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Lyme disease

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Related Terms
  • Arrhythmias, B. burgdorferi, Bell's palsy, black-legged ticks, Borrelia burgdorferi, carditis, deer ticks, DEET, ELISA, enzyme-linked immunosorbent assay, erythema migrans, fibromyalgia, hepatitis, Lxodes, Lxodes scapularis, magnetic resonance imaging, meningitis, meta-N,N-diethyl toluamide, MRI, neurological, non-steroidal anti-inflammatory drugs, NSAID, palpitations, paralysis, PCR, permethrin, polymerase chain reaction, western black-legged ticks, Western blot.

Background
  • Lyme disease is an infection caused by Borrelia burgdorferi. B. burgdorferi is a bacterium that is carried by a group of closely related species of ticks known as Lxodes. An infected tick can transmit the bacteria to humans and animals through its bite. The bacteria enter the body at the spot where the tick has bitten.
  • Ticks in the species of Lxodes, including deer ticks (also called black-legged ticks) and western black-legged ticks, are much smaller than the common dog or cattle ticks, and attach to any part of the body, most often to moist or hairy areas such as the groin, armpits, and scalp. The deer tick (Lxodes scapularis) is the primary carrier of Lyme disease in eastern North America.
  • If not treated, the bacteria travel through the bloodstream and attach to various body tissues. This may cause a number of symptoms, some of which are severe. Lyme disease is an inflammatory disorder, affecting joints, the nervous system, the heart, and the skin.
  • Symptoms include joint pain and flu-like signs, such as a fever, aches, and chills. Pain in the muscles and joints is common early on in Lyme disease. Many individuals experience spontaneous improvement of the pain, or a diminishment of it over time. In about 20% of people with untreated Lyme disease, arthritis (inflammation) of the joints can become chronic.
  • Severe symptoms include neurological (nerve) damage, including memory loss, difficulty concentrating, and changes in mood or sleep habits.
  • This disease has been recognized since November 1975 when 12 children of a small rural community, Old Lyme, Connecticut, were diagnosed with juvenile rheumatoid arthritis. Nearby several other people also reported a similar type of arthritis that came on suddenly. Research was done and 51 individuals were found to have developed the same disorder in a small geographical area and at the same time of the year. Most had brief attacks of pain and swelling involving a few large joints, and many reported having noticed a peculiar, expanding, red skin area several weeks before the joint pain and skin redness.
  • Lyme disease is a rapidly emerging infectious disease. The exact number of people affected by Lyme disease is not known. The U.S. Centers for Disease Control and Prevention (CDC) reported 23,305 cases of Lyme disease in the United States in 2005. Most occurred in the coastal northeast, the Mid-Atlantic States, Wisconsin, Minnesota, and northern California.
  • There are many factors contributing to the rise of Lyme disease in humans: an increase in the tick population (partially due to climate warming) and the expansion of suburbs into formerly wooded areas, which increases people's exposure to infected ticks. Because there are more and more people these days engaging in outdoor activities such as hiking, hunting, and climbing, more and more individuals are exposed to ticks, thereby increasing the incidence of Lyme disease. These people more frequently encounter deer or may be in areas where deer have been.
  • Most cases begin in the summer. In areas that have mild winters, the pattern is less seasonally specific.
  • If diagnosed and treated early with antibiotics, Lyme disease is almost always readily cured. However, the virus may lie dormant in the body for years and reappear.

