People treated with appropriate antibiotics in the early stages of Lyme disease usually recover rapidly and completely.

Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or cefuroxime axetil.

People with certain neurological or cardiac forms of illness may require intravenous treatment with antibiotics such as ceftriaxone or penicillin.

Treatment regimens listed in the following table are for localized (early) Lyme disease.

See references below (Hu 2016; Sanchez 2016) for treatment of patients with disseminated (late) Lyme disease.

These regimens are guidelines only and may need to be adjusted depending on a person’s age, medical history, underlying health conditions, pregnancy status, or allergies. *Recent publications suggest the efficacy of shorter courses of treatment for early Lyme disease.

NOTE: For people intolerant of amoxicillin, doxycycline, and cefuroxime axetil, the macrolides azithromycin, clarithromycin, or erythromycin may be used, although they have a lower efficacy.

People treated with macrolides should be closely monitored to ensure that symptoms resolve The National Institutes of Health (NIH) has funded several studies on the treatment of Lyme disease that show most people recover when treated within a few weeks of antibiotics taken by mouth.

In a small percentage of cases, symptoms such as fatigue (being tired) and muscle aches can last for more than 6 months.

This condition is known as “Post-treatment Lyme Disease Syndrome” (PTLDS), although it is often called “chronic Lyme disease.” For details on research into “chronic Lyme disease” and long-term treatment trials sponsored by NIH, visit the visit the National Institutes of Health Lyme Disease web site.

Kowalski  TJ, Tata  S, Berth  W, Mathiason  MA, Agger  WA.  Antibiotic treatment duration and long-term outcomes of patients with early Lyme disease from a Lyme disease-hyperendemic area.

Diagnosis, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: A review. JAMA.

Stupica  D, Lusa  L, Ruzić-Sabljić  E, Cerar  T, Strle  F.  Treatment of erythema migrans with doxycycline for 10 days versus 15 days.If Lyme disease is not diagnosed and treated early, it may become late-stage or chronic.

This may also occur when early treatment is inadequate.

While some symptoms of chronic or late stage Lyme disease are similar to those of early Lyme, as the graphic below shows, there are important differences.  Lyme disease may spread to any part of the body and affect any body system.

In our survey, which drew over 5,000 responses, patients with chronic Lyme disease reported an average of three severe or very severe symptoms, with 74% reporting at least one symptom as severe or very severe.

An extensive list of symptoms of chronic Lyme disease was developed by Dr.

Joseph Burrascano, a pioneer in treating chronic Lyme disease.Two Standards of Care There is significant controversy in science, medicine, and public policy regarding Lyme disease.

Two medical societies hold widely divergent views on the best approach to diagnosing and treating Lyme disease.

The conflict makes it difficult for patients to be properly diagnosed and receive treatment.

One medical society, the Infectious Diseases Society of America (IDSA), regards Lyme disease as “hard to catch and easy to cure” with a short course of antibiotics.

IDSA claims that spirochetal infection cannot persist in the body after a short course of antibiotics.

The group also denies the existence of chronic Lyme disease.

In contrast, the International Lyme and Associated Diseases Society (ILADS), regards Lyme disease as often difficult to diagnose and treat, resulting in persistent infection in many patients.

ILADS recommends individualized treatment based on the severity of symptoms, the presence of tick-borne coinfections and patient response to treatment.

LDo believes that patients and their doctors should make Lyme disease treatment decisions together.

This requires that patients be given sufficient information about the risks and benefits of different treatment options.

Then, patient and health care provider can collaborate to reach an informed decision, based on the patient’s circumstances, beliefs and preferences.

LDo endorses the ILADS guidelines, which allow greater exercise of clinical discretion by physicians and provide patients with more treatment options.

It is the doctor’s responsibility to tell patients about the different treatment options so that patients can make an informed choice.

Early Lyme ILADS doctors are likely to recommend more aggressive and longer antibiotic treatment for patients.

They may, for instance, treat “high risk” tick bites where the tick came from an endemic area, was attached a long time, and was removed improperly.

They may treat a Lyme rash for a longer period of time than the IDSA recommends, to ensure that the disease does not progress.

They are unlikely to withhold treatment pending laboratory test results.

Late or Chronic Lyme Experts agree that the earlier you are treated the better, since early treatment is often successful.

Unfortunately, a substantial portion of patients treated with short-term antibiotics continue to have significant symptoms.

The quality of life of patients with chronic Lyme disease is similar to that of patients with congestive heart failure.

Doctors don’t agree about the cause of these ongoing symptoms.

The primary cause of this debate is flawed diagnostic testing.

There is currently no test that can determine whether a patient has active infection or whether the infection has been eradicated by treatment.

The IDSA thinks Lyme disease symptoms after treatment represent a possibly autoimmune, “post-Lyme syndrome” that is not responsive to antibiotics.

The IDSA essentially regards Lyme disease as an acute infection like strep throat that can be treated with a short course of antibiotics.

The IDSA guidelines are now eight years old and do not reflect recent science.

ILADS physicians believe that ongoing symptoms probably reflect active infection, which should be treated until the symptoms have resolved.

These physicians use treatment approaches employed for persistent infections like tuberculosis, including a combination of drugs and longer treatment durations.

The ILADS guidelines have just recently been updated using a rigorous review of the medical literature.

The ideal antibiotics, route of administration and duration of treatment for persistent Lyme disease are not established.

No single antibiotic or combination of antibiotics appears to be capable of completely eradicating the infection, and treatment failures or relapses are reported with all current regimens, although they are less common with early aggressive treatment.

All medical treatments have risks associated with them.

While the safety profile of antibiotics is generally quite good, only the patient (in consultation with his or her physician) can determine whether the risks outweigh the potential benefits of any medical treatment.

An ILADS doctor may consider the possibility of tick-borne coinfections, particularly if a patient does not respond to treatment or relapses when treatment is terminated.

Other factors to consider are immune dysfunction caused by Lyme; silent, opportunistic infections enabled by the immune dysfunction; hormonal imbalance caused by Lyme; and other complications.

Considerations while on treatment Antibiotics can wipe out beneficial intestinal flora, leading to a wide variety of additional health problems.

It is important to take probiotics while on antibiotics to maintain a healthy balance of gut bacteria.

Furthermore, antibiotics may interact with other drugs, supplements or food.

The National Institutes of Health’s MedLinePlus website gives information about drug interactions.Overview Lyme disease is an underreported, under-researched, and often debilitating disease transmitted by spirochete bacteria.

The spiral-shaped bacteria, Borrelia burgdorferi, are transmitted by blacklegged deer ticks.

Lyme’s wide range of symptoms mimic those of many other ailments, making it difficult to diagnose (1, 2).

The blacklegged ticks can also transmit other disease-causing bacteria, viruses, and parasites.

These ticks that transmit Lyme are increasing their geographical spread.

As of 2016, they were found in about half the counties in 43 of 50 states in the United States (3).

Lyme is the fifth most reported of notifiable diseases in the United States, with an estimated 329,000 new cases found annually (4).

But in some states, estimates suggest that Lyme disease is profoundly underreported (4).

Some studies estimate that there are as many as 1 million cases of Lyme in the United States every year (5).

Most people with Lyme who are treated right away with three weeks of antibiotics have a good prognosis.

But if you’re not treated for weeks, months, or even years after infection, Lyme becomes more difficult to treat.

Within days of the bite, the bacteria can move to your central nervous system, muscles and joints, eyes, and heart (6, 7).

Lyme is sometimes divided into three categories: acute, early disseminated, and late disseminated.

But the progression of the disease can vary by individual, and not all people go through each stage (8).

Every individual reacts to the Lyme bacteria differently.

Here is a list of 13 common signs and symptoms of Lyme disease.

Rashes The signature rash of a Lyme tick bite looks like a solid red oval or a bull’s-eye.

The bull’s-eye has a central red spot, surrounded by a clear circle with a wide red circle on the outside.

The rash is a sign that the infection is spreading within your skin tissues.

The rash expands and then resolves over time, even if you’re not treated.

Thirty percent or more of people with Lyme disease don’t remember having the rash (9).

The ticks in the nymph stage are the size of poppy seeds, and their bites are easy to miss.

The initial red rash usually appears at the site of the bite within 3 to 30 days (11).

Similar but smaller rashes can appear three to five weeks later, as the bacteria spread through tissues (12).

The rash can also take other forms, including a raised rash or blisters (14).

If you do have a rash, it’s important to photograph it and see your doctor to get treated promptly.

Summary: If you see a flat rash shaped like an oval or bull’s-eye anywhere on your body, it could be Lyme.

Fatigue Whether or not you see the tick bite or the classic Lyme rash, your early symptoms are likely to be flu-like.

Symptoms are often cyclical, waxing and waning every few weeks (12).

Tiredness, exhaustion, and lack of energy are the most frequent symptoms.

The Lyme fatigue can seem different from regular tiredness, where you can point to activity as a cause.

This fatigue seems to take over your body and can be severe.

You may find yourself needing a nap during the day, or needing to sleep one or more hours longer than usual.

In one study, about 84 percent of children with Lyme reported fatigue (8).

In a 2013 study of adults with Lyme, 76 percent reported fatigue (15).

Sometimes Lyme-related fatigue is misdiagnosed as chronic fatigue syndrome, fibromyalgia, or depression (8).

In some Lyme cases, fatigue can be disabling (16).

Summary: Extreme fatigue is a frequent symptom of Lyme.

Achy, stiff, or swollen joints Joint pain and stiffness, often intermittent, are early Lyme symptoms.

Your joints may be inflamed, warm to the touch, painful, and swollen.

You may have stiffness and limited range of motion in some joints (1).

Sometimes your knees may hurt, whereas other times it’s your neck or your heels.

Bursae are the thin cushions between bone and surrounding tissue.

The pain may be severe, and it may be transitory.

People often attribute joint problems to age, genetics, or sports.

Lyme should be added to that list, as these statistics indicate: One study estimates that 80 percent of people with untreated Lyme have muscle and joint symptoms (17).

Fifty percent of people with untreated Lyme have intermittent episodes of arthritis (17).

Two-thirds of people have their first episode of joint pain within six months of the infection (18).

Use of anti-inflammatory drugs may mask the actual number of people with joint swelling (19).

Summary: Joint pain that comes and goes, or moves from joint to joint, could be a sign of Lyme.

Headaches, dizziness, fever Other common flu-like symptoms are headaches, dizziness, fever, muscle pain, and malaise.

About 50 percent of people with Lyme disease have flu-like symptoms within a week of their infection (18).

Your symptoms may be low-level, and you may not think of Lyme as a cause.

For example, when fever occurs, it’s usually low-grade (18).

In fact, it can be difficult to distinguish Lyme flu symptoms from a common flu or viral infection.

But, unlike a viral flu, for some people the Lyme flu-like symptoms come and go.

Here are a few statistics from different studies of Lyme patients: Seventy-eight percent of children in one study reported headaches (8).

Forty-eight percent of adults with Lyme in one study reported headaches (20).

Fifty-one percent of children with Lyme reported dizziness (8).

In a 2013 study of adults with Lyme, 30 percent experienced dizziness (15).

Thirty-nine percent of children with Lyme reported fevers or sweats (8).

Among adults with Lyme, 60 percent reported fever in a 2013 study (15).

Forty-three percent of children with Lyme reported neck pain (8).

A smaller number of children with Lyme reported sore throats (8).

Summary: Low-level flu symptoms that periodically return could be a sign of Lyme.

Night sweats and sleep disturbances Sleep disturbances in Lyme are common.

Your body temperature may fluctuate, and night sweats or chills can wake you.

Here are some of the statistics from studies: In a 2013 study, 60 percent of adults with early Lyme reported sweats and chills (15).

The same study reported that 41 percent experienced sleep disturbances (15).

Twenty-five percent of children with Lyme reported disturbed sleep (8).

Summary: Sleep disturbances are common with Lyme, including night sweats and chills.

Cognitive decline There are many kinds and degrees of cognitive disturbances, and they can be scary.

You may notice that you have difficulty concentrating in school or at work.

Your memory may have lapses that weren’t there before.

You may have to reach to remember a familiar name.

You may feel as though you’re processing information more slowly.

Sometimes when driving or taking public transportation to a familiar place, you may forget how to get there.

Or you may be confused about where you are or why you’re there.

You might get to a store to shop, but entirely forget what it was that you were supposed to look for.

You might at first attribute this to stress or age, but the decline in capabilities may worry you.

Here are some statistics: Seventy-four percent of children with untreated Lyme reported cognitive problems (8).

Twenty-four percent of adults with early Lyme reported difficulty concentrating (15).

In later Lyme, 81 percent of adults reported memory loss (21).

Summary: Lyme bacteria can affect your brain and mental processes.

Sensitivity to light and vision changes Bright indoor light may feel uncomfortable or even blinding.

Light sensitivity is bad enough for some people to need sunglasses indoors, in addition to wearing sunglasses outdoors in normal light.

Light sensitivity was found in 16 percent of adults with early Lyme (15).

In the same study, 13 percent reported blurry vision.

Summary: Light sensitivity, including to indoor light, is a symptom of Lyme.

Other neurological problems Neurological symptoms can be subtle and sometimes specific.

In general, you may feel unsure of your balance or less coordinated in your movements.

Walking down a slight incline on your driveway might take an effort that it never did before.

You might trip and fall more than once, although this never happened to you before.

For example, the Lyme bacteria may affect one or more of your cranial nerves.

These are the 12 pairs of nerves that come from your brain to your head and neck area.

