and human granulocytic anaplasmosis (HGA), as well as new emerging infections, are transmitted by the same tick that carries Lyme disease. People may be co-infected with one or more of these infections, all of which can cause flu-like symptoms. If these symptoms persist and there is no rash, it is less likely that Lyme disease is present.

Other Tick-Borne Infections. A number of other tick-borne diseases may resemble Lyme disease. The most important of these is southern tick-associated rash illness (STARI), which is caused by the bite of the Lone star tick. It causes a rash very similar to Lyme disease.

Allergic Reactions and Insect Bites. If a rash appears hours (rather than days) after a tick bite, it is most likely an allergic reaction to the tick, not a symptom of Lyme disease. An allergic rash may also be circular, like that from Lyme disease. In addition, not every rash seen in regions where Lyme disease is common is caused by a tick. The bites of many other insects such as spiders can cause a skin reaction, but they do not resemble the bull’s-eye rash of Lyme disease.

Other Diseases. Chronic fatigue and joint and muscle aches are common symptoms of post-Lyme disease syndrome. These symptoms can also be caused by other conditions, including mononucleosis, chronic fatigue syndrome, and fibromyalgia. Early neurologic symptoms of Lyme disease (headache, stiff neck, and fatigue) may be mistaken for viral meningitis.

Treatment

Antibiotics are the drugs used for treating all phases of Lyme disease. In nearly all cases they can cure Lyme disease, even in later stages.

Preventive Antibiotics After a Tick Bite

According to guidelines from the Infectious Diseases Society of America (IDSA), people bitten by deer ticks should not routinely receive antibiotics to prevent the disease.

A single dose of the antibiotic doxycycline may be given in situations that meet all of the following conditions.

  • The tick is still attached to the patient and is positively identified as a species of Ixodes tick that carries the Lyme disease B. burgdorferi spirochete.
  • Doxycycline treatment can be given within 72 hours of the tick bite.
  • There is proof that at least 20% of ticks in the patient's geographic area are infected with B. burgdorferi.
  • It is safe for the patient to receive doxycycline. (This drug should not be given to pregnant women or children younger than 8 years of age.)

In general, the risk of developing Lyme disease after being bitten by a tick is only 1 - 3%. However, patients who have removed attached ticks from themselves should inform their doctors. Patients who have been bitten by a tick should be monitored for up to 30 days to make sure they do not develop symptoms of Lyme disease, especially the bull’s-eye rash. If you do develop a skin lesion or flu-like symptoms during this time, be sure to tell your doctor.

Treating Early Stage Lyme Disease

The early stages of Lyme disease usually include the bull’s-eye rash (erythema migrans) and flu-like symptoms of chills and fever, fatigue, muscle pain, and headache. In rare cases, patients develop an abnormal heartbeat (Lyme carditis).

All of these conditions are treated with 10 - 28 days with antibiotics. The exact number of days depends on the drug used and the patient’s response to it. Antibiotics for treating Lyme disease generally include:

  • Doxycycline. This antibiotic is effective against both Lyme disease and human granulocytic anaplasmosis (HGA). It is the standard antibiotic for any patient over 8 years old, except for pregnant women. It is a form of tetracycline and can discolor teeth and inhibit bone growth. It can also cause birth defects if used during pregnancy.
  • Amoxicillin. This type of penicillin is the first and probably the best antibiotic for pregnant women. Unfortunately, many people are allergic to penicillin and strains of bacteria are emerging that are resistant to it.
  • Cefuroxime. This  cephalosporin antibiotic is known as Ceftin in its generic form. It is also an alternative treatment for young children and some adults.
  • Intravenous ceftriaxone or cefotaxime. Intravenous infusions of one of these cephalosporin antibiotics may be warranted if there are signs of infection in the central nervous system (the brain or spinal region) or heart.

Other types of antibiotics, such as macrolides, are not recommended for first-line therapy.

Side Effects of Antibiotics. The most common side effects of nearly all antibiotics are gastrointestinal problems, including cramps, nausea, vomiting, and diarrhea. Allergic reactions can also occur with all antibiotics, but are most common with medications derived from penicillin or sulfa. A reaction could be as minor as a mild skin rash, but could also be as severe or life-threatening as anaphylactic shock. Some drugs, including certain over-the-counter medications, interact with antibiotics. Patients should report to their doctors all medications they are taking.