Signs and symptoms
  • Signs and symptoms vary widely because Lyme disease can affect various parts of the body. Not everyone with the disease will have all of the signs and symptoms.
  • Skin: After being bitten by a tick, a small, red bump may appear within a few days to a month, often at the site of the tick bite (the groin, belt area, or behind the knees). The area may be warm to the touch and mildly tender. Over the next few days, the redness expands, forming a rash that may be as small as a dime or as large as 12 inches across. The bite site often resembles a bull's-eye, with a red ring surrounding a clear area and a red center. The rash, called erythema migrans, is one of the hallmarks of Lyme disease, affecting about 70-80% percent of infected individuals. Erythema migrans is an early-stage symptom of Lyme disease.
  • Another type of redness may develop also at the site if the individual is allergic to tick saliva. The redness usually fades within a week. This is not the same as erythema migrans, which tends to expand and get redder over time. Having the rash does not increase the severity of other symptoms.
  • Flu-like symptoms: Flu-like symptoms include fever, chills, fatigue, body aches, and a headache. These symptoms may accompany the rash.
  • Migratory joint pain: If the infection is not treated, the individual may develop bouts of severe joint pain and swelling several weeks to months after being infected. The knees are especially likely to be affected, but the pain can shift from one joint to another.
  • Neurological problems: In some cases, inflammation of the membranes surrounding the brain (meningitis), temporary paralysis of one side of the face (Bell's palsy), numbness or weakness in the limbs, and impaired muscle movement may occur weeks, months, or even years after an untreated infection. Memory loss, difficulty concentrating, and changes in mood or sleep habits also can be symptoms of late-stage Lyme disease.
  • Other signs and symptoms: Some individuals may develop heart problems, such as an arrhythmia or irregular heartbeat, several weeks after infection. This complication is rare and usually does not last more than a few days or weeks. Eye inflammation, hepatitis (liver inflammation), and severe fatigue are also possible.

Diagnosis
  • History of exposure: A doctor will determine a history of exposure to potentially infected ticks, especially in areas of the country known to have Lyme disease.
  • Physical examination: Physical findings include the characteristic rash. The signs and symptoms of Lyme disease are nonspecific and are often found in other conditions, such as viral infections, various joint disorders (arthritis), muscle pain (fibromyalgia), chronic fatigue syndrome, and even depression.
  • Enzyme-linked immunosorbent assay (ELISA) test: The enzyme-linked immunosorbent assay (ELISA) test is used most often to detect Lyme disease. ELISA detects antibodies to B. burgdorferi. Antibodies are proteins made by the body to fight off antigens (foreign invaders) such as B. burgdorferi. ELISA is not used as the sole basis for diagnosis because it can sometimes provide false-positive results.
  • Western blot test: If the ELISA test is positive, another assay called the Western blot is usually done to confirm the diagnosis. The Western blot detects antibodies to several proteins of B. burgdorferi.
  • Polymerase chain reaction (PCR): The polymerase chain reaction (PCR) test helps detect bacterial DNA in fluid drawn from an infected joint. PCR is not effective at detecting infection of blood or urine, and is used for individuals who may have chronic Lyme arthritis. PCR may also be used to detect persistent infection in the cerebrospinal fluid of individuals who have nervous system symptoms.
  • Magnetic resonance imaging (MRI): Magnetic resonance imaging (MRI) may be used in early or late stage Lyme disease to determine neurological (nerve) damage.

Complications
  • Complications of Lyme disease include neurological problems, such as Bell's palsy (paralysis of the facial muscles), visual disturbances, and meningitis symptoms such as fever, stiff neck, and severe headache. Other problems, which may not appear until weeks, months, or years after a tick bite, include decreased concentration, irritability, memory and sleep disorders, and nerve damage in the arms and legs.
  • Some individuals may develop arrhythmias (irregular heartbeat). These usually develop several weeks after infection. This complication is rare and usually does not last more than a few days or weeks. Eye inflammation, hepatitis (liver inflammation), and severe fatigue are also possible complications.
  • Rarely, Lyme disease can cause death in infected individuals.

Treatment
  • Lyme disease can usually be cured if treated promptly and properly. However, without treatment the disease can continue to progress and affect more parts of the body.
  • Medications: Early stage Lyme disease is treated with a three to four week course of oral (by mouth) antibiotics, such as amoxicillin (Amoxil®), doxycycline (Vibramycin®), and cefuroxime (Ceftin®). Advanced disease may require intravenous (IV, or through the veins) ceftriaxone (Rocephin®) or penicillin (PenG®) for four weeks or longer.
  • Acetaminophen (Tylenol®) is often given to manage the pain of Lyme disease. Acetaminophen can relieve pain but does not reduce inflammation.
  • Anti-inflammatory medication is often given to treat the inflammation of Lyme disease. Aspirin can help reduce inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a type of medication that help reduce the pain and swelling of the joints and decrease stiffness. NSAIDs reduce pain when taken at a low dose, and relieve inflammation when taken at a higher dose. NSAIDs that can be purchased without a prescription include ibuprofen (Motrin®, Advil®) and naproxen (Alleve®). Examples of NSAIDs that require a prescription include nabumetone (Relafen®), indomethacin (Indocin®), and piroxicam (Feldene®). NSAIDs may cause stomach upset, nausea, and vomiting.
  • Exercise: Once Lyme disease is under control, doing exercises can help strengthen joints and muscles. Exercises to improve the range of motion of the joints will also assist with the individual's ability to resume normal activities.

