LYME DISEASE Spring Update

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LYME DISEASESpring Update

• Joseph J. Burrascano Jr. M.D.
• East End Medical Associates, P.C.
• East Hampton, NY

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WHAT IS LYME DISEASE?

• Lyme Disease is the illness that results from the
  bite of an infected deer tick

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The Deer Tick

• Adult Female Deer Tick

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The Deer Tick

• The three life stages of the deer tick

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The Deer Tick

• Tick Larva

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The Deer Tick

• Both are deer ticks!
• The one on the right is
• engorged

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The Dog Tick

• Dog ticks on top-
• note the pattern
• on shell
• Deer tick on bottom

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Lone Star Ticks

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Lyme- Nationwide

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More Than Just Lyme Disease!

• Lyme- spirochete Borrelia burgdorferi
• very complex bacterium
• Bartonella- newly discovered bacterium, and very
  common
• Babesiosis- blood parasite distantly related to
  Malaria
• Ehrlichiosis (Anaplasma)- blood cell bacterium

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Co-Infections

• Quite common as the deer tick may carry several
  infections
• Symptoms overlap
• Co-infected patients are more ill
• Co-infected patients require more intensive
  treatments
• Difficult to determine whether someone is
  co-infected

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LYME DISEASEBorrelia burgdorferi

• Gradual onset of symptoms
• FEWER THAN HALF get the bullseye rash
• Bells palsy and heart problems are rare!
• Symptoms-
• fatigue, aches, neck pain and stiffness, headache
• then involvement of the brain and nerves
• joint pain and arthritis

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TYPES OF LYME DISEASE

• Early Lyme Disease (Stage I)
• At or before the onset of symptoms
• Can be cured if treated properly
• Disseminated Lyme (Stage II)
• Multiple major body systems affected
• More difficult to treat
• Chronic Lyme Disease (Stage III)
• Ill for one or more years
• Serologic tests less reliable
• Treatment must be more aggressive and of longer
  duration

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Erythema Migrans

• Typical bullseye rash
• Several concentric circles
• Expands over time
• Painless
• Raised
• May be warm

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Erythema Migrans

• Uniform Rash

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Erythema Migrans

• Large rash with gradual change of color intensity

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Erythema Migrans

• Not always circular!

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Erythema Migrans

• Less often recognized rashes- may miss the
  diagnosis

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Erythema Migrans

• Atypical rashes

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Other RashesNot Lyme Disease

• RINGWORM
• Scaly center
• Not raised or warm
• SPIDER BITE
• Painful!
• Necrotic center

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Lymphocytoma

• Hot, red, tender ear
• May also involve the nipple
• Site of active infection with B. burgdorferi

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Bells Palsy

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BARTONELLA

• Possibly the most common tick-borne disease in
  our area
• Gradual onset
• Rarely a rash- can be stretch marks, raised red
  dots, painful spider veins
• Symptoms- brain fog, irritability, low grade
  fevers, sore nodules deep under skin, sore soles,
  enlarged lymph nodes, abdominal pain, gastritis

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Bartonella Rashes

• Red bumps- may form scabs

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Bartonella Rashes

• Linear rashes- look like stretch marks
• Photos taken by Dr. Martin Fried, with thanks to
  the Lyme Disease Association

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More Bartonella

• Back of legs

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Bartonella

• Lower back

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Bartonella

• Under the arm

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BABESIOSIS

• Acute and chronic forms
• Acute-
• Abrupt onset of symptoms no rash
• Sweats, high fever, chills, dark urine, acute
  anemia, severe illness
• Can be fatal!
• Chronic-
• Fatigue, headache, severe night sweats, air
  hunger, dry cough, off balance

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EHRLICHIOSIS

• Less common than the other tick-borne infections
• Acute and chronic forms
• Acute- rarely causes a rash
• Abrupt onset, high fever, muscle pain, headache,
  low WBC count, elevated liver tests
• Chronic-
• Headaches and muscle soreness

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Rocky Mountain Spotted Fever

• From the bite of a Dog Tick
• Abrupt onset
• Rash is common- large spots including on hands
  and feet
• Headache, fever, body pains
• Low WBC, elevated liver enzymes,
• Can be fatal
• Responds rapidly to Doxycycline

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Rocky Mountain Spotted Fever

• Hand, foot, arm

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DIAGNOSING TICK-BORNE INFECTIONS

• Not a simple task!