Treating Late Stage Lyme Disease

Most cases of Lyme disease involve a rash and flu-like symptoms that resolve within 1 month of antibiotic treatment. However, some patients go on to develop late-stage Lyme disease, which includes Lyme arthritis and neurologic Lyme disease.

Slightly more than half of patients infected with B. burgdorferi develop Lyme arthritis. About 10 - 20 % of patients develop neurologic Lyme disease. A very small percentage of patients may develop acrodermatitis chronica atrophicans, a serious type of skin inflammation. These conditions are treated for up to 28 days with antibiotic therapy. If arthritis symptoms persist for several months, a second 2 - 4 week course of antibiotics may be recommended. Oral antibiotics (doxycycline, amoxicillin, or cefuroxime) are used for Lyme arthritis and acrodermatitis chronica atrophicans.

In rare cases, patients with arthritis may need intravenous antibiotics. A 2 - 4 week course of intravenous ceftriaxone is used for treating severe cases of neurological Lyme disease. For milder cases, 2 - 4 weeks of oral doxycycline is an effective option.

Treating Post-Lyme Disease Syndrome

In about 5% of cases, symptoms persist after treatment. This condition is referred to as post-Lyme disease syndrome. The treatment of post-Lyme disease syndrome is a controversial issue. Most doctors do not recommend continuing antibiotic therapy beyond 30 days. Scientific studies do not show any evidence that the benefits of long-term antibiotic treatment outweigh its risks.

Long-term antibiotic treatment can lead to a serious and difficult-to-treat infection called Clostridiumdifficile, and can also cause the patient to become allergic to the antibiotic. In addition, long-term antibiotic treatment carries its own serious risks, such as the development of antibiotic-resistant super bugs.

Experimental and alternative remedies are not recommended. However, some patients may benefit from learning pain control and cognitive behavioral techniques to help them cope with and manage their symptoms.

Herbs and Supplements

Some people use vitamin B complex, omega-3 and omega-6 fatty acids (found in primrose oil and fish oils), and magnesium supplements to help relieve symptoms. No evidence suggests that they are beneficial. Any such therapies should be discussed with a doctor. Newsletters and Internet sites have cropped up in recent years advertising untested treatments to patients with symptoms of Lyme disease who are frustrated with standard medical treatment. Some remedies are dangerous, and most are ineffective.

The Food and Drug Administration (FDA) has warned people not to use an alternative medicine product called bismacine (also known as chromacine). This injectable product contains high amounts of bismuth, a heavy metal that can be poisonous. People who have taken bismacine have experienced heart and kidney failure, and one death has been reported. Although some people claim that bismacine can help treat Lyme disease, it is not approved for the treatment of any illness or condition.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Prevention

Everyone should avoid specific tick-infested areas, including tall grass, woods, and bushes where ticks tend to congregate. If this is not possible, people should take additional preventive measures. The U.S. Centers for Disease Control (CDC) also recommends:

  • Use of tick repellent. Insect repellants that contain DEET are the most effective.
  • Routine checks for ticks. Removal of infected ticks within 48 hours of attachment substantially reduces the likelihood of Lyme disease transmission.
  • Prompt antibiotic prevention for high-risk tick bites. Although this method is controversial, the CDC concludes that it is probably beneficial.
  • Removing brush and leaves. Such landscaping measures can reduce transmission rates by 50 - 90%.
  • Applying pesticides to yards once or twice per year. This can decrease the number of ticks by 68 - 100%.

Protecting Property from Tick Infestation

Mowing the grass regularly, clearing away leaves, and placing wood chips as a barrier around a lawn can help greatly reduce the tick population.

Permethrin for the Lawn. Insecticides can significantly reduce tick infestation. Insecticides should be applied in late spring or early fall in a strip a few feet wide along the perimeter of the lawn where small animals are likely to enter or live.

The most commonly used insecticides are pyrethrins, which are compounds derived from the Chrysanthemum family. They are available as natural products or in synthetic forms (permethrin). They are poisons that affect the nerve system of insects. However, they are safe, particularly the natural products, and for humans and pets. All pyrethrins are highly toxic for certain fish and slightly toxic for birds, such as mallard ducks. Some people do experience an allergic reaction to them. As with all insecticides, there is some concern about the possible consequences of long-term exposure. But to date there is no evidence of any harm.