Integrative therapies
  • Unclear or conflicting scientific evidence:
  • Eucalyptus oil: Eucalyptus (Eucalyptus globulus) oil contains 70-85% 1,8-cineole (eucalyptol), which is also present in other plant oils. Preliminary research shows that Citriodiol® spray, containing eucalyptus, may reduce the number of tick bites and thereby tick-borne infections. Additional studies are needed to better understand the use of eucalyptus as a topical tick repellant.
  • Case reports describe allergic rash after exposure to eucalyptus oil, either alone or as an ingredient in creams. Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.
  • Garlic: According to preliminary research, self-reports of tick bites were significantly less in people who received garlic over placebo "sugar" pills. Further well-designed research is needed to confirm the effectiveness of garlic as a tick repellant.
  • Avoid if allergic or hypersensitive to garlic or other members of the Lilaceae(lily) family (like hyacinth, tulip, onion, leek, chive). Avoid with history of bleeding problems, asthma, diabetes, low blood pressure, or thyroid disorders. Stop using supplemental garlic two weeks before dental/surgical/diagnostic procedures and avoid using immediately after such procedures to avoid bleeding problems. Avoid in supplemental doses if pregnant or breastfeeding due to insufficient evidence of safety.
  • Traditional or theoretical uses lacking sufficient evidence:
  • Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures, with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. Traditionally, the Alexander technique has been used for the supportive treatment of Lyme disease.
  • No serious side effects have been reported. It has been suggested that the technique may be less effective with learning disabilities or mental illnesses. The Alexander technique has been used safely in pregnant women.
  • Beta-glucan: Beta-glucan is a soluble fiber derived from the cell walls of algae, bacteria, fungi, yeast, and plants. Beta-glucan may help stimulate the immune system. Traditionally, beta-glucan has been used for the supportive treatment of Lyme disease.
  • Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.
  • Colloidal silver: Colloidal silver is a suspension of submicroscopic metallic silver particles in a colloidal base. Colloidal silver is not generally recognized as safe or effective. However, some researchers believe that it has antibacterial properties, which may warrant further studies. Despite the lack of scientific evidence, colloidal silver is most commonly used as a natural antibiotic or healing agent. It is either applied to the skin or ingested as a drink to promote healing or to treat disease. Some integrative practitioners use colloidal silver for the supportive treatment of Lyme disease.
  • Long-term use of silver preparations can lead to argyria, a permanent condition in which silver salts deposit in the skin, eyes, and internal organs. The skin can often appear ashen-gray due to the deposition of the silver salts. Argyria has been mistaken for cyanotic heart disease. Avoid if allergic or hypersensitive to silver. Avoid if pregnant or breastfeeding.
  • Essiac: Essiac® contains a combination of herbs, including burdock root (Arctium lappa), sheep sorrel (Rumex acetosella), slippery elm inner bark (Ulmus fulva), and Turkish rhubarb (Rheum palmatum). The original formula was developed by the Canadian nurse Rene Caisse (1888-1978) in the 1920s ("Essiac" is Caisse spelled backwards). The recipe is said to be based on a traditional Ojibwa (Native American) remedy, and Caisse administered the formula by mouth and injection to numerous cancer patients during the 1920s and 1930s. The exact ingredients and amounts in the original formulation remain a secret. Some integrative practitioners use Essiac® for the supportive treatment of Lyme disease.
