Lyme Disease

1
(No Transcript)
2
Lyme Disease an evidence-based summary
3
(No Transcript)
4
Organization Definition History Etiology
Incidence Geographic Spread Transmission Preven
tion Testing Clinical Course Treatment
5
Definition
6
Lyme Disease Definition a multisystem disease
caused by Borrelia burgdorferi infection
7
CDC Definition Lyme Disease - presence of
erythema migrans rash 5cm or - at least one
late manifestation (without alternate
explanation) and laboratory confirmation
MWWR March 16, 2001 page 181
8
CDC Case definition late manifestations musculos
keletal system - recurrent attacks of joint
swelling sometimes followed by chronic
arthritis nervous system - lymphocytic
meningitis - cranial neuritis (especially facial
palsy) - radiculoneuropathy - rarely
encephalomyelitis cardiovascular system - acute
onset of second-to-third degree
atrioventricular conduction defects
resolving in days to weeks that may be
associated with myocarditis
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 21.
9
CDC case definition laboratory confirmation -
isolation of the spirochete from tissue or body
fluid - demonstration of diagnostic levels of
IgM or IgG antibodies to the spirochete in serum
or CSF - significant change in IgM or IgG
antibody response to Borrelia burgdorferi in
paired acute-phase and convalescent-phase serum
samples.
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 21.
10
Notice that the CDC clinical criteria does not
say erythema migrans plus laboratory
confirmation Erythema migrans is sufficient
11
What does erythema migrans look like? Erythema
migrans - begins as small red papule at bite
site - expands centrifugally over days to
weeks - central punctum often remains
hyperemic - average diameter 16cm - may reach
70cm in diameter
Andy Gale and Erika Ringdahl, Tick-borne
Diseases, American Family Physician, August 1,
2001, Vol 64, No 1, page 462
12
Erythema migrans
13
(No Transcript)
14
(No Transcript)
15
History
16
History November 20, 1975 Dr. Allen C.
Steere rheumatology fellow at Yale met Polly
Murray artist with listlessness headaches
swollen joints

David Gran, New York Times Magazine June 17, 2001
pages 53-57
17
Dr. Steere noticed other people with similar
symptoms more prevalent in
summertime more prevalent in wooded
areas sometimes preceded by skin lesion called
new disease Lyme Disease named after Lyme
Connecticut
David Gran, New York Times Magazine June 17, 2001
pages 53-57
18
(No Transcript)
19
there is more to the history than just the US ..
20
1883 Alfred Buchwald in Germany described skin
lesion of Acrodermatitis atrophicans
chronica in Andrews, Diseases of the Skin
(1938).. begins with a well-defined
erythematous lentil-sized macule, which soon
fades at the center and forms a circular lesion
.
21
1910 Swedish dermatologist Arvid Afzelius
described an annular skin lesion caused by the
Ixodes tick
22
1980s an entomologist, Willy Burgdorfer discove
red a spirochete in the intestines of Ixodes
dammini and in 1982 established that the
spirochete is the cause of Lyme disease
23
Etiology
24
Lyme Disease Etiology infection by the
spirochete Borrelia burgdorferi
25
(No Transcript)
26
Once the spirochete enters the human skin,
the spirochete multiplies in the skin causing
the erythema migrans rash. Over weeks, the
spirochete spreads from skin to other sites
for which it has trophism, e.g. other skin
sites, joints, heart, nervous system.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 249.
27
Borrelia burgdorferi stimulates the human
immune system to release inflammatory
cytokines from neutrophils and macrophages.
Also, interleukin-1 and tumor necrosis factor
are released.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 250.
28
Incidence
29
Incidence 6 cases per 100,000 population in
US
MWWR March 16, 2001 page 181
30
Reported Cases in California 1994 68 1995
84 1996 64 1997 154 1998 135 1999 139

MWWR March 16, 2001 page 181
31
Reported Cases of Lyme Disease in California
1990-1999 1,619 cases
MWWR March 16, 2001 page 181
32
Compare this to the East Coast Reported Lyme
Disease cases from 1990 to 1999 California
1,619 Connecticut 20,634 New York 40,762 Pennsylv
ania 17,072
MWWR March 16, 2001 page 183
33
Geographic Spread
34
Lyme disease geographic spread - primarily in
-northeastern US -mid-Atlantic US -northern
central US - also in -western US -eastern
Ontario -much of Europe -northern Asia
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 248.