Cardboard tubes stuffed with permethrin-treated cotton are available in hardware stores. The tubes are placed where mice can find them (dense, dark brush) and collect the cotton for lining their nests. The pesticide on the cotton kills any immature ticks that are feeding on the mice. Best results are obtained with regular applications early in the spring and again in late summer.

Other Pesticides. Other tick-killing spray pesticides that have been used include those containing diazinon, chlorpyrifos, and carbaryl. Animal studies have reported severe toxic effects associated with these chemicals. Some of these chemicals are being phased out for home use. Parents should balance the effects of a very negligible risk for a highly treatable infection against excessive use of possibly harmful chemicals.

Protective Clothing in the Woods

Anyone who walks or camps in the woods during tick season should wear protective clothing, including:

  • Light-colored clothing that makes it easier to spot ticks
  • Long-sleeved shirts and long pants with cuffs tucked into shoes or socks (ticks can’t jump or fly but they do crawl upward)
  • High boots, preferably rubber

Simply washing clothes will not kill ticks. After being outdoors, people should run their clothes through a dryer at high temperature for a half hour. Spraying clothes with solutions containing permethrin (Permanone, Duranon, and Permakill) provides additional protection. Keep in mind that these sprays should not be applied to the skin. Clothes should not be retreated with permethrin for 48 hours unless they have been washed after the first application.

Insect Repellent

DEET. Most insect repellents contain the chemical DEET (N,N-diethyl-meta-toluamide), which remains the gold standard of currently available mosquito and tick repellents. DEET has been used for more than 40 years and is safe for most children when used as directed. Comparison studies suggest that DEET preparations are the most effective insect repellents now available.

Concentrations range from 4 to almost 100%. The concentration determines the duration of protection. Most adults and children over 12 years old can use preparations containing a DEET concentration of 20 - 35% (such as Ultrathon), which provides complete protection for an average of 5 hours. Higher DEET concentrations may be necessary for adults who are in high-risk regions for prolonged periods.

DEET products should never be used on infants younger than 2 months. According to the Environmental Protection Agency, DEET products can safely be used on all children age 2 months and older. The EPA recommends that parents check insect repellent product labels for age restrictions.

If there is no age restriction listed, the product is safe for any age. The American Academy of Pediatrics recommends that children use concentrations of 10% or less; 30% DEET is the maximum concentration that should be used for children. In deciding what concentration is most appropriate, parents should consider the amount of time that children will be spending outside and the risk of insect bites and insect-borne disease.

When applying DEET, take the following precautions.

  • Do not use on the face, and apply only enough to cover exposed skin on other areas.
  • Do not over apply and do not use under clothing.
  • Do not apply over any cuts, wounds, or irritated skin.
  • Parents or an adult should apply repellent to a child and not let the child apply it. They should first put DEET on their own hands and then apply it to the child. Avoid putting DEET near the child's eyes, mouth, and hands (since children frequently touch their faces).
  • Wash any treated skin after going back inside.
  • If using a spray, apply DEET outdoors -- never indoors. Spray repellents should not be applied inside or directly on anyone's face.

Picaridin. Picaridin, also known as KBR 3023 or Bayrepel, is an ingredient that has been used for many years in repellents sold in Europe, Latin America, and Asia. A product containing 7% picaridin is now available in the United States. Picaridin can safely be applied to young children and is also safe for women who are pregnant or breastfeeding. Insect repellents containing DEET or picaridin work better than other products for protection against ticks.

Tick Check and Tick Removal

Tick Check. Studies indicate that ticks begin transmitting the Lyme disease spirochete within 36 – 48 hours after attachment. Removing a tick within 48 hours can reduce your chance of contracting Lyme disease. The following tips are important for self-inspection:

  • Ticks responsible for Lyme disease are very small and may resemble freckles or scabs.
  • People spending time in tick-infested locations should inspect themselves several times a day, including at bedtime.
  • Check non-exposed areas, such as the back of the knee, as well as exposed areas. Someone else should check the scalp, back of the neck, and other difficult to reach areas.
  • Check clothing as well as skin. A tick on can be hidden in folds or creases.