If the bacteria invade the facial nerve (the seventh cranial nerve), you can develop muscle weakness or paralysis on one or both sides of your face.

This palsy is sometimes mistakenly called Bell’s palsy.

Lyme disease is one of the few illnesses that cause palsies on both sides of the face.

Or you may have numbness and tingling on your face.

Other affected cranial nerves can cause loss of taste and smell.

A Centers for Disease Control and Prevention (CDC) study of 248,074 reported Lyme disease cases nationwide from 1992 to 2006 found that 12 percent of Lyme patients had cranial nerve symptoms (9).

As the Lyme bacteria spread through the nervous system, they can inflame the tissues where the brain and spinal cord meet (the meninges).

Some of the common symptoms of Lyme meningitis are neck pain or stiffness, headache, and light sensitivity.

Encephalopathy, which alters your mental state, is less common.

These neurological symptoms occur in about 10 percent of adult individuals with untreated Lyme disease (18).

Summary: Neurological problems, ranging from balance issues, to stiff neck, to facial palsy, could be symptoms of Lyme.

Skin outbreaks Skin symptoms appear early in Lyme (21).

You may have unexplained skin rashes or large bruises without usual cause.

They could also be more serious, such as B cell lymphoma (21).

Other skin ailments associated with Lyme are: morphea, or discolored patches of skin (21) lichen sclerosus, or white patches of thin skin (21) parapsoriasis, a precursor to skin lymphoma In Europe, some of the skin diseases that result from Lyme transmitted by a different Borrelia species are: borrelial lymphocytoma, which is common in Europe as an early Lyme marker (22) acrodermatitis chronica atrophicans (21) Summary: In addition to the classic Lyme rash, other unexplained rashes can be Lyme symptoms.

Heart problems Lyme bacteria can invade your heart tissue, a condition called Lyme carditis.

The bacterial interference in your heart can cause chest pains, light-headedness, shortness of breath, or heart palpitations (23).

The inflammation caused by the infection blocks the transmission of electrical signals from one chamber of the heart to the other, so the heart beats irregularly.

Here are some statistics: The CDC reports that only 1 percent of reported Lyme cases involve carditis (23).

Other studies report that 4 to 10 percent of Lyme patients (or more) have carditis (24, 25).

However, these figures may include a broader definition of carditis.

With treatment, most people will recover from an episode of Lyme carditis.

The CDC reported three sudden Lyme carditis deaths from 2012–2013 (26).

Summary: Lyme bacteria can affect your heart, producing a range of symptoms.

You may be more irritable, anxious, or depressed.

Twenty-one percent of early Lyme patients reported irritability as a symptom.

Ten percent of Lyme patients in the same study reported anxiety (15).

Unexplained pain and other sensations Some people with Lyme may have sharp rib and chest pains that send them to the emergency room, suspecting a heart problem (27).

When no problem is found, after the usual testing, the ER diagnosis is noted as an unidentified “musculoskeletal” cause.

You can also have strange sensations like skin tingling or crawling, or numbness or itchiness (27).

Tinnitus can be a nuisance, especially at bedtime when it seems to get louder as you’re trying to fall asleep.

About 10 percent of people with Lyme experience this (15).

One study reported that 15 percent of Lyme patients experienced loss of hearing (28).

Jaw pain or toothaches that are not related to actual tooth decay or infection.

Summary: Lyme can be the cause of unexplained sensations or pain.

Regression and other symptoms in children Children are the largest population of Lyme patients.

The CDC study of reported Lyme cases from 1992–2006 found that the incidence of new cases was highest among 5- to 14-year-olds (9).

About one quarter of reported Lyme cases in the United States involve children under 14 years old (29).

Children can have all the signs and symptoms of Lyme that adults have, but they may have trouble telling you exactly what they feel or where it hurts.

You may notice a decline in school performance, or your child’s mood swings may become problematic.

Your child’s social and speech skills or motor coordination may regress.

Children are more likely than adults to have arthritis as an initial symptom (25).

In a 2012 Nova Scotian study of children with Lyme, 65 percent developed Lyme arthritis (30).

Summary: Children have the same Lyme symptoms as adults, but are more likely to have arthritis.

What to do if you suspect Lyme disease If you have some of the signs and symptoms of Lyme, see a doctor — preferably one familiar with treating Lyme disease!

The International Lyme and Associated Diseases Society (ILADS) can provide a list of Lyme-aware doctors in your area (31).

Summary: Find a doctor familiar with treating Lyme disease.

The commonly used ELISA test is not a reliable indicator for many Lyme patients (32).

The Western blot test tends to be more sensitive, but it still misses 20 percent or more of Lyme cases (32).

If you don’t have the initial Lyme rash, diagnosis is usually based on your symptoms and your potential exposure to blacklegged ticks.

The doctor will rule out other possible diseases that may cause the same symptoms.

Summary: Lyme diagnosis is usually based on your symptoms.

What to do if you have a blacklegged tick bite Remove the tick by pulling it directly out with fine-tipped tweezers.

Don’t crush it or put soap or other substances on it.

See if you can identify what kind of a tick it is.

Immediately after removing the tick, wash your skin well with soap and water or with rubbing alcohol.

The Lyme bacteria is transmitted only by blacklegged ticks in their nymph or adult stage.

The doctor will want to determine if it’s a blacklegged tick and if there’s evidence of feeding.

Your risk of getting Lyme from an infected tick increases with the length of time that the tick fed on your blood.

Summary: Pull the tick out with tweezers and save it in a resealable container for identification.

Antibiotics work If you have the classic Lyme rash or other symptoms of early Lyme, you’ll need at least three weeks of oral antibiotics.

Shorter courses of treatment have resulted in a 40 percent relapse rate (33).

Even with three weeks of antibiotics, you may need one or more courses of antibiotics if your symptoms return.

Lyme is tricky and affects different people in different ways.

The longer you’ve had symptoms, the more difficult it is to treat.

Summary: At least three weeks of oral antibiotics are recommended when you have symptoms of early Lyme.

The bottom line Lyme is a serious tick-borne disease with a wide range of symptoms.

If you get treated as soon as possible with an adequate course of antibiotics, you’ll have a better outcome.Early Signs and Symptoms (3 to 30 days after tick bite) Fever, chills, headache, fatigue, muscle and joint aches, and swollen lymph nodes Erythema migrans (EM) rash: Occurs in approximately 70 to 80 percent of infected persons Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days) Expands gradually over a period of days reaching up to 12 inches or more (30 cm) across May feel warm to the touch but is rarely itchy or painful Sometimes clears as it enlarges, resulting in a target or “bull’s-eye” appearance May appear on any area of the body See examples of EM rashes Later Signs and Symptoms (days to months after tick bite) Severe headaches and neck stiffness Additional EM rashes on other areas of the body Arthritis with severe joint pain and swelling, particularly the knees and other large joints.Editor's note: This article was updated on May 10, 2018.

And as it continues to expand its range into the southern and western U.

S. and into Canada, it’s likely that the number of Lyme disease cases in North America will climb, experts say.

A recent CDC study found that cases of Lyme increased more than 80% between 2004 and 2016 -- from 19,804 to 36,429.

The CDC estimates there are more than 300,000 cases of Lyme infection in the U.

S. each year -- or 10 times as many as what is reported. “There’s obviously year-to-year bouncing around, but the trend line is upward,” says John Aucott, MD, director of the Johns Hopkins Lyme Disease Clinical Research Center in Baltimore. “It won’t stop in the foreseeable future.” Most cases are clustered in 14 states in the Northeast and Upper Midwest, but Lyme has been reported as far south as Florida and Mexico, and increasingly, in Canada.

The black-legged tick (Ixodes scapularis), also known as the deer tick, carries the bacteria that causes Lyme infection.

The same tick also can spread other diseases, including babesiosis, anaplasmosis, and Powassan virus -- other diseases on the rise in the U.

Here’s more about the disease and what to expect this year and beyond.

Lyme disease is caused by bacteria, Borrelia burgdorferi that are transmitted to humans through a bite from an infected black-legged or deer tick.

Symptoms can occur anywhere from 3 to 30 days after the bite and can be wide-ranging, depending on the stage of the infection.

In some cases, symptoms can appear months after the bite.

The chances you might get Lyme disease from a tick bite depend on the kind of tick, where you were when the bite occurred, and how long the tick was attached to you, the CDC says.

Black-legged ticks must be attached to you for 36 to 48 hours to transmit Lyme disease.

If you remove the tick or ticks within 48 hours, you aren’t likely to get infected, says Cleveland Clinic infectious disease specialist Alan Taege, MD.

Early signs and symptoms include fever, chills, headache, fatigue, muscle and joint pain, and swollen lymph nodes -- all common in the flu.

In up to 80% of Lyme infections, a rash is one of the first symptoms, Aucott says.

They might include: Severe headache or neck stiffness Rashes on other areas of the body Arthritis with severe joint pain and swelling, particularly in the knees Loss of muscle tone or “drooping” on one or both sides of the face.

Heart palpitation or an irregular heartbeat Inflammation of the brain and spinal cord Shooting pains, numbness, or tingling in the hands or feet What does the rash look like?

About 20% to 30% of Lyme rashes have a “bull's-eye” appearance -- concentric circles around a center point -- but most are round and uniformly red and at least 5 centimeters (about 2 inches) across, Aucott says. “Most are just red,” he says. “They do not have the classic ring within a ring like the Target logo.” The rash expands gradually over a period of days and can grow to about 12 inches across, the CDC says.

It may feel warm to the touch, but it rarely itches or is painful, and it can appear on any part of the body.

TIcks come in three sizes, depending on their stage of life.

Larvae are the size of grains of sand, nymphs the size of poppy seeds, and adults the size of an apple seed.  How is Lyme disease diagnosed?

Doctors diagnose it based on symptoms and a history of tick exposure.

Two-step blood tests are helpful if used correctly.

But the accuracy of the test depends on when you got infected.

In the first few weeks of infection, the test may be negative, as antibodies take a few weeks to develop.

Tests aren’t recommended for patients who don’t have Lyme disease symptoms.

Aucott says the most promising development in the fight against Lyme disease are better diagnostic tests that are accurate in the first few weeks after exposure.

The earlier the treatment, the less likely the disease will progress.

Aucott says he expects the tests to be available soon.

Doctors may not recognize symptoms, especially those who practice in areas where Lyme infection isn’t prevalent, and up to 30% of the infections are not accompanied by a rash.

There are three stages: Early localized Lyme: Flu-like symptoms such as fever, chills, headache, swollen lymph nodes, sore throat, and typically a rash that has a “bull's-eye” appearance or is uniformly round and red and at least 5 centimeters in size Early disseminated Lyme: Flu-like symptoms that now include pain, weaknessor numbness in the arms and legs, vision changes, heart palpitations and chest pain, a rash, and facial paralysis (Bell’s palsy) Late disseminated Lyme: This can occur weeks, months, or years after the tick bite.

Symptoms might include arthritis, severe fatigue and headaches, vertigo, sleep disturbances, and mental confusion.

While experts don’t understand it, roughly 10% of people treated for Lyme infection do not shake the disease.

They may go on to have three core symptoms -- joint or muscle pain, fatigue, and short-term memory loss or mental confusion This is called post-treatment Lyme disease syndrome.

It’s considered controversial because its symptoms are shared with other diseases and there isn’t a blood test to diagnose it, Aucott says.

There are theories as to why Lyme symptoms become chronic.

One is that the body continues fighting the infection long after the bacteria are gone, much like an autoimmune disorder.

Antibiotics are used to treat early stage Lyme infection.

Patients typically take doxycycline for 10 days to 3 weeks, or amoxicillin and cefuroxime for 2 to 3 weeks.

In up to 90% of cases, the antibiotic cures the infection.

If it doesn’t, patients might get other antibiotics either by mouth or intravenously.

For early disseminated Lyme disease, which may happen when a Lyme infection goes untreated, oral antibiotics are recommended for symptoms such as facial palsy and abnormal heart rhythm.

Intravenous antibiotics are recommended if a person has meningitis, inflammation of the lining of the brain and spinal cord, or more severe heart problems.

In late-stage Lyme, a patient may receive oral or intravenous antibiotics.

Patients with lingering arthritis would receive standard arthritis treatment.

There is no treatment for post-treatment Lyme disease syndrome. “Ten percent of people don’t get better after antibiotics,” Aucott says. “We think it’s very significant if 30,000 people a year don’t get better.” What areas are more likely to have it?

Mainly New England, the Mid-Atlantic states, and part of the Upper Midwest.

The CDC says 95% of confirmed cases in 2016 were in 14 states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.

From 2006 to 2016, case numbers have increased in Ohio, Indiana, and Michigan as the tick’s range expands westward.

In 2016, the highest number of confirmed Lyme infection cases -- 9,000 -- was reported in Pennsylvania, followed by New Jersey, with more than 3,300 cases.

S., which is more prone to hot weather, ticks tend to stay under leaf litter and don’t come up higher to feed much, Aucott says -- “ticks don’t like to dry out.” This means Southern ticks don’t transmit Lyme as frequently because they don’t tend to feed on humans.

Infection is more common in males up to age 15 and between the ages of 40 and 60, says Taege. “These are people who are more likely to play outside, and go camping, hunting, and hiking,” he says.

Aucott adds that Lyme infection drops off in older teens and those in their 20s “because they’re inside on their computers.” Older adults, he says, tend to have more time to work in their backyards, which is where most Lyme infection is transmitted.

Scientists point to a variety of causes for the spread of Lyme infection.