35
Borrelia Species Geography
Borrelia burgdorferi sensu stricto US and
Europe Borrelia garinii Europe Borrelia
afzelii Europe
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 248.
36
Borrelia Species Manifestations
Borrelia garinii meningopolyneuritis Borrelia
afzelii acrodermatitis atrophicans
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 248.

37
(No Transcript)
38
Transmission
39
Lyme disease is transmitted to humans by
infected ticks.
40
Between tick feedings, Borrelia burgdorferi
remains dormant in the tick midgut. During
feedings, blood enters the gut and the
spirochetes multiply and migrate from the
midgut to the salivary glands. This process
takes 24 to 48 hours from the time of the
tick bite.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 249.
41
Nymphs are the tick stage most responsible for
transmission of Lyme disease.
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 428
42
Nymphs - are active in spring and summer
when people when less protective clothing - are
so small they cannot be detected when they
bite - outnumber adult ticks ten to one
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 427
43
Ixodes scapularis ticks - female, male, nymph,
larva
44
Ixodes scapularis ticks - engorged on the right
45
Inside hook - Ixodes scapularis (female, male,
two nymphs) Outside hook - Dermacentor veriabilis
- the dog tick
46
Most important reservoir for Borrelia
burgdorferi in the US is the white-footed
mouse. Earlier researchers implicated the
white-tailed deer, but deer seem to be much less
important in the Borrelia life-cycle even though
they can harbor the Ixodes tick.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 248.
47
What percentage of Californians are exposed
to Ixodes ticks?
Robert S. Lane, Richarb B. Moss, Yao-Pi Hsu et
alii, Anti-Atrhopod Saliva Antibodies
among Residents of a Community at High Risk for
Lyme Disease in California, The American Journal
of Tropical Medicine and Hygiene, November 1999
61(5), page 853
48
By anti-Ixodes salivary antibodies rural
area near Ukiah 78 SF Bay 36 Imperial
County 6
Robert S. Lane, Richarb B. Moss, Yao-Pi Hsu et
alii, Anti-Atrhopod Saliva Antibodies
among Residents of a Community at High Risk for
Lyme Disease in California, The American Journal
of Tropical Medicine and Hygiene, November 1999
61(5), page 853
49
What percentage of Ixodes pacificus ticks are
positive for Borrelia burgdorferi? 12 of
nymphs in study near Ukiah
Robert S. Lane, Richarb B. Moss, Yao-Pi Hsu et
alii, Anti-Atrhopod Saliva Antibodies
among Residents of a Community at High Risk for
Lyme Disease in California, The American Journal
of Tropical Medicine and Hygiene, November 1999
61(5), page 854.
50
What human behaviors are associated with being
diagnosed with Lyme disease?
51
A study has addressed this. Case-Control Study
(N176 cases with matched controls) cases from
counties all over California, though majority
from Mendocino, Humboldt, and Sonoma counties.
Catherine Ley, Elyse Olshen and Arthur Reingold,
Case-Control Study of Risk Factors for Incident
Lyme Disease in California, American Journal of
Epidemiology, 1995, Vol 142, No. 9, page S
52
Not associated gardening, jogging,
fishing yard work, hiking
Catherine Ley, Elyse Olshen and Arthur Reingold,
Case-Control Study of Risk Factors for Incident
Lyme Disease in California, American Journal of
Epidemiology, 1995, Vol 142, No. 9, page S42
53
Positive association with use of unpaved
trails for 5 hours per week OR 2.71 tick
bites OR 2.5
Catherine Ley, Elyse Olshen and Arthur Reingold,
Case-Control Study of Risk Factors for Incident
Lyme Disease in California, American Journal of
Epidemiology, 1995, Vol 142, No. 9, page S42
54
What percentage of Sonoma County residents
believe they have Lyme disease?
Curtis L. Fritz, Anne M. Kjemtrup, Pratricia A
Conrad, George R. Flores, Grant L. Campbell,
Martin E. Schriefer, Dana Gallo, and Duc J.