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Clinical Diagnosis because blood tests are not
accurate enough to be definitive

• History
• Symptoms and their onset
• Changes in symptoms over time
• Specific tests for the various tick-borne
  diseases
• Tests to rule out other illnesses
• Response to treatment

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Lyme Disease- Lab Tests

• Blood tests will not become positive for several
  weeks after the tick bite
• Blood tests pick up 50 to 70 of cases
• Can be 5 to 10 false positives
• DNA technology- PCR
• 30 sensitive but 100 specific
• Urine antigen capture
• Also 30 sensitive but 100 specific

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Bartonella Blood Tests

• No test for the newly discovered strain!
• Cat Scratch Disease tests pick up only 20 of
  cases
• Can test blood and spinal fluid
• Can test tissue biopsies

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Babesia Blood Tests

• Standard blood smear useful only during the first
  two weeks of illness
• With diseases of longer duration, may have to
  test with a variety of methods
• FISH
• PCR
• Serology
• No single test is very sensitive

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Babesiosis

• Blood smear in acute infections
• Ring forms
• Maltese Cross

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Babesiosis

• FISH test in chronic infections
• Fluorescent dye
• 100 times more sensitive than standard smears
• (Fluorescent in-situ hybridization assay)

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Ehrlichia Blood Tests

• Nonspecific tests
• Low WBC count and elevated liver enzymes
• Specific tests
• Antibody tests and DNA tests (PCR)
• None are very sensitive

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Antibiotic Therapy
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ROUTE OF ADMINISTRATION

• Repeated Antibiotic Treatment in Chronic Lyme
  Disease (Fallon, JSTBD, 1999)
• No response to placebo
• Slight benefit from oral antibiotics
• Intramuscular benzathine penicillin more
  effective than oral antibiotics
• Intravenous therapy most effective

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ANTIBIOTIC CHOICESOral antibiotics

• Amoxicillin probenecid, Augmentin XR
• Cefuroxime (Ceftin)
• Doxycycline, minocycline and tetracycline
• Clarithromycin (Biaxin), Azithromycin
  (Zithromax), Telithromycin (Ketek)
• Metronidazole (Flagyl)
• Rifampin

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BICILLIN-LA

• Injection of long acting penicillin- Benzathine
  Penicillin
• Efficacy is close to that of IVs!
• 1.2 million U- 3 or 4 doses per week
• No GI side effects and minimal yeast
• Excellent foundation for combination Rx
• Given for 6 to 12 months

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INDICATIONS FOR INTRAVENOUS THERAPY

• Abnormal spinal fluid (WBC, Protein)
• Acute Heart Block
• Synovitis with high ESR
• Illness for more than one year
• Age over 60
• Prior use of steroids
• Failure or intolerance of oral therapy

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INTRAVENOUS THERAPY

• Ceftriaxone (Rocephin) still used the most
• Current recommendation 2 grams twice a day, 4
  days in a row each week
• more effective
• safer, and better lifestyle
• can use peripheral IV line
• May also prescribe Actigall to prevent gallstones
  (Bb in gallbladder!)

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INTRAVENOUS THERAPYOther Options

• Cefotaxime (Claforan)
• Doxycycline
• Azithromycin (Zithromax)
• Vancomycin
• Imipenem (Primaxin)

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KEY POINTS- I

• In chronic Lyme Disease, infection may persist
  despite prior antibiotic therapy
• Repeated or prolonged antibiotic therapy may be
  necessary- follow 4-week cycles
• Illogical to follow serologies
• PCR positivity and low CD-57 counts imply
  persisting, active infection
• Search for co-infections (clinical diagnosis!)