Among them are reforestation, especially in the Northeast U.

S., where Lyme disease is more prevalent; climate change and temperature extremes; suburbanization; and more exposure to the white-tailed deer, which is the black-legged tick’s favorite mode of travel.

Development led to record low numbers of deer early in the last century, says CDC epidemiologist Paul Mead, MD.

But the deer population has rebounded as reforestation took place over several decades, meaning the tick population has risen and expanded as well. “Ticks have a pretty long life cycle, lasting 2-3 years, and typically don’t move very far within their lifetime, so it takes a while to see large changes,” he says.

Deer and white-footed mice, which transmit Lyme disease to ticks that bite them, are moving closer to humans as their habitats disappear, says Taege.

Ticks don’t mind dogs, either, which carry them into homes and spread them to their humans.

Another reason: Warmer weather and mild winters may bring more people outside, raising their chances of being bitten, particularly in Lyme-prone areas, Taege says. “Whether you believe in global warming or not, we have longer, warmer summer months, and people are outdoors more,” says Taege. “We’ve seen an expansion [of ticks] in areas in which the vectors live, and we’ve slowly seen more Lyme disease.” That doesn’t mean you should be afraid of outdoor activities, as long as you take precautions to avoid tick bites, Aucott says.

Ticks can’t fly or jump, but instead live in shrubs and bushes, and grab onto someone when they pass by.

To avoid getting bitten: Wear pants and socks in the woods, areas with lots of trees, and while handling fallen leaves Wear a tick repellent on your skin and clothing that has DEET, lemon oil, or eucalyptus.

For even more protection, use the chemical permethrin on clothing and camping gear.

Shower within 2 hours after coming inside, if possible.

Look at your skin and wash ticks out of your hair.

Put your clothing and any exposed gear into a hot dryer to kill whatever pests might remain.

Given that the ticks are the size of a poppy seed, you’ve got to have pretty good eyes.

The CDC recommends that if you’ve been walking in the woods, in tall grass, or working in the garden, check your skin afterward, ideally in the shower or bath.

That way, you’ve removed your clothes, which may carry ticks, too.

What do you do if there’s a tick under your skin?

Remove it with a pair of fine-tipped tweezers as soon as possible, pulling upward with steady pressure.

If parts of the tick remain in the skin, also try to remove them with the tweezers.

After everything is out, clean the bite area with rubbing alcohol or soap and water.

Mead says you’re not likely to get infected if you remove the tick within 36 to 48 hours.

Some people have an allergic reaction to ticks, so they’ll notice a bite right away.

Place it in soapy water or alcohol, stick it to a piece of tape, or flush it down the toilet.

When should you see a doctor if you suspect you have Lyme?

The rash is a pretty good indication that you may have been bitten.

Take a photo of the rash and see your doctor, Aucott says.

At this stage of the illness, treatment with antibiotics will probably be successful.

If you don’t have the telltale rash but have a summer flu -- fatigue, fever, headache but no respiratory symptoms like a cough -- you may want to talk to your doctor, Aucott says.

Is there any progress on a vaccine for Lyme disease?

The FDA in July 2017 gave "fast-track" approval to French biotech company Valneva to test potential Lyme disease vaccine VLA15 on adults in the U.

Data from the first phase are expected to be released soon, and then the second phase will begin.

The more ticks in your region, the likelier it is that your furry pal will bring them home.

Dogs are much more likely than humans to be bitten by ticks, and where Lyme disease is more prevalent, up to 25% of dogs have evidence of past infection, he says. “On the flip side, low rates of exposure in dogs is a good indicator that Lyme is not a problem in the area.” And they can get sick.

About 10% of dogs with Lyme disease will become ill.

Common symptoms, which may show up 7-21 days after a tick bite, are lameness -- your dog will appear to be walking on eggshells -- a fever, lethargy, and enlarged lymph nodes.

Practice prevention habits and use a tick control product on your pet.Lyme disease, also known as Lyme borreliosis, is an infectious disease caused by bacteria of the Borrelia type which is spread by ticks.[2] The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans, that begins at the site of a tick bite about a week after it has occurred.[1] The rash is typically neither itchy nor painful.[1] Approximately 25–50% of infected people do not develop a rash.[1] Other early symptoms may include fever, headache and feeling tired.[1] If untreated, symptoms may include loss of the ability to move one or both sides of the face, joint pains, severe headaches with neck stiffness, or heart palpitations, among others.[1] Months to years later, repeated episodes of joint pain and swelling may occur.[1] Occasionally, people develop shooting pains or tingling in their arms and legs.[1] Despite appropriate treatment, about 10 to 20% of people develop joint pains, memory problems, and feel tired for at least six months.[1][5] Lyme disease is transmitted to humans by the bite of infected ticks of the genus Ixodes.[6] Usually, the tick must be attached for 36 to 48 hours before the bacteria can spread.[7] In North America, Borrelia burgdorferi and Borrelia mayonii are the cause.[2][8] In Europe and Asia, the bacteria Borrelia afzelii and Borrelia garinii are also causes of the disease.[2] The disease does not appear to be transmissible between people, by other animals, or through food.[7] Diagnosis is based upon a combination of symptoms, history of tick exposure, and possibly testing for specific antibodies in the blood.[3][9] Blood tests are often negative in the early stages of the disease.[2] Testing of individual ticks is not typically useful.[10] Prevention includes efforts to prevent tick bites such as by wearing long pants and using DEET.[2] Using pesticides to reduce tick numbers may also be effective.[2] Ticks can be removed using tweezers.[11] If the removed tick was full of blood, a single dose of doxycycline may be used to prevent development of infection, but is not generally recommended since development of infection is rare.[2] If an infection develops, a number of antibiotics are effective, including doxycycline, amoxicillin, and cefuroxime.[2] Standard treatment usually lasts for two or three weeks.[2] Some people develop a fever and muscle and joint pains from treatment which may last for one or two days.[2] In those who develop persistent symptoms, long-term antibiotic therapy has not been found to be useful.[2][12] Lyme disease is the most common disease spread by ticks in the Northern Hemisphere.[13] It is estimated to affect 300,000 people a year in the United States and 65,000 people a year in Europe.[2][4] Infections are most common in the spring and early summer.[2] Lyme disease was diagnosed as a separate condition for the first time in 1975 in Old Lyme, Connecticut.[14] It was originally mistaken for juvenile rheumatoid arthritis.[14] The bacterium involved was first described in 1981 by Willy Burgdorfer.[15] Chronic symptoms following treatment are well described and are known as post-treatment Lyme disease syndrome (PTLDS).[12] PTLDS is different to chronic Lyme disease; a no longer supported term used in different ways by different groups.[12] Some healthcare providers claim that it is due to ongoing infection; however, this is not believed to be true, due to the inability to detect infectious organisms after standard treatment.[16] A Lyme vaccine was marketed in the US between 1998 and 2002; it was withdrawn from the market due to poor sales, originally due to lack of reimbursement by insurance companies and then due to rumors about adverse effects.[2][17] Research is ongoing to develop new vaccines.[2] Contents Signs and symptoms This "classic" bull's-eye rash is also called erythema migrans.

A rash caused by Lyme does not always look like this and approximately 25% of those infected with Lyme disease may have no rash. [1] [18] Raised, red borders around indurated central portion Lyme disease can affect multiple body systems and produce a broad range of symptoms.

Not all patients with Lyme disease have all symptoms, and many of the symptoms are not specific to Lyme disease, but can occur with other diseases, as well.

The incubation period from infection to the onset of symptoms is usually one to two weeks, but can be much shorter (days), or much longer (months to years).[19] Symptoms most often occur from May to September, because the nymphal stage of the tick is responsible for most cases.[19] Asymptomatic infection exists, but occurs in less than 7% of infected individuals in the United States.[20] Asymptomatic infection may be much more common among those infected in Europe.[21] Early localized infection Early localized infection can occur when the infection has not yet spread throughout the body.

Only the site where the infection has first come into contact with the skin is affected.

The classic sign of early local infection with Lyme disease is a circular, outwardly expanding rash called erythema chronicum migrans (EM), which occurs at the site of the tick bite three to 32 days after the tick bite.[2] The rash is red, and may be warm, but is generally painless.

Classically, the innermost portion remains dark red and becomes indurated (is thicker and firmer), the outer edge remains red, and the portion in between clears, giving the appearance of a bull's eye.

However, partial clearing is uncommon, and the bull's-eye pattern more often involves central redness.[2] The EM rash associated with early infection is found in about 70–80% of people infected.[1] It can have a range of appearances including the classic target bull's-eye lesion and nontarget appearing lesions.

The 20–30% without the EM and the nontarget lesions can often cause misidentification of Lyme disease.[22] Affected individuals can also experience flu-like symptoms, such as headache, muscle soreness, fever, and malaise.[23] Lyme disease can progress to later stages even in people who do not develop a rash.[21][24] Early disseminated infection Within days to weeks after the onset of local infection, the Borrelia bacteria may begin to spread through the bloodstream.

EM may develop at sites across the body that bear no relation to the original tick bite.[25] Another skin condition, apparently absent in North American patients, but found in Europe, is borrelial lymphocytoma, a purplish lump that develops on the ear lobe, nipple, or scrotum.[26] Various acute neurological problems, termed neuroborreliosis, appear in 10–15% of untreated people.[23][27] These include facial palsy, which is the loss of muscle tone on one or both sides of the face, as well as meningitis, which involves severe headaches, neck stiffness, and sensitivity to light.

Inflammation of the spinal cord's nerve roots can cause shooting pains that may interfere with sleep, as well as abnormal skin sensations.

Mild encephalitis may lead to memory loss, sleep disturbances, or mood changes.

In addition, some case reports have described altered mental status as the only symptom seen in a few cases of early neuroborreliosis.[28] The disease may adversely impact the heart's electrical conduction system and can cause abnormal heart rhythms such as atrioventricular block.[29] Late disseminated infection After several months, untreated or inadequately treated patients may go on to develop severe and chronic symptoms that affect many parts of the body, including the brain, nerves, eyes, joints, and heart.

Many disabling symptoms can occur, including permanent impairment of motor or sensory function of the lower extremities in extreme cases.[21] The associated nerve pain radiating out from the spine is termed Bannwarth syndrome,[30] named after Alfred Bannwarth.

The late disseminated stage is where the infection has fully spread throughout the body.

Chronic neurologic symptoms occur in up to 5% of untreated patients.[23] A polyneuropathy that involves shooting pains, numbness, and tingling in the hands or feet may develop.

A neurologic syndrome called Lyme encephalopathy is associated with subtle cognitive difficulties, insomnia, a general sense of feeling unwell, and changes in personality.[31] Other problems, however, such as depression and fibromyalgia, are no more common in people with Lyme disease than in the general population.[32][33] Chronic encephalomyelitis, which may be progressive, can involve cognitive impairment, brain fog, migraines, balance issues, weakness in the legs, awkward gait, facial palsy, bladder problems, vertigo, and back pain.

In rare cases, untreated Lyme disease may cause frank psychosis, which has been misdiagnosed as schizophrenia or bipolar disorder.

Panic attacks and anxiety can occur; also, delusional behavior may be seen, including somatoform delusions, sometimes accompanied by a depersonalization or derealization syndrome, where the patients begin to feel detached from themselves or from reality.[34][35] Lyme arthritis usually affects the knees.[36] In a minority of patients, arthritis can occur in other joints, including the ankles, elbows, wrists, hips, and shoulders.

Pain is often mild or moderate, usually with swelling at the involved joint.

Acrodermatitis chronica atrophicans (ACA) is a chronic skin disorder observed primarily in Europe among the elderly.[26] ACA begins as a reddish-blue patch of discolored skin, often on the backs of the hands or feet.

The lesion slowly atrophies over several weeks or months, with the skin becoming first thin and wrinkled and then, if untreated, completely dry and hairless.[37] Cause Deer tick life cycle Borrelia bacteria, the causative agent of Lyme disease, magnified Ixodes scapularis, the primary vector of Lyme disease in eastern North America Tick Ixodes ricinus, developmental stages Lyme disease is caused by spirochetal bacteria from the genus Borrelia.

Spirochetes are surrounded by peptidoglycan and flagella, along with an outer membrane similar to other Gram-negative bacteria.

Because of their double-membrane envelope, Borrelia bacteria are often mistakenly described as Gram negative despite the considerable differences in their envelope components from Gram-negative bacteria.[38] The Lyme-related Borrelia species are collectively known as Borrelia burgdorferi sensu lato, and show a great deal of genetic diversity.

B. burgdorferi sensu lato is made up of 21 closely related species, but only three clearly cause Lyme disease: B. burgdorferi sensu stricto (predominant in North America, but also present in Europe), B. afzelii, and B. garinii (both predominant in Eurasia).[39][40] Some studies have also proposed B. bissettii and B. valaisiana may sometimes infect humans, but these species do not seem to be important causes of disease.[41][42] Transmission Lyme disease is classified as a zoonosis, as it is transmitted to humans from a natural reservoir among small mammals and birds by ticks that feed on both sets of hosts.[43] Hard-bodied ticks of the genus Ixodes are the main vectors of Lyme disease (also the vector for Babesia).[44] Most infections are caused by ticks in the nymphal stage, because they are very small and thus may feed for long periods of time undetected.[43] Larval ticks are very rarely infected.[45] Although deer are the preferred hosts of the adult stage of deer ticks, and tick populations are much lower in the absence of deer, ticks generally do not acquire Lyme disease spirochetes from deer.