  • Safety concerns are based on reactions associated with the herbal components of Essiac®: burdock root (Arctium lappa), sheep sorrel (Rumex acetosella), slippery elm bark (Ulmus fulva), and Turkish rhubarb (Rheum palmatum). However, the safety and toxicities of these individual herbs are also not well studied. Various essiac-like products may contain different or additional ingredients, and patients are advised to carefully review product labels. Reports of allergy to Essiac® are lacking in the published scientific literature, but reactions potentially can occur due to any of the included herbs. Anaphylaxis has been reported after rhubarb leaf ingestion, and there are reports of allergic reactions to sorrel products taken by mouth. Contact dermatitis (skin rash after direct contact) has been reported with exposure to burdock, slippery elm bark, and rhubarb leaves. Cross-sensitivity to burdock may occur in individuals with allergy to members of the Asteraceae/Compositaefamily, such as ragweed, chrysanthemums, marigolds, and daisies. Use caution with diabetes or hypoglycemia. Avoid if pregnant or breastfeeding.
  • Physical therapy: Physical therapy is tailored to the patient's condition and health issues. A common goal of physical therapy is to increase how the patient functions at home and at work. Some integrative practitioners use physical therapy to stimulate immunity and for the supportive treatment of Lyme disease.
  • Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Prevention
  • A Lyme disease vaccine is under development but is not yet available. The only sure way to prevent the disease is to avoid exposure to infected ticks. Healthcare professionals recommend avoiding areas where wild mice might live, such as the edges of yards, fields, and woods with low, dense groundcover.
  • Healthcare professionals also recommend to: wear long sleeves and long pants tucked into socks during outside activities,wear a hat, and tie hair back; use insecticides to repel or kill ticks. Repellents containing the compound meta-N,N-diethyl toluamide (DEET) can be used on exposed skin except for the face, but they do not kill ticks and are not 100% effective in discouraging ticks from biting. It is important when using any of these chemicals to follow label directions carefully, especially when using them on children; check for ticks after outdoor activities. Check body areas where ticks are commonly found, such as behind the knees, between the fingers and toes, under the arms, in and behind the ears, and on the neck, hairline, and top of the head. Check places where clothing presses on the skin; and remove attached ticks promptly. Removing a tick before it has been attached for more than 24 hours greatly reduces the risk of infection. Use tweezers, and grab as closely to the skin as possible. Do not try to remove ticks by squeezing them, coating them with petroleum jelly, or burning them with a match.
  • Large brown ticks that are commonly found on dogs and cattle do not carry the Lyme disease bacterium. When removing a very small tick to have it tested for Lyme disease, place it in a clean pill vial or tight-sealed plastic storage bag with a moistened cotton swab. Contact a healthcare provider and local health department.
  • Monitor the site of the bite for the appearance of a rash beginning three to 30 days after the bite. If a rash or other early symptoms develop, see a doctor immediately.
  • It is recommended by healthcare professionals to visit a doctor if the individuals have been bitten by a tick in areas where there is a high risk for deer ticks.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Academy of Family Physicians. . Accessed April 13, 2009.
  2. Centers for Disease Control and Prevention. . Accessed April 13, 2009.
  3. Halperin JJ, Shapiro ED, Logigian E, et al. Quality Standards Subcommittee of the American Academy of Neurology. 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.
  4. Hayes E. Lyme disease. Clin Evid. 2002;(7):652-64.
  5. Klempner MS. Controlled trials of antibiotic treatment in patients with post-treatment chronic Lyme disease. Vector Borne Zoonotic Dis. 2002;2(4):255-63.
  6. Krupp LB, Hyman LG, Grimson R, et al. Study and treatment of post Lyme disease (STOP-LD): a randomized double masked clinical trial. Neurology. 2003;60(12):1923-30.
  7. Lyme Disease Foundation. . Accessed April 13, 2009.
  8. National Institute of Allergy and Infectious Diseases. . Accessed April 13, 2009.
  9. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed April 13, 2009.
  10. Stricker RB. Counterpoint: long-term antibiotic therapy improves persistent symptoms associated with lyme disease. Clin Infect Dis. 2007;45(2):149-57.