Tick Removal. If an attached tick is discovered, there is no reason to panic. Not all ticks are infected, and not everyone who is bitten by a tick will get Lyme disease. Do not put a hot match to the tick or try to smother it with petroleum jelly, nail polish, or other substances. This only prolongs exposure time and may cause the tick to eject the Lyme spirochete into the body.

The following is the safest and most effective way to remove an attached tick:

  • Grasp the tick's mouth area with clean, fine-tipped tweezers as close to the skin as possible. (Take care not to handle it with bare fingers as this can also spread infection.)
  • Next, pull upward with a steady even pressure. Do not twist, crush, or squeeze the body area of the tick, because this region contains the infectious organism. In fact, do not be alarmed if some of the mouth parts remain in the skin. They are not infectious.
  • Put the tick in a jar or container of alcohol, which will kill it. You can place a piece of adhesive tape on the top of the tick and fold it over, without touching the insect. Then simply throw it away. Tape is also effective for trapping a tick that has not yet attached to the skin.
  • Once the tick is removed, wash the bite area with soap and water or with an antiseptic to destroy any contaminating microorganisms. Wash hands as well.

Protecting Pets

Since dogs, cats, and even horses can get Lyme disease, inspect pets for ticks regularly. Discuss with your veterinarian the best tick prevention product for your pet. Lyme disease vaccines are available for dogs, but they do not offer total protection. Veterinarians vary in their use of the vaccines. There is no Lyme disease vaccine for humans.

Resources

References

Bakken JS, Dumler S. Human granulocytic anaplasmosis. Infect Dis Clin North Am. 2008;22(3):433-448, viii.

Bockenstedt L. Lyme disease. In: Firestein GS, Budd RC, Gabriel SE, McInnes IB, O’Del JR, eds. Kelley’s Textbook of Rheumatology. 9th ed. Philadelphia, Pa; Saunders Elsevier; 2012:1815-1828.e3.

Bratton RL, Whiteside JW, Hovan MJ, Engle RL, Edwards FD. Diagnosis and treatment of Lyme disease. Mayo Clin Proc. 2008;83(5):566-571.

Centers for Disease Control and Prevention. Tickborne Diseases of the United States: A Reference Manual for Health Care Providers. First Edition 2013. Accessed March 17, 2014.

Centers for Disease Control and Prevention (CDC). Three sudden cardiac deaths associated with Lyme carditis - United States, November 2012-July 2013. MMWR. 2013;62(49):993-996.

Chowdri HR, Gugliotta JL, Berardi VP, et al. Borrelia miyamotoi infection presenting as human granulocytic anaplasmosis: a case report. Ann Intern Med. 2013;159(1):21-27.  

Clark RP, Hu LT. Prevention of lyme disease and other tick-borne infections. Infect Dis Clin North Am. 2008;22(3):381-396, vii.

Feder HM Jr, Johnson BJ, O'Connell S, et al.; Ad Hoc International Lyme Disease Group. A critical appraisal of "chronic Lyme disease." N Engl J Med. 2007;357(14):1422-1430.

Gugliotta JL, Goethert HK, Berardi VP, Telford III SR. Meningoencephalitis from Borrelia miyamotoi in an immunocompromised patient. N Engl J Med. 2013;368:240-245.

Halperin JJ, Shapiro ED, Logigian E, et al. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2007;69(1):91-102.

Hu LT. In the clinic. Lyme disease. Ann Intern Med. 2012;157(3):ITC2-2 - ITC2-16.

Kuehn BM. CDC estimates 300,000 US cases of Lyme disease annually. JAMA. 2013;310(11):1110.

Krause PJ, Bockenstedt LK. Cardiology patient pages. Lyme disease and the heart. Circulation. 2013;127(7):e451-e454.

Nadelman RB, Hanincová K, Mukherjee P, et al. Differentiation of reinfection from relapse in recurrent Lyme disease. N Engl J Med. 2012;367(20):1883-1890.

Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet. 2012;379(9814):461-473.

Tavakoli NP, Wang H, Dupuis M, et al. Fatal case of deer tick virus encephalitis. N Engl J Med. 2009;360(20):2099-2107.

Vannier E, Krause PJ. Human babesiosis. N Engl J Med. 2012;366(25):2397-2407.

Wormser GP. Lyme disease. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:1930-1935.

Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-1134.


Review Date: 3/7/2013
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team. Editorial Update: 04/14/2014
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