Rather, deer ticks acquire Borrelia microbes from infected small mammals and occasionally birds, including the white-footed mouse, Peromyscus leucopus.[46] Within the tick midgut, the Borrelia's outer surface protein A (OspA) binds to the tick receptor for OspA, known as TROSPA.

When the tick feeds, the Borrelia downregulates OspA and upregulates OspC, another surface protein.

After the bacteria migrate from the midgut to the salivary glands, OspC binds to Salp15, a tick salivary protein that appears to have immunosuppressive effects that enhance infection.[47] Successful infection of the mammalian host depends on bacterial expression of OspC.[48] Tick bites often go unnoticed because of the small size of the tick in its nymphal stage, as well as tick secretions that prevent the host from feeling any itch or pain from the bite.

However, transmission is quite rare, with only about 1% of recognized tick bites resulting in Lyme disease.

In Europe, the vector is Ixodes ricinus, which is also called the sheep tick or castor bean tick.[49] In China, Ixodes persulcatus (the taiga tick) is probably the most important vector.[50] In North America, the black-legged tick or deer tick (Ixodes scapularis) is the main vector on the East Coast.[45] The lone star tick (Amblyomma americanum), which is found throughout the Southeastern United States as far west as Texas, is unlikely to transmit the Lyme disease spirochetes,[51] though it may be implicated in a related syndrome called southern tick-associated rash illness, which resembles a mild form of Lyme disease.[52] On the West Coast of the United States, the main vector is the western black-legged tick (Ixodes pacificus).[53] The tendency of this tick species to feed predominantly on host species such as lizards that are resistant to Borrelia infection appears to diminish transmission of Lyme disease in the West.[54][55] Transmission across the placenta during pregnancy has not been demonstrated, and no consistent pattern of teratogenicity or specific "congenital Lyme borreliosis" has been identified.

As with a number of other spirochetal diseases, adverse pregnancy outcomes are possible with untreated infection; prompt treatment with antibiotics reduces or eliminates this risk.[56][57] While Lyme spirochetes have been found in insects, as well as ticks,[58] reports of actual infectious transmission appear to be rare.[59] Lyme spirochete DNA has been found in semen[60] and breast milk.[61] However, according to the CDC, live spirochetes have not been found in breast milk, urine, or semen and thus is not sexually transmitted.[62] Tick-borne coinfections Ticks that transmit B. burgdorferi to humans can also carry and transmit several other parasites, such as Theileria microti and Anaplasma phagocytophilum, which cause the diseases babesiosis and human granulocytic anaplasmosis (HGA), respectively.[63] Among early Lyme disease patients, depending on their location, 2–12% will also have HGA and 2–40% will have babesiosis.[64] Ticks in certain regions, including the lands along the eastern Baltic Sea, also transmit tick-borne encephalitis.[65] Coinfections complicate Lyme symptoms, especially diagnosis and treatment.

It is possible for a tick to carry and transmit one of the coinfections and not Borrelia, making diagnosis difficult and often elusive.

The Centers for Disease Control and Prevention studied 100 ticks in rural New Jersey, and found 55% of the ticks were infected with at least one of the pathogens.[66] Pathophysiology B. burgdorferi can spread throughout the body during the course of the disease, and has been found in the skin, heart, joints, peripheral nervous system, and central nervous system.[48][67] Many of the signs and symptoms of Lyme disease are a consequence of the immune response to the spirochete in those tissues.[23] B. burgdorferi is injected into the skin by the bite of an infected Ixodes tick.

Tick saliva, which accompanies the spirochete into the skin during the feeding process, contains substances that disrupt the immune response at the site of the bite.[68] This provides a protective environment where the spirochete can establish infection.

The spirochetes multiply and migrate outward within the dermis.

The host inflammatory response to the bacteria in the skin causes the characteristic circular EM lesion.[48] Neutrophils, however, which are necessary to eliminate the spirochetes from the skin, fail to appear in the developing EM lesion.

This allows the bacteria to survive and eventually spread throughout the body.[69] Days to weeks following the tick bite, the spirochetes spread via the bloodstream to joints, heart, nervous system, and distant skin sites, where their presence gives rise to the variety of symptoms of the disseminated disease.

The spread of B. burgdorferi is aided by the attachment of the host protease plasmin to the surface of the spirochete.[70] If untreated, the bacteria may persist in the body for months or even years, despite the production of B. burgdorferi antibodies by the immune system.[71] The spirochetes may avoid the immune response by decreasing expression of surface proteins that are targeted by antibodies, antigenic variation of the VlsE surface protein, inactivating key immune components such as complement, and hiding in the extracellular matrix, which may interfere with the function of immune factors.[72][73] In the brain, B. burgdorferi may induce astrocytes to undergo astrogliosis (proliferation followed by apoptosis), which may contribute to neurodysfunction.[74] The spirochetes may also induce host cells to secrete quinolinic acid, which stimulates the NMDA receptor on nerve cells, which may account for the fatigue and malaise observed with Lyme encephalopathy.[75] In addition, diffuse white matter pathology during Lyme encephalopathy may disrupt gray matter connections, and could account for deficits in attention, memory, visuospatial ability, complex cognition, and emotional status.

White matter disease may have a greater potential for recovery than gray matter disease, perhaps because the neuronal loss is less common.

Resolution of MRI white matter hyperintensities after antibiotic treatment has been observed.[76] Tryptophan, a precursor to serotonin, appears to be reduced within the central nervous system in a number of infectious diseases that affect the brain, including Lyme.[77] Researchers are investigating if this neurohormone secretion is the cause of neuropsychiatric disorders developing in some patients with borreliosis.[78] Immunological studies Exposure to the Borrelia bacterium during Lyme disease possibly causes a long-lived and damaging inflammatory response,[79] a form of pathogen-induced autoimmune disease.[80] The production of this reaction might be due to a form of molecular mimicry, where Borrelia avoids being killed by the immune system by resembling normal parts of the body's tissues.[81][82] Chronic symptoms from an autoimmune reaction could explain why some symptoms persist even after the spirochetes have been eliminated from the body.

This hypothesis may explain why chronic arthritis persists after antibiotic therapy, similar to rheumatic fever, but its wider application is controversial.[83][84] Diagnosis Lyme disease is diagnosed clinically based on symptoms, objective physical findings (such as EM, facial palsy, or arthritis), or a history of possible exposure to infected ticks, as well as serological blood tests.

The EM rash is not always a bull's eye, i.e., it can be solid red.

When making a diagnosis of Lyme disease, health care providers should consider other diseases that may cause similar illnesses.

Not all individuals infected with Lyme disease develop the characteristic bull's-eye rash, and many may not recall a tick bite.[85] Because of the difficulty in culturing Borrelia bacteria in the laboratory, diagnosis of Lyme disease is typically based on the clinical exam findings and a history of exposure to endemic Lyme areas.[44] The EM rash, which does not occur in all cases, is considered sufficient to establish a diagnosis of Lyme disease even when serologic blood tests are negative.[86][87] Serological testing can be used to support a clinically suspected case, but is not diagnostic by itself.[44] Diagnosis of late-stage Lyme disease is often complicated by a multifaceted appearance and nonspecific symptoms, prompting one reviewer to call Lyme the new "great imitator".[88] Lyme disease may be misdiagnosed as multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, lupus, Crohn's disease, HIV, or other autoimmune and neurodegenerative diseases.

As all people with later-stage infection will have a positive antibody test, simple blood tests can exclude Lyme disease as a possible cause of a person's symptoms.[89] Laboratory testing Several forms of laboratory testing for Lyme disease are available, some of which have not been adequately validated.

The most widely used tests are serologies, which measure levels of specific antibodies in a patient's blood.

These tests may be negative in early infection as the body may not have produced a significant quantity of antibodies, but they are considered a reliable aid in the diagnosis of later stages of Lyme disease.[90] Serologic tests for Lyme disease are of limited use in people lacking objective signs of Lyme disease because of false positive results and cost.[91] The serological laboratory tests most widely available and employed are the Western blot and ELISA.

A two-tiered protocol is recommended by the Centers for Disease Control and Prevention: the sensitive ELISA test is performed first, and if it is positive or equivocal, then the more specific Western blot is run.[92] The reliability of testing in diagnosis remains controversial.[44] Studies show the Western blot IgM has a specificity of 94–96% for people with clinical symptoms of early Lyme disease.[93][94] The initial ELISA test has a sensitivity of about 70%, and in two-tiered testing, the overall sensitivity is only 64%, although this rises to 100% in the subset of people with disseminated symptoms, such as arthritis.[95] Erroneous test results have been widely reported in both early and late stages of the disease, and can be caused by several factors, including antibody cross-reactions from other infections, including Epstein–Barr virus and cytomegalovirus,[96] as well as herpes simplex virus.[97] The overall rate of false positives is low, only about 1 to 3%, in comparison to a false-negative rate of up to 36% in the early stages of infection using two-tiered testing.[95] Polymerase chain reaction (PCR) tests for Lyme disease have also been developed to detect the genetic material (DNA) of the Lyme disease spirochete.

PCR tests are susceptible to false positive results from poor laboratory technique.[98] Even when properly performed, PCR often shows false negative results with blood and cerebrospinal fluid specimens.[99] Hence, PCR is not widely performed for diagnosis of Lyme disease, but it may have a role in the diagnosis of Lyme arthritis because it is a highly sensitive way of detecting ospA DNA in synovial fluid.[100] Culture or PCR are the current means for detecting the presence of the organism, as serologic studies only test for antibodies of Borrelia.

OspA antigens, shedded by live Borrelia bacteria into urine, are a promising technique being studied.[101] The use of nanotrap particles for their detection is being looked at and the OspA has been linked to active symptoms of Lyme.[102][103] High titers of either immunoglobulin G (IgG) or immunoglobulin M (IgM) antibodies to Borrelia antigens indicate disease, but lower titers can be misleading, because the IgM antibodies may remain after the initial infection, and IgG antibodies may remain for years.[104] Western blot, ELISA, and PCR can be performed by either blood test via venipuncture or cerebrospinal fluid (CSF) via lumbar puncture.

Though lumbar puncture is more definitive of diagnosis, antigen capture in the CSF is much more elusive; reportedly, CSF yields positive results in only 10–30% of affected individuals cultured.

The diagnosis of neurologic infection by Borrelia should not be excluded solely on the basis of normal routine CSF or negative CSF antibody analyses.[105] New techniques for clinical testing of Borrelia infection have been developed, such as LTT-MELISA,[106] although the results of studies are contradictory.

The first peer reviewed study assessing the diagnostic sensitivity and specificity of the test was presented in 2012 and demonstrated potential for LTT to become a supportive diagnostic tool.[107] In 2014, research of LTT-MELISA concluded that it is "sensible" to include the LTT test in the diagnostic protocol for putative European-acquired Lyme borreliosis infections.[108] Other diagnostic techniques, such as focus floating microscopy, are under investigation.[109] New research indicates chemokine CXCL13 may also be a possible marker for neuroborreliosis.[110] Some laboratories offer Lyme disease testing using assays whose accuracy and clinical usefulness have not been adequately established.

These tests include urine antigen tests, PCR tests on urine, immunofluorescent staining for cell-wall-deficient forms of B. burgdorferi, and lymphocyte transformation tests.

The CDC does not recommend these tests, and stated their use is "of great concern and is strongly discouraged".[99] Imaging Neuroimaging is controversial in whether it provides specific patterns unique to neuroborreliosis, but may aid in differential diagnosis and in understanding the pathophysiology of the disease.[111] Though controversial, some evidence shows certain neuroimaging tests can provide data that are helpful in the diagnosis of a patient.

Magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) are two of the tests that can identify abnormalities in the brain of a patient affected with this disease.

Neuroimaging findings in an MRI include lesions in the periventricular white matter, as well as enlarged ventricles and cortical atrophy.

The findings are considered somewhat unexceptional because the lesions have been found to be reversible following antibiotic treatment.

Images produced using SPECT show numerous areas where an insufficient amount of blood is being delivered to the cortex and subcortical white matter.

However, SPECT images are known to be nonspecific because they show a heterogeneous pattern in the imaging.

The abnormalities seen in the SPECT images are very similar to those seen in people with cerebral vacuities and Creutzfeldt–Jakob disease, which makes them questionable.[112] Prevention Protective clothing includes a hat, long-sleeved shirt, and long pants tucked into socks or boots.

Light-colored clothing makes the tick more easily visible before it attaches itself.

People should use special care in handling and allowing outdoor pets inside homes because they can bring ticks into the house.

People who work in areas with woods, bushes, leaf litter, and tall grass are at risk of becoming infected with Lyme at work.

Employers can reduce the risk for employees by providing education on Lyme transmission and infection risks, and about how to check themselves for ticks on the groin, armpits, and hair.

Work clothing used in risky areas should be washed in hot water and dried in a hot dryer to kill any ticks.[113] Permethrin sprayed on clothing kills ticks on contact, and is sold for this purpose.

According to the CDC, only DEET is effective at repelling ticks.[114] Host animals Lyme and other deer tick-borne diseases can sometimes be reduced by greatly reducing the deer population on which the adult ticks depend for feeding and reproduction.

Lyme disease cases fell following deer eradication on an island, Monhegan, Maine[115] and following deer control in Mumford Cove, Connecticut.[116] It is worth noting that eliminating deer may lead to a temporary increase in tick density.[117] For example, in the U.