Vugia. Seroepidemiology of Emerging Tickborne
Infectious Diseases in a Northern California
Community. The Journal of Infectious Diseases,
1997, June, Vol 175, page 1434
55
In an NIH-supported study of 219 Sonoma County
residents (eastern slope of foothills in the
Sonoma Valley in a subdivision) 51
reported they had a tick bite in past 12
months 13 believed they had Lyme disease 1.4
had antibodies to Borrelia burgdorferi.
Curtis L. Fritz, Anne M. Kjemtrup, Pratricia A
Conrad, George R. Flores, Grant L. Campbell,
Martin E. Schriefer, Dana Gallo, and Duc J.
Vugia. Seroepidemiology of Emerging Tickborne
Infectious Diseases in a Northern California
Community. The Journal of Infectious Diseases,
1997, June, Vol 175, page 1434
56
Prevention
57
Prevention - patient education - protective
clothing - inspection for ticks after outdoor
activities - removal of ticks
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 435
58
Diagnosis
59
Lyme disease is a clinical diagnosis and
laboratory tests should only be used to clarify
diagnostic issues
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 427
60
Testing
61
Often best not to test. In the presence of
erythema migrans, routine serologic testing for
antibodies to Borrelia burgdorferi is not
recommended.
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 433
62
Why not test? Many false positives 3-5 of
population has false positive ELISA or
IFA for anti-Borrelia antibodies.
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 433
63
Potential false positives syphilis pinta yaws be
jel leptospirosis juvenile rheumatoid
arthritis systemic lupus erythematosus mononucleos
is subacute bacterial endocarditis
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 433
64
Why so many false positives? The ELISA uses
whole cell lysates or partially purified B.
burgdorferi this is an efficient way to get
antigen, but also creates a medium rich in
antigens to which the tested serum
antibodies could react.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 259.
65
Also false negatives IgG is often negative in
early disease, - usually not evident until
6-8 weeksafter disease onset - titers peak
at 6 months Igm also can be negative early on,
- first rise a few weeks after infection
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 28.
66
Even a test with a very high specificity will
produce large numbers of false positives if
applied to a population with a low prevalence of
the disease.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 260.
67
What tests are available here? ELISA
screen confirmed by Western Blot for IgG and
IgM
68
How do you run the test? Red-top tube of
patients serum store tube in refrigerator deliv
er within two days to Sonoma County Public
Health Laboratory 3313 Chanate Road Santa Rosa,
CA 95404 [phone]
69
How much does it cost? ELISA
24 Western Blot 67 (done only if positive
ELISA)
70
no PCR available in this county yet
71
For now, avoid the commercial labs which
promise easy Lyme urine test. in a recent
study of one lab, urine was taken from 10
healthy volunteers each sample was divided into
5 identical samples and sent to lab.
Results - each volunteers sample had at
least 1 positive result - concordance between
identical samples was no better than chance
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 264.
72
How do we interpret the Western blot test?
73
(No Transcript)
74
CDC Lyme disease Western Blot criteria Positive
for Lyme disease by IgM criteria if 2 of
the following 3 bands are present 24 kd 39
kd 41 kd
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 28.
75
CDC Lyme disease Western Blot criteria Positive
for Lyme disease by IgG criteria if 5 of the
following 10 bands are present 18 kd 21 kd 28
kd 30 kd 39 kd 41 kd 45 kd 58 kd 66 kd 93
kd
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 28.
76
Can we test the ticks? Yes! Sonoma County
Public health will run IFA on tick. Submit moist
tick, dead or alive, in small container. Costs
20 per tick. Results run about 2 positive
source David Yong, PhD (telephone chat, July
2001) Lab Director, Sonoma County
Department of Health
77
Clinical Course
78
In past, Lyme disease was compared to
syphilis and similar terminology was
used. Now, most authors use a three-stage
clinical classification.
79
Lyme Disease, three stages - early
localized Lyme disease - early disseminated Lyme
disease - chronic or late Lyme disease
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 18.