Causes
  • In the United States, Lyme disease is caused by the bacterium Borrelia burgdorferi, which is carried primarily by deer ticks (Lxodes scapularis). Ticks feed on blood, latching onto a host and feeding until they're swollen to many times their normal size. During feeding, ticks that carry disease-producing bacteria can transmit the bacteria to a healthy host. Or they may pick up bacteria themselves if the host is infected. In areas where Lyme disease is common, as many as 50% of deer ticks may carry Borrelia burgdorferi.
  • Deer ticks live in low bushes and tall grasses of wooded areas, waiting to attach to a warm-blooded animal in order to feed. Ticks are most active in the summer.
  • Once bitten by an infected deer tick, the bacteria enter the skin through the bite and eventually enter into the bloodstream. Only ticks that are attached to the skin and have fed can transmit the bacteria. Feeding can take between 36-48 hours. An attached tick that has a swollen appearance may indicate that enough time has elapsed to transmit bacteria. Removing the tick as soon as possible may prevent infection.

Risk factors
  • Geographic location: Anyone who lives in an area where there are ticks has a risk of being bitten by a Lyme disease-infected tick. An increased risk is usually directly related to the amount of time a person spends outdoors in areas where there are a lot of ticks. Lyme disease is found most often in three geographic locations in the United States. These are: the Northeastern and Mid-Atlantic regions (Maine to Maryland); the upper North-Central region (Minnesota and Wisconsin); and the Northwest (northwestern California and Oregon).
  • Time of year: Ticks are most active during the warmer months of the year. Peak at-risk times vary from region to region, based on the temperature: the Northeast and North-Central United States have an increased risk between April and November, with the peak occurring in July; the West Coast risk is higher between November and April; the non-coastal Western States have a higher risk between January and May; and the South has active ticks year-round.
  • Activities: Individuals who work outdoors in jobs such as surveying, landscaping, forestry, gardening, and utility service have a higher risk of Lyme disease. Participating in outdoor recreational activities such as hiking, camping, hunting, and gardening can also increase the risk.
  • Landscape: The ticks that carry Lyme disease are more likely to live in wet, green, brushy, or wooded areas. They are less likely to be near pruned, well-cared-for plants, but more likely near un-maintained shrubby or brushy plants. Living near or visiting wooded or brushy areas can increase the risk.
  • Age: Lyme disease occurs more often in children under age 15, and adults between 25-44 years old. This is most likely due to outdoor activities that expose them to ticks.

Stages
  • There are three separate stages of Lyme disease. Each has different symptoms.
  • Localized early disease stage: The onset of Lyme disease is called the localized early disease stage. If an individual is infected with Lyme disease, they may get a skin rash at the site of a tick bite. Common bite locations are the groin, the buttocks, behind the knee, or in the armpit. The rash may appear anywhere from a few days to a month after the tick has bitten. The bite site may feel hot to the touch and is usually red around the outside with a clear centre (called a bullseye). Beginning as a small area, the bite site expands slowly in size over several days and is usually not painful. Many individuals do not realize they have been bitten by a tick, and about one-third of people do not develop this rash.
  • Secondary stage: The secondary stage begins within several days of the appearance of the skin lesion, and many individuals develop symptoms and evidence of more widespread infection. There may be a vague feeling of discomfort or uneasiness, sluggishness or fatigue, headaches, and fever and chills. Aching joints and muscles and skin sores or rashes on various parts of the body may be present.
  • Third stage: About 20% of people with Lyme disease go into remission (temporary absence of disease) after the secondary stage has passed. Most individuals, however, will move into the third stage of the disease. In the third stage, other health conditions that involve the heart, nervous system, and joints can develop. The third stage may develop weeks, months, or rarely, years after the initial infection.
  • Carditis, or inflammation of the heart, develops in fewer than 10% of people with untreated Lyme disease. Initial symptoms can include rapid beating of the heart (palpitations or arrhythmias) or unexplained fainting. This condition may pass without medical intervention, but it sometimes requires medical treatment.
  • If the nervous system becomes inflamed, headaches, irritability, sensitivity to bright light, and lethargy can be experienced. In about 15% of people, meningitis (inflammation of the protective membranes covering the brain) may occur a few weeks after the initial rash.
  • Other symptoms indicating involvement of the disease in the brain and the nerves may occur months to years after the disease onset. Nerves in the limbs or around the head may be affected, and individuals could experience muscle weakness, paralysis, or loss of sensation. Bell's palsy, a condition that results in weakness or paralysis of the facial muscles, can also occur. If the disease affects the brain, short-term memory loss, difficulty concentrating, chronic fatigue, headaches, and sleep disturbance can occur. In rare cases, the disease can cause seizures and lesions on the spinal cord.
  • Most individuals with advanced Lyme disease experience attacks of arthritis involving one or only a few joints. Usually it is the large joints, such as the knees, that are affected. Involvement of many joints is uncommon. Attacks can last a few days to a few weeks. In children, the arthritis is usually much milder. Despite the ongoing inflammation, it is unusual for it to result in damage to the cartilage and bone, as may occur more commonly in other forms of arthritis. In comparison to rheumatoid arthritis, which affects both joints, Lyme disease can affect one or both joints.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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