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KEY POINTS- II

• Do not use too low a dose
• Antibiotic combinations
• Target all morphologic forms of Borrelia
• Treat all body compartments
• Appropriate route of administration
• Appropriate duration of therapy
• Supportive measures
• Treat co-infections

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LYME DISEASE AND PREGNANCY
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Lyme Disease and Pregnancy

• The Lyme spirochete, Borrelia burgdorferi, can be
  transmitted from mother to baby
• Acute Lyme infection during the first trimester
  is most likely to cause problems
• However, any stage of active Lyme can affect the
  fetus at any stage of pregnancy
• Full spectrum includes miscarriage, stillbirth,
  serious birth defects, apparently healthy babies
  who became ill later on, and sudden infant death

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Lyme Disease and Pregnancy

• LDF Pregnancy Registry
• Followed pregnant Lyme patients
• Study ran over 11 years
• My patients have continued to be monitored
• Looked for adverse effects on the baby and on the
  mother

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Lyme Disease and Pregnancy

• FINDINGS
• If the mother was kept on appropriate antibiotic
  therapy for the duration of the pregnancy, then
  there were NO ADVERSE FETAL OUTCOMES RELATED TO
  LYME
• No adverse effects to the baby from the
  antibiotic therapy
• Breast milk can carry the Lyme spirochete, and
  possibly be infectious to the baby

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Lyme Disease and Pregnancy

• THE MOTHER
• Goal of treatment is to protect the baby, even if
  the treatment is not optimal for the mother
• Most felt better while pregnant!
• No evidence of increased maternal problems from
  the Lyme
• Serious post partum depression is very common and
  should be expected
• Parents must arrange for help at home for at
  least the first month after delivery

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Lyme Disease and Pregnancy

• PROCEDURE
• Mother to be placed on antibiotics known to be
  safe, and follow a rigid schedule!
• Antibiotics should begin before conception and be
  continued through to after delivery
• Antibiotics can be oral (amoxicillin,
  cefuroxime), injection (Bicillin LA), or
  intravenous (ceftriaxone or cefotaxime)
• Must monitor antibiotic blood levels when oral
  meds are used

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Lyme Disease and Pregnancy

• TESTING
• At delivery, test cord blood and placenta for
  Lyme and Bartonella by PCR (and culture if
  available)
• Test babys urine monthly for Lyme by PCR
• No breast feeding
• Lyme literate pediatrician to follow babys
  development

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LYME DISEASE MANAGEMENT ISSUES

• Lyme and its co-infections comprise a complicated
  medial condition with many effects on nearly all
  body systems
• EVERY item must be addressed and corrected, or
  full recovery will not occur
• Attention to even the smallest detail

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More Than an Infection

• Immune system
• Neurotoxins
• Hormonal disturbances
• Deconditioning and tissue damage
• Nutritional disturbances
• Metabolic effects

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TreatmentMore Than Antibiotics!

• Enforced rest
• No caffeine
• No alcohol
• No smoking at all
• Vitamins and other nutritional support
• Exercise program

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Proper Tick Removal

• Fine tweezers- Grasp tick close to the skin and
  pull straight out
• No chemicals
• No heat
• Try not to break open the tick
• Save the tick for identification and testing

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Proper Tick Removal

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Prevention
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Prevention
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Prevention

• Personal protection
• Avoid tick-infected areas
• Check for ticks while outside and after coming
  inside
• DEET on skin
• Permethrin on clothing
• Long pants and pull socks up, over cuffs

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Prevention

• Property protection
• Deer fence
• Rodent control
• Damminix and mouse bait boxes
• Yard sprays twice each spring and each fall,
  using permethrins
• Remove wood piles, rock walls, bird feeders
• Clear brush away from active yard areas

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Resources

• Lyme Disease Association
• www.lymediseaseassociation.org
• International Lyme and Associated Diseases
  Society
• www.ILADS.org
• Lyme Disease Foundation
• www.lyme.org
• Foundation for the Advancement of Innovative
  Medicine
• www.FAIM.org

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THANK YOU!