80
Early localized Lyme disease hallmark is
erythema migrans appears in 50-80 of infected
people 2 to 30 days after bite of infected
tick some folks are otherwise asymptomatic most
people have accompanying flu-like
symptoms fever fatigue myalgia headache
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 18.
81
Early disseminated Lyme disease neurologic
manifestations lymphocytic meningitis facial
palsy peripheral neuropathy cardiac
manifestations conduction defects myopericarditi
s cardiomyopathy
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 21.
82
Neuroborreliosis occurs in 10-15 of untreated
early disseminated Lyme disease most commonly
lymphocytic meningitis or facial palsy
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 20.
83
Of the neurologic involvements, facial palsy
is the most common (40-50 of patients with
neurologic involvement). Approx 30 of
patients with facial palsy will have it on
both sides. Antibiotic therapy does not appear
to alter the course of resolution.
Prognosis is excellent.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 253.
84
Headache and neck stiffness are reported by
56 and 42 of patients with acute Lyme
disease. Antibiotics may hasten the resolution
of these systems, but evidence is scant.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 251.
85
Lyme carditis 5 of untreated early disseminated
Lyme disease cases will progress to Lyme
carditis
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 20.
86
Most common manifestation is AV
block. Clinical symptoms include - fatigue -
syncope - shortness of breath -
palpitations - chest pain this usually resolves
in one week even without treatment.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 251.
87
Most symptoms of early Lyme disease resolve
even without antibiotic treatment.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 254.
88
Late or Chronic Lyme disease musculoskeletal
manifestations neurologic manifestations cutane
ous manifestations
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 21.
89
Late musculoskeletal manifestations
90
monoarthritis and oligoarthritis - onset of
arthritis usually within first year if
left untreated. - attacks usually intermittent
and last anywhere from 3 days to 12
months. - knees are most often affected, but
other large and small joint arthritides also
reported. - a small percentage progress to
erosive arthritis
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 255.
91
Late neurologic manifestations subtle
encephalopathies most common changes in
concentration memory mood sleep
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 255.
92
Encephalomyelitis is rare (changes focal neurologic deficits CSF shows
lymphocytic pleocytosis antibiotics improve or
halt progression
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 255.
93
Peripheral neuropathies rare but
possible typically manifest as paresthesias
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 256.
94
Late Cutaneous Manifestations lymphocytoma acrode
rmatitis chronicum atrophicans
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 254.
95
Lymphocytoma - solitary red-blue nodules -
composed of dense lymphocyte infiltrate - often
in ear lobes of children - often in nipples of
adults resolve with antibiotic treatment
96
Acrodermatitis chronicum atrophicans - usually
caused by Borrelia garinii Borrelia
afzelii - thus more common in Europe - begins
as blue-red lesion with doughy consistency -
evolves to atrophic or sclerotic lesion - most
commonly in distal extremities
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 255.
97
Post-treatment Chronic Lyme Disease -
controversial - causes unclear - ? autoimmune
disorder - studies plagued by poor definitions
of syndrome
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 257.
98
One web site gives this self-diagnosis
questionnaire 1. Tick bite? 2. Rash at bite
site? 3. Rashes at other sites? 4. Joint/muscle
pain in feet? 5. Swelling in toes, balls of
feet? 6. Ankle pain? 7. Burning in feet? 8. Shin
splints? 9. Unexpected fevers, sweats, or
chills? 10. Unexpected weight change (loss or
gain)? 11. Fatigue, tiredness? 12. Unexplained
hair loss? 13. Swollen glands? 14. Sore
throat? 15. Testicular pain/ pelvic pain?
99
16. Unexplained menstrual irregularity? 17.
Unexplained milk production? 18. Irritable
bladder or bladder dysfunction? 19. Sexual
dysfunction or loss of libido? 20. Upset
stomach? 21. Change in bowel function
(constipation, diarrhea)? 22. Chest pain or rib
soreness? 23. Shortness of breath, cough? 24.
Heart palpitations, pulse skips, heart block? 25.
Joint pain or swelling? 26. Stiffness of the
joints, neck, or back? 27. Muscle pain or
cramps? 28. Twitching of the face or other
muscles? 29. Headache?
