Coping with Lyme Disease By Mark B. Levin, M.D. The Pediatric Group, P.A., Princeton

Unfortunately, people can contract a number of illnesses from the bite of an infected tick. In endemic areas of the Northeast (central New Jersey, New York, Pennsylvania, Massachusetts, Connecticut and Rhode Island) the most common and well publicized of these illnesses is Lyme Disease. Although infection is possible any time of the year, the disease most commonly infects children during the warm months. 75% of infected children first display symptoms during June, July and August.

Lyme Disease received its name in the mid-1970s, being recognized as a distinct infectious disease responsible for an outbreak of illness in Old Lyme, Connecticut. The characteristic rash of Lyme Disease (Erythema Migrans, or "spreading redness") was actually documented early than this in 1909 at a Dermatological Society meeting in Sweden. Still earlier in 1894, DNA from the causative agent, Borrelia Burgdorferi, had been identified in museum samples of rodents captured in Cape Cod, Massachusetts. So, although the condition has become a relatively recent endemic in the northeastern United States, it has been around for a long time.

While other ticks in other parts of the country and the world can transmit Lyme Disease to humans, the small deer tick (so named because carriage on deer is an integral part of the life cycle of the adult insect), Ixodes scapularis (formerly, Ixodes dammini), is the most common carrier of Lyme Disease in our area. The adult female deer tick is about 1/10-1/4 inch long and black and brick red in color. The adult male is slightly smaller and darker in color. Nymph and larval forms, which more frequently transmit the disease, are much smaller ("moving freckle", "pepper grain" or "poppy seed"). These are the most difficult to find and remove, so your discovery and removal efforts must be particularly diligent in the height of the summer when these forms are actively feeding. Ticks become infected with the Lyme Disease spirochete (cork screw shaped bacteria) when they feed on an infected animal (deer, white-footed field mouse). People, in turn, get Lyme Disease when an infected tick takes a blood meal from them. It takes time (at least 36-48 hours) for the attached tick to transmit the bacterium, so frequent "tick checks" can help prevent Lyme Disease by allowing early removal of the tick.

If you find a tick, the best way to remove it is with a good fine-pointed forceps (tweezers). Grasp the tick as close to the skin as possible and apply a firm and steady pulling motion directly away from the skin. Do not twist or bend the tick, as the body might snap off, leaving the head and mouth parts (which contain the Lyme Disease germ) imbedded in the skin. Do not use a hot match or gasoline as this may irritate the skin and stimulate the tick to introduce infection at the site of attachment. Do not use vaseline as this will make the tick too slippery to remove. After tick removal, clean the area with soap and water and then alcohol. If any parts of the tick remain, call your doctor for an appointment to have the rest of the tick removed. There is no need to save the tick for identification. Even if the tick carries the Lyme Disease germ, the only way to know if it has been transmitted is to watch for symptoms.

In about 90% of pre-adolescent children, the presenting sign of Lyme Disease is a distinct red rash. It begins a few days to a few weeks after the tick bite and expands into a circular or oval shape with central clearing (a target or bull's eye appearance). It usually reaches 3-5 inches in diameter and lasts at this size for about a week before fading. It may be itchy, warm or tender, and may be associated with fever, malaise, headache, and muscle or joint pains. A blood test can be done to confirm Lyme Disease. In the past, laboratory confirmation of Lyme Disease was less reliable than it is now. With current ELISA antibody capture, immunoblot (western blot) and PCR (polymerase chain reaction) techniques, the clinical diagnosis and staging are much more readily confirmed. When diagnosed at an early stage, Lyme Disease can be easily and thoroughly eradicated with 3-4 weeks of oral antibiotic treatment. Late complications, such as arthritis, heart inflammation, ocular inflammation and nervous system problems, can also be prevented by early treatment. Advanced Lyme Disease, as is more common in adolescents and adults, may require treatment for longer periods or intravenous antibiotics. This is all the more reason for everyone to perform tick checks on themselves during the Lyme Disease season. The prognosis for children, even with later stages of the disease, is generally very good.

We get many calls from parents who question whether they should have Lyme tests performed on their children periodically. The test looks for antibodies against Borrelia burgdorferi. About 10% of a random sample of people in a Lyme endemic area will have anti- Lyme antibodies without clinical evidence of disease. The test does not tell whether there is current infection. Since the decision to treat with antibiotics is based on the clinical presence of symptoms compatible with Lyme Disease, and the test is merely confirmatory of the clinical impression, there are no recommendations for treatment based on test results alone. Hence, there is no point in performing the test in the absence of clinical suspicion of Lyme Disease.

Likewise, people frequently ask about a preventative course of antibiotic upon discovering a deer tick bite. Between 10-50% of deer ticks are infected with Borrelia burgdorferi. Since it takes at least 36-48 hours for a feeding tick to transmit the germ to its host, only about 10% of bites by infected ticks feeding for 2 days result in Lyme Disease transmission. The chance of getting Lyme Disease from a random identified deer tick bite, therefore, is only 1- 5%. There is no scientific data that documents the effectiveness prophylactic antibiotics for Lyme Disease and neither a dosage nor duration of treatment in this situation have been defined. In fact, two studies intended to address just this issue found that treatment in this situation is not appropriate. The medical community is very concerned about unnecessary exposure to antibiotics causing side effects and engendering resistant bacterial strains. Therefore, prophylactic antibiotic treatment of tick bites is unwarranted. Careful observation for and awareness of symptoms will allow early treatment of Lyme Disease cases and result in good outcomes.

We live in a tick-infested area, but there are several things you can do to minimize the risks when you venture outdoors. Tuck pants legs into socks or boots, and keep shirts tucked into pants when outside. Wear light colored clothes so ticks are easier to see. Stay near the center of trails and avoid walking through the shrub layer of the of the forest when hiking. Insect repellents which contain permethrin, such as Permanone®, Duranon Tick Repellent® or Coulstons Tick Repellent®, are not considered harmful to humans and are effective when applied to clothing. 8-10% DEET (diethyltoluamide)-containing preparations are nearly as effective in repelling ticks, but can be absorbed through the skin. For extended effectiveness, either type of tick repellent should be sprayed on the clothing, rather than on the skin. Check family members and pets at day's end for ticks. Finally, call your doctor if you have any questions.

All Rights Reserved 4/98 The Pediatric Group, P.A.

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.