S., reducing the deer population to levels of 8 to 10 per square mile (from the current levels of 60 or more deer per square mile in the areas of the country with the highest Lyme disease rates), may reduce tick numbers and reduce the spread of Lyme and other tick-borne diseases.[118] However, such a drastic reduction may be very difficult to implement in many areas, and low to moderate densities of deer or other large mammal hosts may continue to feed sufficient adult ticks to maintain larval densities at high levels.

Routine veterinary control of ticks of domestic animals, including livestock, by use of acaricides can contribute to reducing exposure of humans to ticks.

Action can be taken to avoid getting bitten by ticks by using insect repellants, for example, those that contain DEET.

DEET-containing repellants are thought to be moderately effective in the prevention of tick bites.[119] In Europe known reservoirs of Borrelia burgdorferi were 9 small mammals, 7 medium-sized mammals and 16 species of birds (including passerines, sea-birds and pheasants).[120] These animals seem to transmit spirochetes to ticks and thus participate in the natural circulation of B. burgdorferi in Europe.

The house mouse is also suspected as well as other species of small rodents, particularly in Eastern Europe and Russia.[120] "The reservoir species that contain the most pathogens are the European roe deer Capreolus capreolus;[121] "it does not appear to serve as a major reservoir of B. burgdorferi" thought Jaenson & al. (1992)[122] (incompetent host for B. burgdorferi and TBE virus) but it is important for feeding the ticks,[123] as red deer and wild boars (Sus scrofa),[124] in which one Rickettsia and three Borrelia species were identified",[121] with high risks of coinfection in roe deer.[125] Nevertheless, in the 2000s, in roe deer in Europe " two species of Rickettsia and two species of Borrelia were identified".[124] Vaccination A recombinant vaccine against Lyme disease, based on the outer surface protein A (ospA) of B. burgdorferi, was developed by SmithKline Beecham.

In clinical trials involving more than 10,000 people, the vaccine, called LYMErix, was found to confer protective immunity to Borrelia in 76% of adults and 100% of children with only mild or moderate and transient adverse effects.[126] LYMErix was approved on the basis of these trials by the Food and Drug Administration (FDA) on 21 December 1998.

Following approval of the vaccine, its entry in clinical practice was slow for a variety of reasons, including its cost, which was often not reimbursed by insurance companies.[127] Subsequently, hundreds of vaccine recipients reported they had developed autoimmune and other side effects.

Supported by some patient advocacy groups, a number of class-action lawsuits were filed against GlaxoSmithKline, alleging the vaccine had caused these health problems.

These claims were investigated by the FDA and the Centers for Disease Control, which found no connection between the vaccine and the autoimmune complaints.[128] Despite the lack of evidence that the complaints were caused by the vaccine, sales plummeted and LYMErix was withdrawn from the U.

S. market by GlaxoSmithKline in February 2002,[129] in the setting of negative media coverage and fears of vaccine side effects.[128][130] The fate of LYMErix was described in the medical literature as a "cautionary tale";[130] an editorial in Nature cited the withdrawal of LYMErix as an instance in which "unfounded public fears place pressures on vaccine developers that go beyond reasonable safety considerations."[17] The original developer of the OspA vaccine at the Max Planck Institute told Nature: "This just shows how irrational the world can be...

There was no scientific justification for the first OspA vaccine LYMErix being pulled."[128] New vaccines are being researched using outer surface protein C (OspC) and glycolipoprotein as methods of immunization.[131][132] Vaccines have been formulated and approved for prevention of Lyme disease in dogs.

Currently, three Lyme disease vaccines are available.

LymeVax, formulated by Fort Dodge Laboratories, contains intact dead spirochetes which expose the host to the organism.

Galaxy Lyme, Intervet-Schering-Plough's vaccine, targets proteins OspC and OspA.

The OspC antibodies kill any of the bacteria that have not been killed by the OspA antibodies.

Canine Recombinant Lyme, formulated by Merial, generates antibodies against the OspA protein so a tick feeding on a vaccinated dog draws in blood full of anti-OspA antibodies, which kill the spirochetes in the tick's gut before they are transmitted to the dog.[133] Valneva's hexavalent (OspA) protein subunit-based vaccine candidate VLA15 was granted fast track designation by the U.

Food and Drug Administration in July 2017 which will allow further study.[134] Tick removal Removal of a tick using tweezers Attached ticks should be removed promptly, as removal within 36 hours can reduce transmission rates.[135] Folk remedies for tick removal tend to be ineffective, offer no advantages in preventing the transfer of disease, and may increase the risks of transmission or infection.[136] The best method is simply to pull the tick out with tweezers as close to the skin as possible, without twisting, and avoiding crushing the body of the tick or removing the head from the tick's body.[137] The risk of infection increases with the time the tick is attached, and if a tick is attached for less than 24 hours, infection is unlikely.

However, since these ticks are very small, especially in the nymph stage, prompt detection is quite difficult.[135] The Australian Society of Clinical Immunology recommends against using tweezers to remove ticks but rather to kill the tick first by using a product to rapidly freeze the tick to prevent it from injecting more allergen-containing saliva.

In a tick allergic person, the tick should be killed and removed in a safe place (e.g. an emergency department of a hospital).[138] Preventive antibiotics The risk of infectious transmission increases with the duration of tick attachment.[139] It requires between 36 and 48 hours of attachment for the bacteria that causes Lyme to travel from within the tick into its saliva.[139] If a deer tick that is sufficiently likely to be carrying Borrelia is found attached to a person and removed, and if the tick has been attached for 36 hours or is engorged, a single dose of doxycycline administered within the 72 hours after removal may reduce the risk of Lyme disease.

It is not generally recommended for all people bitten, as development of infection is rare: about 50 bitten people would have to be treated this way to prevent one case of erythema migrans (i.e. the typical rash found in about 70-80% of people infected).[2][139] Occupational exposure Outdoor workers are at risk of Lyme disease if they work at sites with infected ticks.

In 2010, the highest number of confirmed Lyme disease cases were reported from New Jersey, Pennsylvania, Wisconsin, New York, Massachusetts, Connecticut, Minnesota, Maryland, Virginia, New Hampshire, Delaware, and Maine.

S. workers in the northeastern and north-central States are at highest risk of exposure to infected ticks.

Ticks may also transmit other tick-borne diseases to workers in these and other regions of the country.

Worksites with woods, bushes, high grass, or leaf litter are likely to have more ticks.

Outdoor workers should be most careful to protect themselves in the late spring and summer when young ticks are most active.[140] Treatment Antibiotics are the primary treatment.[2][139] The specific approach to their use is dependent on the individual affected and the stage of the disease.[139] For most people with early localized infection, oral administration of doxycycline is widely recommended as the first choice, as it is effective against not only Borrelia bacteria but also a variety of other illnesses carried by ticks.[139] Doxycycline is contraindicated in children younger than eight years of age and women who are pregnant or breastfeeding;[139] alternatives to doxycycline are amoxicillin, cefuroxime axetil, and azithromycin.[139] Individuals with early disseminated or late infection may have symptomatic cardiac disease, refractory Lyme arthritis, or neurologic symptoms like meningitis or encephalitis.[139] Intravenous administration of ceftriaxone is recommended as the first choice in these cases;[139] cefotaxime and doxycycline are available as alternatives.[139] These treatment regimens last from one to four weeks.[139] If joint swelling persists or returns, a second round of antibiotics may be considered.[139] Outside of that, a prolonged antibiotic regimen lasting more than 28 days is not recommended as no clinical evidence shows it to be effective.[139][141] IgM and IgG antibody levels may be elevated for years even after successful treatment with antibiotics.[139] As antibody levels are not indicative of treatment success, testing for them is not recommended.[139] Prognosis For early cases, prompt[specify] treatment is usually curative.[142] However, the severity and treatment of Lyme disease may be complicated due to late diagnosis, failure of antibiotic treatment, and simultaneous infection with other tick-borne diseases (coinfections), including ehrlichiosis, babesiosis, and immune suppression[citation needed] in the patient.

It is believed that less than 5% of people have lingering symptoms of fatigue, pain, or joint and muscle aches at the time they finish treatment.[143] These symptoms can last for more than 6 months.

This condition is called post-treatment lyme disease syndrome.

As of 2016 the reason for the lingering symptoms was not known; the condition is generally managed similarly to fibromyalgia or chronic fatigue syndrome.[144] In dogs, a serious long-term prognosis may result in glomerular disease,[145] which is a category of kidney damage that may cause chronic kidney disease.[133] Dogs may also experience chronic joint disease if the disease is left untreated.

However, the majority of cases of Lyme disease in dogs result in a complete recovery with, and sometimes without, treatment with antibiotics.[146][verification needed] In rare cases, Lyme disease can be fatal to both humans and dogs.[147] Epidemiology Countries with reported Lyme disease cases.

Lyme disease occurs regularly in Northern Hemisphere temperate regions.[148] Africa In northern Africa, B. burgdorferi sensu lato has been identified in Morocco, Algeria, Egypt and Tunisia.[149][150][151] Lyme disease in sub-Saharan Africa is presently unknown, but evidence indicates it may occur in humans in this region.

The abundance of hosts and tick vectors would favor the establishment of Lyme infection in Africa.[152] In East Africa, two cases of Lyme disease have been reported in Kenya.[153] Asia B. burgdorferi sensu lato-infested ticks are being found more frequently in Japan, as well as in northwest China, Nepal, Thailand and far eastern Russia.[154][155] Borrelia has also been isolated in Mongolia.[156] Europe In Europe, Lyme disease is caused by infection with one or more pathogenic European genospecies of the spirochaete B. burgdorferi sensu lato, mainly transmitted by the tick Ixodes ricinus.[157] Cases of B. burgdorferi sensu lato-infected ticks are found predominantly in central Europe, particularly in Slovenia and Austria, but have been isolated in almost every country on the continent.[158] Incidence in southern Europe, such as Italy and Portugal, is much lower.[159] United Kingdom In the United Kingdom the number of laboratory confirmed cases of Lyme disease has been rising steadily since voluntary reporting was introduced in 1986[160] when 68 cases were recorded in the UK and Republic of Ireland combined.[161] In the UK there were 23 confirmed cases in 1988 and 19 in 1990,[162] but 973 in 2009[160] and 953 in 2010.[163] Provisional figures for the first 3 quarters of 2011 show a 26% increase on the same period in 2010.[164] It is thought, however, that the actual number of cases is significantly higher than suggested by the above figures, with the UK's Health Protection Agency estimating that there are between 2,000 and 3,000 cases per year,[163] (with an average of around 15% of the infections acquired overseas[160]), while Dr Darrel Ho-Yen, Director of the Scottish Toxoplasma Reference Laboratory and National Lyme Disease Testing Service, believes that the number of confirmed cases should be multiplied by 10 "to take account of wrongly diagnosed cases, tests giving false results, sufferers who weren't tested, people who are infected but not showing symptoms, failures to notify and infected individuals who don't consult a doctor."[165][166] Despite Lyme disease (Borrelia burgdorferi infection) being a notifiable disease in Scotland[167] since January 1990[168] which should therefore be reported on the basis of clinical suspicion, it is believed that many GPs are unaware of the requirement.[169] Mandatory reporting, limited to laboratory test results only, was introduced throughout the UK in October 2010, under the Health Protection (Notification) Regulations 2010.[160] Although there is a greater incidence of Lyme disease in the New Forest, Salisbury Plain, Exmoor, the South Downs, parts of Wiltshire and Berkshire, Thetford Forest[170] and the West coast and islands of Scotland[171] infected ticks are widespread, and can even be found in the parks of London.[162][172] A 1989 report found that 25% of forestry workers in the New Forest were seropositive, as were between 2% and 4-5% of the general local population of the area.[173][174] Tests on pet dogs, carried out throughout the country in 2009 indicated that around 2.

5% of ticks in the UK may be infected, considerably higher than previously thought.[175][176] It is thought that global warming may lead to an increase in tick activity in the future, as well as an increase in the amount of time that people spend in public parks, thus increasing the risk of infection.[177] North America Many studies in North America have examined ecological and environmental correlates of Lyme disease prevalence.

A 2005 study using climate suitability modelling of I. scapularis projected that climate change would cause an overall 213% increase in suitable vector habitat by the year 2080, with northward expansions in Canada, increased suitability in the central U.

S., and decreased suitable habitat and vector retraction in the southern U.

S.[178] A 2008 review of published studies concluded that the presence of forests or forested areas was the only variable that consistently elevated the risk of Lyme disease whereas other environmental variables showed little or no concordance between studies.[179] The authors argued that the factors influencing tick density and human risk between sites are still poorly understood, and that future studies should be conducted over longer time periods, become more standardized across regions, and incorporate existing knowledge of regional Lyme disease ecology.[179] Canada Owing to changing climate, the range of ticks able to carry Lyme disease has expanded from a limited area of Ontario to include areas of southern Quebec, Manitoba, northern Ontario, southern New Brunswick, southwest Nova Scotia and limited parts of Saskatchewan and Alberta, as well as British Columbia.

Cases have been reported as far east as the island of Newfoundland.[180][181][182] A model-based prediction by Leighton et al. (2012) suggests that the range of the I. scapularis tick will expand into Canada by 46 km/year over the next decade, with warming climatic temperatures as the main driver of increased speed of spread.[183] Mexico A 2007 study suggests Borrelia burgdorferi infections are endemic to Mexico, from four cases reported between 1999 and 2000.[184] United States CDC map showing the risk of Lyme disease in the United States, particularly its concentration in the Northeast Megalopolis and western Wisconsin.

Each year, approximately 30,000 new cases are reported to the CDC however, this number is likely underestimated.