100
30. Neck creaks or cracks, neck stiffness? 31.
Tingling, numbness, burning, or stabbing
sensations? 32. Facial paralysis (Bells
palsy)? 33. Eyes/vision double, blurry, pain,
increased floaters? 34. Ears/hearing buzzing,
ringing, ear pain? 35. Dizziness, poor balance,
increased motion sickness? 36. Lightheadedness,
wooziness, difficulty walking? 37. Tremor? 38.
Confusion, difficulty in thinking? 39. Difficulty
with concentration or reading? 40. Forgetfulness,
poor short term memory? 41. Disorientation
getting lost, going to wrong places? 42.
Difficulty with speech? 43. Mood swings,
irritability, depression? 44. Disturbed sleep
too much, too little, early awakening? 45.
Exaggerated symptoms or worse hangover from
alcohol?
101
Quite hard to study with such diffuse definitions.
102
Post-treatment chronic lyme disease - often
significant disability - normal results
for nerve conduction studies CSF
studies PCR studies Borrelia cultures
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 255.
103
Post-Treatment Chronic Lyme Disease no studies
have shown that antibiotics help long-term
antibiotics are not recommended at this time (
in spite of internet self-help group
demands) NIH has sponsored two
placebo-controlled double-blind studies.
Hu, Linden T., and Klempner, Mark S. Update on
the Prevention, Diagnosis and Treatment of Lyme
Disease, Advances in Internal Medicine, 2001,
46page 255.
104
Treatment
105
Whom do you treat? - definitely treat if you see
erythema migrans - dont treat simple tick bites
Mary E. Verdun, Recognition and Management of
Lyme Disease American Family Physician, August
1997, page 435
106
How do you treat? Oral therapy early localized
disease IV therapy early disseminated
disease late disease
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 22.
107
Oral Therapy - 2 weeks adults doxycycline
100mg po bid x 10-14 days amoxicillin 500mg po
tid x 10-14 days children (doses should be
divided appropriately) amoxicillin 40mg/kg/day e
rythromycin 30mg/kg/day
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 28.
108
Remember, though, no doxycycline for children
younger than 9 years old or for pregnant women.
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 22.
109
Intravenous Therapy - 3 to 4 weeks ( for
early disseminated or late disease
) adults ceftriaxone 2 grams qd or 1 gram
bid cefotaxime 3 grams bid penicillin G 20
million units q 4 hours children ceftriaxone
50-100mg/kg/day in 2 divided doses cefotaxime 15
0mg/kg/day in 4 divided doses penicillin
G 250,000 units/kg/day in 6 divided doses
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 28.
110
One interesting twist Klein argues that oral
doxycycline is as effective as IV ceftriaxone
in neuroborreliosis
Natalie C. Klein and Burke A. Cunha, Lyme
Disease Unmasking the Great Imitator, Emergency
Medicine, July 1997, page 21.
111
Do you treat simple tick bites? Maybe! Study of
- 482 people in Lyme-endemic area - confirmed
Ixodes tick bites - randomized to doxycyline
200mg po or placebo results erythema migrans
developed in 1 doxycycline recipient 8
placebo recipients thus maybe we should treat in
high-risk areas
Nadelman RB et al, Prophylaxis with single dose
doxycycline for he prevention of Lyme disease
after an Ixodes scapularis tick bite, New
England Journal of Medicine, July 12 2001, pages
79-84
112
Controversies
113
Controversies Dr. Allen Steere did later
research on chronic Lyme disease and decided
over half of those patients had no evidence of
Lyme disease.
David Gran, New York Times Magazine June 17, 2001
page 55
114
Since then, he has been harrassed by Lyme
disease advocacy groups. - in 1993, Senate
hearing was packed with Lyme disease advocates
who yelled Hes wrong, Hes wrong! while he
was giving testimony. - complaints to medical
board (closed after investigation) - death
threats
David Gran, New York Times Magazine June 17, 2001
pages 53-57
115
Thankfully, he continues his research.
David Gran, New York Times Magazine June 17, 2001
page 57.
116
Take-home messages Lyme disease is caused by a
spirochete. Only infected ticks can transmit
Lyme disease. Infected ticks are uncommon in
California. Erythema migrans is diagnosis
enough. Testing is fraught with
peril. Treatment is short and efficacious.