Many symptoms persist even after taking all recommended antibiotics, especially among those suffering from late Lyme disease. Direct diagnostic tests like PCR of blood or cerebrospinal fluid (CSF) cannot always accurately pinpoint this illness in these instances.
Diagnoses of PTLD occur when an individual reports persistent or recurrent objective manifestations and fulfills all the following criteria.
Symptoms
After being exposed to Lyme disease through tick bite, symptoms often emerge within weeks after exposure, including fever, headache, muscle and joint ache and pains, and an expanding red ring known as Erythema Migrans (EM) at the site of bite that eventually forms a red circle with clear centers in several weeks’ time. This rash typically appears on chest, abdomen or groin area and in approximately 7-8 out of 10 individuals the EM spreads throughout other parts of their bodies.
Early symptoms of Lyme disease often include extracutaneous manifestations like migratory or bull’s-eye joint rash, muscle aches and fatigue. Later stages may involve periods of latency where nervous system complications develop – these may affect either peripheral (cranial neuritis, radiculoneuritis and plexopathies) or central nervous systems (meningitis and increased intracranial pressure).
Cardiovascular complications associated with Lyme disease are rare but serious. Heart attacks may result when bacteria infiltrate blood vessel walls surrounding the heart, leading to blockages that prevent blood from flowing freely into it. Less frequently, myocarditis – inflammation of heart muscle caused by mycobacterium infection – enters the bloodstream and leads to inflammation of its muscle that makes the heart beat faster than usual while disrupting electrical signals controlling heart rhythm.
Antibiotic treatments for Lyme disease typically include a 14-day course of antibiotics with activity against B. burgdorferi. Preferred choices are doxycycline or tetracycline; oral administration within 72 hours after tick removal is recommended over observation (strong recommendation and moderate quality evidence). Patients experiencing mild residual joint swelling may benefit from continuing antibiotic treatment for an additional month based on factors including medication adherence, duration of arthritis prior to initial treatment, degree of synovial proliferation vs joint swelling, patient preferences etc.
Diagnosis
This evidence-based guideline was produced by a joint panel from IDSA, AAN and ACR. It offers recommendations for Lyme disease prevention; diagnosis and treatment for those exhibiting neurologic, cardiac, rheumatologic or other manifestations; management of co-infection with other tick-borne pathogens such as Babesiosis or Rickettsial infections which are covered separately; however this does not address them comprehensively.
Lyme disease symptoms vary depending on both individual and location, with most experiencing an itchy rash at the site of their bite. Most cases in the US are due to B. burgdorferi bacteria; other tick-borne illnesses like Babesia or Ehrlichia could also lead to similar illness and manifest themselves with similar rashes.
Lyme disease can be diagnosed based on both clinical signs and symptoms as well as lab test results that detect B. burgdorferi antibodies produced in response to exposure. It’s important to remember, though, that serologic test results don’t always represent active infection; false positive results or delayed incubation periods may affect these tests and hinder diagnosis and treatment efforts.
Most often, for bacteria to be transmitted successfully through tick attachment, they need to be attached for at least 24 hours – though the exact length of time depends on both tick type and stage (nymph vs adult).
Antibiotics are used to treat Lyme disease in many forms. The appropriate antibiotic will depend on which clinical manifestation, age and location are being addressed, along with factors like drug allergy, side effect profile and tolerability; cost; likelihood of coinfection between Anaplasma phagocytophilum and Ehrlichia muris eauclairensis necessitating use of macrolide antibiotics; duration based on severity; etc.
Treatment
Lyme disease is an intricate infection caused by tick bites that may manifest with disseminated symptoms that include skin lesions far removed from their location and dispersed pain in joints, heart, nervous system and/or brain. Antibiotics are an integral component of therapy; however, the choice, route of administration and duration will depend on various factors including which species of tick transmitted the pathogen; additionally the initial symptoms play an integral part in determining appropriate interventions for treatment.
Lyme disease endemic areas typically feature high rates of B. burgdorferi infection among both adult and nymphal ticks, thus making diagnosis easier using serologic tests. Unfortunately, due to cross-reactive antibodies and autoimmune diseases a positive test result does not always signify current or past exposure, and does not rule out other possible causes for patient symptoms; using diagnostic tests alone could result in overdiagnosis and overtreatment.
Lyme disease has seen dramatic increase since its first identification in 1982, outpacing new cases of Hepatitis B, Hepatitis C and West Nile virus combined. An estimated 476,000 individuals annually in the US are diagnosed with Lyme disease.
Patients suffering from untreated erythema migrans are at an increased risk for Lyme disease within months. While transmission times vary, most experts agree it takes less than 24 hours for blacklegged ticks in early stages of biting to acquire and transmit bacteria to its next host.
Doxycycline’s effectiveness as a Lyme disease prevention medication is well documented. Three randomized, placebo-controlled trials have demonstrated its success at significantly lowering risk (relative risk 0.27; 95% confidence interval [.10,.75]). Other -lactam antibiotics such as tetracycline and penicillin may also be effective, although no direct comparisons between them and doxycycline exist in placebo-controlled clinical trials.
Prevention
Lyme disease has seen exponentially increasing incidence rates over time in the US. Reported cases increased 25x between 2004 and 2013, making Lyme one of the fastest spreading infectious diseases.
At present, no vaccine exists to prevent Lyme disease; however, best practice guidelines suggest performing daily tick checks/avoiding tick habitat, using year-round acaricides with label claims for Ixodes scapularis control, wearing long pants and shirts with long sleeves while outdoors and vaccination against B. burgdorferi for those living or visiting areas endemic for Lyme disease in the US.
Tick-borne diseases result from complex interactions among hosts, ticks and pathogens themselves; therefore more knowledge must be gained to fully comprehend these relationships and create preventative strategies.
Research is ongoing to assess the efficacy of personal protection measures such as insect repellent use (strong recommendation and moderate-quality evidence) and bathing/showering within two hours after outdoor activities. Furthermore, it’s crucial that we understand what motivates people to adopt and sustain such behaviors over time.
Due to a lack of human Lyme disease vaccines, it is vital that we continue to spread awareness and education on how to avoid tick bites while emphasizing the value of early diagnosis and treatment.
Lyme disease has been nationally reportable since 1991 and state health departments collect and verify reports according to legal mandate and surveillance practices. These reports are vital in tracking its epidemiology as well as identifying areas needing improvement for prevention and treatment.
Authors of this guideline include members from IDSA, AAN, and ACR guidelines development committees. It was created through an open public comment period with public review committee members at each institution adhering to stringent conflict-of-interest policies requiring disclosure of any financial, intellectual or other conflicts of interests that might influence its contents.