The CDC is currently conducting research on evaluation and diagnostics of the disease and preliminary results suggest the number of new cases to be around 300,000.[185][186] Lyme disease is the most common tick-borne disease in North America and Europe, and one of the fastest-growing infectious diseases in the United States.

Of cases reported to the United States CDC, the ratio of Lyme disease infection is 7.

In the ten states where Lyme disease is most common, the average was 31.

6 cases for every 100,000 persons for the year 2005.[187][188][189] Although Lyme disease has been reported in all states[185][190] about 99% of all reported cases are confined to just five geographic areas (New England, Mid-Atlantic, East-North Central, South Atlantic, and West North-Central).[191] New 2011 CDC Lyme case definition guidelines are used to determine confirmed CDC surveillance cases.[192] Effective January 2008, the CDC gives equal weight to laboratory evidence from 1) a positive culture for B. burgdorferi; 2) two-tier testing (ELISA screening and Western blot confirming); or 3) single-tier IgG (old infection) Western blot.[193] Previously, the CDC only included laboratory evidence based on (1) and (2) in their surveillance case definition.

The case definition now includes the use of Western blot without prior ELISA screen.[193] The number of reported cases of the disease has been increasing, as are endemic regions in North America.

For example, B. burgdorferi sensu lato was previously thought to be hindered in its ability to be maintained in an enzootic cycle in California, because it was assumed the large lizard population would dilute the prevalence of B. burgdorferi in local tick populations; this has since been brought into question, as some evidence has suggested lizards can become infected.[194] Except for one study in Europe,[195] much of the data implicating lizards is based on DNA detection of the spirochete and has not demonstrated lizards are able to infect ticks feeding upon them.[194][196][197][198] As some experiments suggest lizards are refractory to infection with Borrelia, it appears likely their involvement in the enzootic cycle is more complex and species-specific.[55] While B. burgdorferi is most associated with ticks hosted by white-tailed deer and white-footed mice, Borrelia afzelii is most frequently detected in rodent-feeding vector ticks, and Borrelia garinii and Borrelia valaisiana appear to be associated with birds.

Both rodents and birds are competent reservoir hosts for B. burgdorferi sensu stricto.

The resistance of a genospecies of Lyme disease spirochetes to the bacteriolytic activities of the alternative complement pathway of various host species may determine its reservoir host association.[citation needed] Several similar but apparently distinct conditions may exist, caused by various species or subspecies of Borrelia in North America.

A regionally restricted condition that may be related to Borrelia infection is southern tick-associated rash illness (STARI), also known as Masters' disease.

Amblyomma americanum, known commonly as the lone-star tick, is recognized as the primary vector for STARI.

In some parts of the geographical distribution of STARI, Lyme disease is quite rare (e.g., Arkansas), so patients in these regions experiencing Lyme-like symptoms—especially if they follow a bite from a lone-star tick—should consider STARI as a possibility.

It is generally a milder condition than Lyme and typically responds well to antibiotic treatment.[citation needed] In recent years there have been 5 to 10 cases a year of a disease similar to Lyme occurring in Montana.

It occurs primarily in pockets along the Yellowstone River in central Montana.

People have developed a red bull's-eye rash around a tick bite followed by weeks of fatigue and a fever.[190] Lyme disease prevalence is comparable among males and females.

A wide range of age groups is affected, though the number of cases is highest among 10- to 19-year-olds.

For unknown reasons, Lyme disease is seven times more common among Asians.[199] South America In South America, tick-borne disease recognition and occurrence is rising.

In Brazil, a Lyme-like disease known as Baggio–Yoshinari syndrome was identified, caused by microorganisms that do not belong to the B. burgdorferi sensu lato complex and transmitted by ticks of the Amblyomma and Rhipicephalus genera.[200] The first reported case of BYS in Brazil was made in 1992 in Cotia, São Paulo.[201] B. burgdorferi sensu stricto antigens in patients have been identified in Colombia and Bolivia.[citation needed] History The evolutionary history of Borrelia burgdorferi genetics has been the subject of recent studies.

One study has found that prior to the reforestation that accompanied post-colonial farm abandonment in New England and the wholesale migration into the mid-west that occurred during the early 19th century, Lyme disease was present for thousands of years in America and had spread along with its tick hosts from the Northeast to the Midwest.[202] John Josselyn, who visited New England in 1638 and again from 1663–1670, wrote "there be infinite numbers of tikes hanging upon the bushes in summer time that will cleave to man's garments and creep into his breeches eating themselves in a short time into the very flesh of a man.

I have seen the stockins of those that have gone through the woods covered with them."[203] This is also confirmed by the writings of Peter Kalm, a Swedish botanist who was sent to America by Linnaeus, and who found the forests of New York "abound" with ticks when he visited in 1749.

When Kalm's journey was retraced 100 years later, the forests were gone and the Lyme bacterium had probably become isolated to a few pockets along the northeast coast, Wisconsin, and Minnesota.[204] Perhaps the first detailed description of what is now known as Lyme disease appeared in the writings of Reverend Dr.

John Walker after a visit to the Island of Jura (Deer Island) off the west coast of Scotland in 1764.[205] He gives a good description both of the symptoms of Lyme disease (with "exquisite pain [in] the interior parts of the limbs") and of the tick vector itself, which he describes as a "worm" with a body which is "of a reddish colour and of a compressed shape with a row of feet on each side" that "penetrates the skin".

Many people from this area of Great Britain emigrated to North America between 1717 and the end of the 18th century.

The examination of preserved museum specimens has found Borrelia DNA in an infected Ixodes ricinus tick from Germany that dates back to 1884, and from an infected mouse from Cape Cod that died in 1894.[204] The 2010 autopsy of Ötzi the Iceman, a 5,300-year-old mummy, revealed the presence of the DNA sequence of Borrelia burgdorferi making him the earliest known human with Lyme disease.[206] The early European studies of what is now known as Lyme disease described its skin manifestations.

The first study dates to 1883 in Breslau, Germany (now Wrocław, Poland), where physician Alfred Buchwald described a man who had suffered for 16 years with a degenerative skin disorder now known as acrodermatitis chronica atrophicans.[207] At a 1909 research conference, Swedish dermatologist Arvid Afzelius presented a study about an expanding, ring-like lesion he had observed in an older woman following the bite of a sheep tick.

He named the lesion erythema migrans.[207] The skin condition now known as borrelial lymphocytoma was first described in 1911.[208] The modern history of medical understanding of the disease, including its cause, diagnosis, and treatment, has been difficult.[209] Neurological problems following tick bites were recognized starting in the 1920s.

French physicians Garin and Bujadoux described a farmer with a painful sensory radiculitis accompanied by mild meningitis following a tick bite.

A large, ring-shaped rash was also noted, although the doctors did not relate it to the meningoradiculitis.

In 1930, the Swedish dermatologist Sven Hellerström was the first to propose EM and neurological symptoms following a tick bite were related.[210] In the 1940s, German neurologist Alfred Bannwarth described several cases of chronic lymphocytic meningitis and polyradiculoneuritis, some of which were accompanied by erythematous skin lesions.

Carl Lennhoff, who worked at the Karolinska Institute in Sweden, believed many skin conditions were caused by spirochetes.

In 1948, he used a special stain to microscopically observe what he believed were spirochetes in various types of skin lesions, including EM.[211] Although his conclusions were later shown to be erroneous, interest in the study of spirochetes was sparked.

In 1949, Nils Thyresson, who also worked at the Karolinska Institute, was the first to treat ACA with penicillin.[212] In the 1950s, the relationship among tick bite, lymphocytoma, EM and Bannwarth's syndrome was recognized throughout Europe leading to the widespread use of penicillin for treatment in Europe.[213][214] In 1970, a dermatologist in Wisconsin named Rudolph Scrimenti recognized an EM lesion in a patient after recalling a paper by Hellerström that had been reprinted in an American science journal in 1950.

This was the first documented case of EM in the United States.

Based on the European literature, he treated the patient with penicillin.[215] The full syndrome now known as Lyme disease was not recognized until a cluster of cases originally thought to be juvenile rheumatoid arthritis was identified in three towns in southeastern Connecticut in 1975, including the towns Lyme and Old Lyme, which gave the disease its popular name.[216] This was investigated by physicians David Snydman and Allen Steere of the Epidemic Intelligence Service, and by others from Yale University, including Dr.

Stephen Malawista, who is credited as a co-discover of the disease.[217] The recognition that the patients in the United States had EM led to the recognition that "Lyme arthritis" was one manifestation of the same tick-borne condition known in Europe.[218] Before 1976, the elements of B. burgdorferi sensu lato infection were called or known as tick-borne meningopolyneuritis, Garin-Bujadoux syndrome, Bannwarth syndrome, Afzelius' disease,[219] Montauk Knee or sheep tick fever.

Since 1976 the disease is most often referred to as Lyme disease,[220][221] Lyme borreliosis or simply borreliosis.[citation needed] In 1980, Steere, et al., began to test antibiotic regimens in adult patients with Lyme disease.[222] In the same year, New York State Health Dept. epidemiologist Jorge Benach provided Willy Burgdorfer, a researcher at the Rocky Mountain Biological Laboratory, with collections of I. dammini [scapularis] from Shelter Island, NY, a known Lyme-endemic area as part of an ongoing investigation of Rocky Mountain spotted fever.

In examining the ticks for rickettsiae, Burgdorfer noticed "poorly stained, rather long, irregularly coiled spirochetes." Further examination revealed spirochetes in 60% of the ticks.

Burgdorfer credited his familiarity with the European literature for his realization that the spirochetes might be the "long-sought cause of ECM and Lyme disease." Benach supplied him with more ticks from Shelter Island and sera from patients diagnosed with Lyme disease.

University of Texas Health Science Center researcher Alan Barbour "offered his expertise to culture and immunochemically characterize the organism." Burgdorfer subsequently confirmed his discovery by isolating, from patients with Lyme disease, spirochetes identical to those found in ticks.[223] In June 1982, he published his findings in Science, and the spirochete was named Borrelia burgdorferi in his honor.[224] After the identification of B. burgdorferi as the causative agent of Lyme disease, antibiotics were selected for testing, guided by in vitro antibiotic sensitivities, including tetracycline antibiotics, amoxicillin, cefuroxime axetil, intravenous and intramuscular penicillin and intravenous ceftriaxone.[225][226] The mechanism of tick transmission was also the subject of much discussion.

B. burgdorferi spirochetes were identified in tick saliva in 1987, confirming the hypothesis that transmission occurred via tick salivary glands.[227] Society and culture Urbanization and other anthropogenic factors can be implicated in the spread of Lyme disease to humans.

In many areas, expansion of suburban neighborhoods has led to gradual deforestation of surrounding wooded areas and increased border contact between humans and tick-dense areas.

Human expansion has also resulted in a reduction of predators that hunt deer as well as mice, chipmunks and other small rodents—the primary reservoirs for Lyme disease.

As a consequence of increased human contact with host and vector, the likelihood of transmission of the disease has greatly increased.[228][229] Researchers are investigating possible links between global warming and the spread of vector-borne diseases, including Lyme disease.[230] Controversy The term "chronic Lyme disease" is controversial and not recognized in the medical literature,[231] and most medical authorities advise against long-term antibiotic treatment for Lyme disease.[91][232][233] Studies have shown that most people diagnosed with "chronic Lyme disease" either have no objective evidence of previous or current infection with B. burgdorferi or are people who should be classified as having post-treatment Lyme disease syndrome (PTLDS), which is defined as continuing or relapsing non-specific symptoms (such as fatigue, musculoskeletal pain, and cognitive complaints) in a person previously treated for Lyme disease.[234] Other animals Prevention of Lyme disease is an important step in keeping dogs safe in endemic areas.

Prevention education and a number of preventative measures are available.

First, for dog owners who live near or who often frequent tick-infested areas, routine vaccinations of their dogs is an important step.[235] Another crucial preventive measure is the use of persistent acaricides, such as topical repellents or pesticides that contain triazapentadienes (Amitraz), phenylpyrazoles (Fipronil), or permethrin (pyrethroids).[236] These acaricides target primarily the adult stages of Lyme-carrying ticks and reduce the number of reproductively active ticks in the environment.[235] Formulations of these ingredients are available in a variety of topical forms, including spot-ons, sprays, powders, impregnated collars, solutions, and shampoos.[236] Examination of a dog for ticks after being in a tick-infested area is an important precautionary measure to take in the prevention of Lyme disease.

Key spots to examine include the head, neck, and ears.[237] Research The National Institutes of Health have supported research into bacterial persistence.[238]  This article incorporates public domain material from the Centers for Disease Control and Prevention document "Post-Treatment Lyme Disease Syndrome".Lyme disease, also known as Lyme borreliosis, is an infectious disease caused by bacteria of the Borrelia type which is spread by ticks.[2] The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans, that begins at the site of a tick bite about a week after it has occurred.[1] The rash is typically neither itchy nor painful.[1] Approximately 25–50% of infected people do not develop a rash.[1] Other early symptoms may include fever, headache and feeling tired.[1] If untreated, symptoms may include loss of the ability to move one or both sides of the face, joint pains, severe headaches with neck stiffness, or heart palpitations, among others.[1] Months to years later, repeated episodes of joint pain and swelling may occur.[1] Occasionally, people develop shooting pains or tingling in their arms and legs.[1] Despite appropriate treatment, about 10 to 20% of people develop joint pains, memory problems, and feel tired for at least six months.[1][5] Lyme disease is transmitted to humans by the bite of infected ticks of the genus Ixodes.[6] Usually, the tick must be attached for 36 to 48 hours before the bacteria can spread.[7] In North America, Borrelia burgdorferi and Borrelia mayonii are the cause.[2][8] In Europe and Asia, the bacteria Borrelia afzelii and Borrelia garinii are also causes of the disease.[2] The disease does not appear to be transmissible between people, by other animals, or through food.[7] Diagnosis is based upon a combination of symptoms, history of tick exposure, and possibly testing for specific antibodies in the blood.[3][9] Blood tests are often negative in the early stages of the disease.[2] Testing of individual ticks is not typically useful.[10] Prevention includes efforts to prevent tick bites such as by wearing long pants and using DEET.[2] Using pesticides to reduce tick numbers may also be effective.[2] Ticks can be removed using tweezers.[11] If the removed tick was full of blood, a single dose of doxycycline may be used to prevent development of infection, but is not generally recommended since development of infection is rare.[2] If an infection develops, a number of antibiotics are effective, including doxycycline, amoxicillin, and cefuroxime.[2] Standard treatment usually lasts for two or three weeks.[2] Some people develop a fever and muscle and joint pains from treatment which may last for one or two days.[2] In those who develop persistent symptoms, long-term antibiotic therapy has not been found to be useful.[2][12] Lyme disease is the most common disease spread by ticks in the Northern Hemisphere.[13] It is estimated to affect 300,000 people a year in the United States and 65,000 people a year in Europe.[2][4] Infections are most common in the spring and early summer.[2] Lyme disease was diagnosed as a separate condition for the first time in 1975 in Old Lyme, Connecticut.[14] It was originally mistaken for juvenile rheumatoid arthritis.[14] The bacterium involved was first described in 1981 by Willy Burgdorfer.[15] Chronic symptoms following treatment are well described and are known as post-treatment Lyme disease syndrome (PTLDS).[12] PTLDS is different to chronic Lyme disease; a no longer supported term used in different ways by different groups.[12] Some healthcare providers claim that it is due to ongoing infection; however, this is not believed to be true, due to the inability to detect infectious organisms after standard treatment.[16] A Lyme vaccine was marketed in the US between 1998 and 2002; it was withdrawn from the market due to poor sales, originally due to lack of reimbursement by insurance companies and then due to rumors about adverse effects.[2][17] Research is ongoing to develop new vaccines.[2] Contents Signs and symptoms This "classic" bull's-eye rash is also called erythema migrans.

A rash caused by Lyme does not always look like this and approximately 25% of those infected with Lyme disease may have no rash. [1] [18] Raised, red borders around indurated central portion Lyme disease can affect multiple body systems and produce a broad range of symptoms.

Not all patients with Lyme disease have all symptoms, and many of the symptoms are not specific to Lyme disease, but can occur with other diseases, as well.

The incubation period from infection to the onset of symptoms is usually one to two weeks, but can be much shorter (days), or much longer (months to years).[19] Symptoms most often occur from May to September, because the nymphal stage of the tick is responsible for most cases.[19] Asymptomatic infection exists, but occurs in less than 7% of infected individuals in the United States.[20] Asymptomatic infection may be much more common among those infected in Europe.[21] Early localized infection Early localized infection can occur when the infection has not yet spread throughout the body.

Only the site where the infection has first come into contact with the skin is affected.

The classic sign of early local infection with Lyme disease is a circular, outwardly expanding rash called erythema chronicum migrans (EM), which occurs at the site of the tick bite three to 32 days after the tick bite.[2] The rash is red, and may be warm, but is generally painless.

Classically, the innermost portion remains dark red and becomes indurated (is thicker and firmer), the outer edge remains red, and the portion in between clears, giving the appearance of a bull's eye.

However, partial clearing is uncommon, and the bull's-eye pattern more often involves central redness.[2] The EM rash associated with early infection is found in about 70–80% of people infected.[1] It can have a range of appearances including the classic target bull's-eye lesion and nontarget appearing lesions.

The 20–30% without the EM and the nontarget lesions can often cause misidentification of Lyme disease.[22] Affected individuals can also experience flu-like symptoms, such as headache, muscle soreness, fever, and malaise.[23] Lyme disease can progress to later stages even in people who do not develop a rash.[21][24] Early disseminated infection Within days to weeks after the onset of local infection, the Borrelia bacteria may begin to spread through the bloodstream.

EM may develop at sites across the body that bear no relation to the original tick bite.[25] Another skin condition, apparently absent in North American patients, but found in Europe, is borrelial lymphocytoma, a purplish lump that develops on the ear lobe, nipple, or scrotum.[26] Various acute neurological problems, termed neuroborreliosis, appear in 10–15% of untreated people.[23][27] These include facial palsy, which is the loss of muscle tone on one or both sides of the face, as well as meningitis, which involves severe headaches, neck stiffness, and sensitivity to light.

Inflammation of the spinal cord's nerve roots can cause shooting pains that may interfere with sleep, as well as abnormal skin sensations.

Mild encephalitis may lead to memory loss, sleep disturbances, or mood changes.

In addition, some case reports have described altered mental status as the only symptom seen in a few cases of early neuroborreliosis.[28] The disease may adversely impact the heart's electrical conduction system and can cause abnormal heart rhythms such as atrioventricular block.[29] Late disseminated infection After several months, untreated or inadequately treated patients may go on to develop severe and chronic symptoms that affect many parts of the body, including the brain, nerves, eyes, joints, and heart.

Many disabling symptoms can occur, including permanent impairment of motor or sensory function of the lower extremities in extreme cases.[21] The associated nerve pain radiating out from the spine is termed Bannwarth syndrome,[30] named after Alfred Bannwarth.

The late disseminated stage is where the infection has fully spread throughout the body.

Chronic neurologic symptoms occur in up to 5% of untreated patients.[23] A polyneuropathy that involves shooting pains, numbness, and tingling in the hands or feet may develop.

A neurologic syndrome called Lyme encephalopathy is associated with subtle cognitive difficulties, insomnia, a general sense of feeling unwell, and changes in personality.[31] Other problems, however, such as depression and fibromyalgia, are no more common in people with Lyme disease than in the general population.[32][33] Chronic encephalomyelitis, which may be progressive, can involve cognitive impairment, brain fog, migraines, balance issues, weakness in the legs, awkward gait, facial palsy, bladder problems, vertigo, and back pain.

In rare cases, untreated Lyme disease may cause frank psychosis, which has been misdiagnosed as schizophrenia or bipolar disorder.

Panic attacks and anxiety can occur; also, delusional behavior may be seen, including somatoform delusions, sometimes accompanied by a depersonalization or derealization syndrome, where the patients begin to feel detached from themselves or from reality.[34][35] Lyme arthritis usually affects the knees.[36] In a minority of patients, arthritis can occur in other joints, including the ankles, elbows, wrists, hips, and shoulders.

Pain is often mild or moderate, usually with swelling at the involved joint.

Acrodermatitis chronica atrophicans (ACA) is a chronic skin disorder observed primarily in Europe among the elderly.[26] ACA begins as a reddish-blue patch of discolored skin, often on the backs of the hands or feet.

The lesion slowly atrophies over several weeks or months, with the skin becoming first thin and wrinkled and then, if untreated, completely dry and hairless.[37] Cause Deer tick life cycle Borrelia bacteria, the causative agent of Lyme disease, magnified Ixodes scapularis, the primary vector of Lyme disease in eastern North America Tick Ixodes ricinus, developmental stages Lyme disease is caused by spirochetal bacteria from the genus Borrelia.

Spirochetes are surrounded by peptidoglycan and flagella, along with an outer membrane similar to other Gram-negative bacteria.

Because of their double-membrane envelope, Borrelia bacteria are often mistakenly described as Gram negative despite the considerable differences in their envelope components from Gram-negative bacteria.[38] The Lyme-related Borrelia species are collectively known as Borrelia burgdorferi sensu lato, and show a great deal of genetic diversity.

B. burgdorferi sensu lato is made up of 21 closely related species, but only three clearly cause Lyme disease: B. burgdorferi sensu stricto (predominant in North America, but also present in Europe), B. afzelii, and B. garinii (both predominant in Eurasia).[39][40] Some studies have also proposed B. bissettii and B. valaisiana may sometimes infect humans, but these species do not seem to be important causes of disease.[41][42] Transmission Lyme disease is classified as a zoonosis, as it is transmitted to humans from a natural reservoir among small mammals and birds by ticks that feed on both sets of hosts.[43] Hard-bodied ticks of the genus Ixodes are the main vectors of Lyme disease (also the vector for Babesia).[44] Most infections are caused by ticks in the nymphal stage, because they are very small and thus may feed for long periods of time undetected.[43] Larval ticks are very rarely infected.[45] Although deer are the preferred hosts of the adult stage of deer ticks, and tick populations are much lower in the absence of deer, ticks generally do not acquire Lyme disease spirochetes from deer.

Rather, deer ticks acquire Borrelia microbes from infected small mammals and occasionally birds, including the white-footed mouse, Peromyscus leucopus.[46] Within the tick midgut, the Borrelia's outer surface protein A (OspA) binds to the tick receptor for OspA, known as TROSPA.

When the tick feeds, the Borrelia downregulates OspA and upregulates OspC, another surface protein.

After the bacteria migrate from the midgut to the salivary glands, OspC binds to Salp15, a tick salivary protein that appears to have immunosuppressive effects that enhance infection.[47] Successful infection of the mammalian host depends on bacterial expression of OspC.[48] Tick bites often go unnoticed because of the small size of the tick in its nymphal stage, as well as tick secretions that prevent the host from feeling any itch or pain from the bite.

However, transmission is quite rare, with only about 1% of recognized tick bites resulting in Lyme disease.

In Europe, the vector is Ixodes ricinus, which is also called the sheep tick or castor bean tick.[49] In China, Ixodes persulcatus (the taiga tick) is probably the most important vector.[50] In North America, the black-legged tick or deer tick (Ixodes scapularis) is the main vector on the East Coast.[45] The lone star tick (Amblyomma americanum), which is found throughout the Southeastern United States as far west as Texas, is unlikely to transmit the Lyme disease spirochetes,[51] though it may be implicated in a related syndrome called southern tick-associated rash illness, which resembles a mild form of Lyme disease.[52] On the West Coast of the United States, the main vector is the western black-legged tick (Ixodes pacificus).[53] The tendency of this tick species to feed predominantly on host species such as lizards that are resistant to Borrelia infection appears to diminish transmission of Lyme disease in the West.[54][55] Transmission across the placenta during pregnancy has not been demonstrated, and no consistent pattern of teratogenicity or specific "congenital Lyme borreliosis" has been identified.

As with a number of other spirochetal diseases, adverse pregnancy outcomes are possible with untreated infection; prompt treatment with antibiotics reduces or eliminates this risk.[56][57] While Lyme spirochetes have been found in insects, as well as ticks,[58] reports of actual infectious transmission appear to be rare.[59] Lyme spirochete DNA has been found in semen[60] and breast milk.[61] However, according to the CDC, live spirochetes have not been found in breast milk, urine, or semen and thus is not sexually transmitted.[62] Tick-borne coinfections Ticks that transmit B. burgdorferi to humans can also carry and transmit several other parasites, such as Theileria microti and Anaplasma phagocytophilum, which cause the diseases babesiosis and human granulocytic anaplasmosis (HGA), respectively.[63] Among early Lyme disease patients, depending on their location, 2–12% will also have HGA and 2–40% will have babesiosis.[64] Ticks in certain regions, including the lands along the eastern Baltic Sea, also transmit tick-borne encephalitis.[65] Coinfections complicate Lyme symptoms, especially diagnosis and treatment.

It is possible for a tick to carry and transmit one of the coinfections and not Borrelia, making diagnosis difficult and often elusive.

The Centers for Disease Control and Prevention studied 100 ticks in rural New Jersey, and found 55% of the ticks were infected with at least one of the pathogens.[66] Pathophysiology B. burgdorferi can spread throughout the body during the course of the disease, and has been found in the skin, heart, joints, peripheral nervous system, and central nervous system.[48][67] Many of the signs and symptoms of Lyme disease are a consequence of the immune response to the spirochete in those tissues.[23] B. burgdorferi is injected into the skin by the bite of an infected Ixodes tick.

Tick saliva, which accompanies the spirochete into the skin during the feeding process, contains substances that disrupt the immune response at the site of the bite.[68] This provides a protective environment where the spirochete can establish infection.

The spirochetes multiply and migrate outward within the dermis.

The host inflammatory response to the bacteria in the skin causes the characteristic circular EM lesion.[48] Neutrophils, however, which are necessary to eliminate the spirochetes from the skin, fail to appear in the developing EM lesion.

This allows the bacteria to survive and eventually spread throughout the body.[69] Days to weeks following the tick bite, the spirochetes spread via the bloodstream to joints, heart, nervous system, and distant skin sites, where their presence gives rise to the variety of symptoms of the disseminated disease.

The spread of B. burgdorferi is aided by the attachment of the host protease plasmin to the surface of the spirochete.[70] If untreated, the bacteria may persist in the body for months or even years, despite the production of B. burgdorferi antibodies by the immune system.[71] The spirochetes may avoid the immune response by decreasing expression of surface proteins that are targeted by antibodies, antigenic variation of the VlsE surface protein, inactivating key immune components such as complement, and hiding in the extracellular matrix, which may interfere with the function of immune factors.[72][73] In the brain, B. burgdorferi may induce astrocytes to undergo astrogliosis (proliferation followed by apoptosis), which may contribute to neurodysfunction.[74] The spirochetes may also induce host cells to secrete quinolinic acid, which stimulates the NMDA receptor on nerve cells, which may account for the fatigue and malaise observed with Lyme encephalopathy.[75] In addition, diffuse white matter pathology during Lyme encephalopathy may disrupt gray matter connections, and could account for deficits in attention, memory, visuospatial ability, complex cognition, and emotional status.

White matter disease may have a greater potential for recovery than gray matter disease, perhaps because the neuronal loss is less common.

Resolution of MRI white matter hyperintensities after antibiotic treatment has been observed.[76] Tryptophan, a precursor to serotonin, appears to be reduced within the central nervous system in a number of infectious diseases that affect the brain, including Lyme.[77] Researchers are investigating if this neurohormone secretion is the cause of neuropsychiatric disorders developing in some patients with borreliosis.[78] Immunological studies Exposure to the Borrelia bacterium during Lyme disease possibly causes a long-lived and damaging inflammatory response,[79] a form of pathogen-induced autoimmune disease.[80] The production of this reaction might be due to a form of molecular mimicry, where Borrelia avoids being killed by the immune system by resembling normal parts of the body's tissues.[81][82] Chronic symptoms from an autoimmune reaction could explain why some symptoms persist even after the spirochetes have been eliminated from the body.

This hypothesis may explain why chronic arthritis persists after antibiotic therapy, similar to rheumatic fever, but its wider application is controversial.[83][84] Diagnosis Lyme disease is diagnosed clinically based on symptoms, objective physical findings (such as EM, facial palsy, or arthritis), or a history of possible exposure to infected ticks, as well as serological blood tests.

The EM rash is not always a bull's eye, i.e., it can be solid red.

When making a diagnosis of Lyme disease, health care providers should consider other diseases that may cause similar illnesses.

Not all individuals infected with Lyme disease develop the characteristic bull's-eye rash, and many may not recall a tick bite.[85] Because of the difficulty in culturing Borrelia bacteria in the laboratory, diagnosis of Lyme disease is typically based on the clinical exam findings and a history of exposure to endemic Lyme areas.[44] The EM rash, which does not occur in all cases, is considered sufficient to establish a diagnosis of Lyme disease even when serologic blood tests are negative.[86][87] Serological testing can be used to support a clinically suspected case, but is not diagnostic by itself.[44] Diagnosis of late-stage Lyme disease is often complicated by a multifaceted appearance and nonspecific symptoms, prompting one reviewer to call Lyme the new "great imitator".[88] Lyme disease may be misdiagnosed as multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, lupus, Crohn's disease, HIV, or other autoimmune and neurodegenerative diseases.

As all people with later-stage infection will have a positive antibody test, simple blood tests can exclude Lyme disease as a possible cause of a person's symptoms.[89] Laboratory testing Several forms of laboratory testing for Lyme disease are available, some of which have not been adequately validated.

The most widely used tests are serologies, which measure levels of specific antibodies in a patient's blood.

These tests may be negative in early infection as the body may not have produced a significant quantity of antibodies, but they are considered a reliable aid in the diagnosis of later stages of Lyme disease.[90] Serologic tests for Lyme disease are of limited use in people lacking objective signs of Lyme disease because of false positive results and cost.[91] The serological laboratory tests most widely available and employed are the Western blot and ELISA.

A two-tiered protocol is recommended by the Centers for Disease Control and Prevention: the sensitive ELISA test is performed first, and if it is positive or equivocal, then the more specific Western blot is run.[92] The reliability of testing in diagnosis remains controversial.[44] Studies show the Western blot IgM has a specificity of 94–96% for people with clinical symptoms of early Lyme disease.[93][94] The initial ELISA test has a sensitivity of about 70%, and in two-tiered testing, the overall sensitivity is only 64%, although this rises to 100% in the subset of people with disseminated symptoms, such as arthritis.[95] Erroneous test results have been widely reported in both early and late stages of the disease, and can be caused by several factors, including antibody cross-reactions from other infections, including Epstein–Barr virus and cytomegalovirus,[96] as well as herpes simplex virus.[97] The overall rate of false positives is low, only about 1 to 3%, in comparison to a false-negative rate of up to 36% in the early stages of infection using two-tiered testing.[95] Polymerase chain reaction (PCR) tests for Lyme disease have also been developed to detect the genetic material (DNA) of the Lyme disease spirochete.

PCR tests are susceptible to false positive results from poor laboratory technique.[98] Even when properly performed, PCR often shows false negative results with blood and cerebrospinal fluid specimens.[99] Hence, PCR is not widely performed for diagnosis of Lyme disease, but it may have a role in the diagnosis of Lyme arthritis because it is a highly sensitive way of detecting ospA DNA in synovial fluid.[100] Culture or PCR are the current means for detecting the presence of the organism, as serologic studies only test for antibodies of Borrelia.

OspA antigens, shedded by live Borrelia bacteria into urine, are a promising technique being studied.[101] The use of nanotrap particles for their detection is being looked at and the OspA has been linked to active symptoms of Lyme.[102][103] High titers of either immunoglobulin G (IgG) or immunoglobulin M (IgM) antibodies to Borrelia antigens indicate disease, but lower titers can be misleading, because the IgM antibodies may remain after the initial infection, and IgG antibodies may remain for years.[104] Western blot, ELISA, and PCR can be performed by either blood test via venipuncture or cerebrospinal fluid (CSF) via lumbar puncture.

Though lumbar puncture is more definitive of diagnosis, antigen capture in the CSF is much more elusive; reportedly, CSF yields positive results in only 10–30% of affected individuals cultured.

The diagnosis of neurologic infection by Borrelia should not be excluded solely on the basis of normal routine CSF or negative CSF antibody analyses.[105] New techniques for clinical testing of Borrelia infection have been developed, such as LTT-MELISA,[106] although the results of studies are contradictory.

The first peer reviewed study assessing the diagnostic sensitivity and specificity of the test was presented in 2012 and demonstrated potential for LTT to become a supportive diagnostic tool.[107] In 2014, research of LTT-MELISA concluded that it is "sensible" to include the LTT test in the diagnostic protocol for putative European-acquired Lyme borreliosis infections.[108] Other diagnostic techniques, such as focus floating microscopy, are under investigation.[109] New research indicates chemokine CXCL13 may also be a possible marker for neuroborreliosis.[110] Some laboratories offer Lyme disease testing using assays whose accuracy and clinical usefulness have not been adequately established.

These tests include urine antigen tests, PCR tests on urine, immunofluorescent staining for cell-wall-deficient forms of B. burgdorferi, and lymphocyte transformation tests.

The CDC does not recommend these tests, and stated their use is "of great concern and is strongly discouraged".[99] Imaging Neuroimaging is controversial in whether it provides specific patterns unique to neuroborreliosis, but may aid in differential diagnosis and in understanding the pathophysiology of the disease.[111] Though controversial, some evidence shows certain neuroimaging tests can provide data that are helpful in the diagnosis of a patient.

Magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) are two of the tests that can identify abnormalities in the brain of a patient affected with this disease.

Neuroimaging findings in an MRI include lesions in the periventricular white matter, as well as enlarged ventricles and cortical atrophy.

The findings are considered somewhat unexceptional because the lesions have been found to be reversible following antibiotic treatment.

Images produced using SPECT show numerous areas where an insufficient amount of blood is being delivered to the cortex and subcortical white matter.

However, SPECT images are known to be nonspecific because they show a heterogeneous pattern in the imaging.

The abnormalities seen in the SPECT images are very similar to those seen in people with cerebral vacuities and Creutzfeldt–Jakob disease, which makes them questionable.[112] Prevention Protective clothing includes a hat, long-sleeved shirt, and long pants tucked into socks or boots.

Light-colored clothing makes the tick more easily visible before it attaches itself.

People should use special care in handling and allowing outdoor pets inside homes because they can bring ticks into the house.

People who work in areas with woods, bushes, leaf litter, and tall grass are at risk of becoming infected with Lyme at work.

Employers can reduce the risk for employees by providing education on Lyme transmission and infection risks, and about how to check themselves for ticks on the groin, armpits, and hair.

Work clothing used in risky areas should be washed in hot water and dried in a hot dryer to kill any ticks.[113] Permethrin sprayed on clothing kills ticks on contact, and is sold for this purpose.

According to the CDC, only DEET is effective at repelling ticks.[114] Host animals Lyme and other deer tick-borne diseases can sometimes be reduced by greatly reducing the deer population on which the adult ticks depend for feeding and reproduction.

Lyme disease cases fell following deer eradication on an island, Monhegan, Maine[115] and following deer control in Mumford Cove, Connecticut.[116] It is worth noting that eliminating deer may lead to a temporary increase in tick density.[117] For example, in the U.

S., reducing the deer population to levels of 8 to 10 per square mile (from the current levels of 60 or more deer per square mile in the areas of the country with the highest Lyme disease rates), may reduce tick numbers and reduce the spread of Lyme and other tick-borne diseases.[118] However, such a drastic reduction may be very difficult to implement in many areas, and low to moderate densities of deer or other large mammal hosts may continue to feed sufficient adult ticks to maintain larval densities at high levels.

Routine veterinary control of ticks of domestic animals, including livestock, by use of acaricides can contribute to reducing exposure of humans to ticks.

Action can be taken to avoid getting bitten by ticks by using insect repellants, for example, those that contain DEET.

DEET-containing repellants are thought to be moderately effective in the prevention of tick bites.[119] In Europe known reservoirs of Borrelia burgdorferi were 9 small mammals, 7 medium-sized mammals and 16 species of birds (including passerines, sea-birds and pheasants).[120] These animals seem to transmit spirochetes to ticks and thus participate in the natural circulation of B. burgdorferi in Europe.

The house mouse is also suspected as well as other species of small rodents, particularly in Eastern Europe and Russia.[120] "The reservoir species that contain the most pathogens are the European roe deer Capreolus capreolus;[121] "it does not appear to serve as a major reservoir of B. burgdorferi" thought Jaenson & al. (1992)[122] (incompetent host for B. burgdorferi and TBE virus) but it is important for feeding the ticks,[123] as red deer and wild boars (Sus scrofa),[124] in which one Rickettsia and three Borrelia species were identified",[121] with high risks of coinfection in roe deer.[125] Nevertheless, in the 2000s, in roe deer in Europe " two species of Rickettsia and two species of Borrelia were identified".[124] Vaccination A recombinant vaccine against Lyme disease, based on the outer surface protein A (ospA) of B. burgdorferi, was developed by SmithKline Beecham.

In clinical trials involving more than 10,000 people, the vaccine, called LYMErix, was found to confer protective immunity to Borrelia in 76% of adults and 100% of children with only mild or moderate and transient adverse effects.[126] LYMErix was approved on the basis of these trials by the Food and Drug Administration (FDA) on 21 December 1998.

Following approval of the vaccine, its entry in clinical practice was slow for a variety of reasons, including its cost, which was often not reimbursed by insurance companies.[127] Subsequently, hundreds of vaccine recipients reported they had developed autoimmune and other side effects.

Supported by some patient advocacy groups, a number of class-action lawsuits were filed against GlaxoSmithKline, alleging the vaccine had caused these health problems.

These claims were investigated by the FDA and the Centers for Disease Control, which found no connection between the vaccine and the autoimmune complaints.[128] Despite the lack of evidence that the complaints were caused by the vaccine, sales plummeted and LYMErix was withdrawn from the U.

S. market by GlaxoSmithKline in February 2002,[129] in the setting of negative media coverage and fears of vaccine side effects.[128][130] The fate of LYMErix was described in the medical literature as a "cautionary tale";[130] an editorial in Nature cited the withdrawal of LYMErix as an instance in which "unfounded public fears place pressures on vaccine developers that go beyond reasonable safety considerations."[17] The original developer of the OspA vaccine at the Max Planck Institute told Nature: "This just shows how irrational the world can be...

There was no scientific justification for the first OspA vaccine LYMErix being pulled."[128] New vaccines are being researched using outer surface protein C (OspC) and glycolipoprotein as methods of immunization.[131][132] Vaccines have been formulated and approved for prevention of Lyme disease in dogs.

Currently, three Lyme disease vaccines are available.

LymeVax, formulated by Fort Dodge Laboratories, contains intact dead spirochetes which expose the host to the organism.

Galaxy Lyme, Intervet-Schering-Plough's vaccine, targets proteins OspC and OspA.

The OspC antibodies kill any of the bacteria that have not been killed by the OspA antibodies.

Canine Recombinant Lyme, formulated by Merial, generates antibodies against the OspA protein so a tick feeding on a vaccinated dog draws in blood full of anti-OspA antibodies, which kill the spirochetes in the tick's gut before they are transmitted to the dog.[133] Valneva's hexavalent (OspA) protein subunit-based vaccine candidate VLA15 was granted fast track designation by the U.

Food and Drug Administration in July 2017 which will allow further study.[134] Tick removal Removal of a tick using tweezers Attached ticks should be removed promptly, as removal within 36 hours can reduce transmission rates.[135] Folk remedies for tick removal tend to be ineffective, offer no advantages in preventing the transfer of disease, and may increase the risks of transmission or infection.[136] The best method is simply to pull the tick out with tweezers as close to the skin as possible, without twisting, and avoiding crushing the body of the tick or removing the head from the tick's body.[137] The risk of infection increases with the time the tick is attached, and if a tick is attached for less than 24 hours, infection is unlikely.

However, since these ticks are very small, especially in the nymph stage, prompt detection is quite difficult.[135] The Australian Society of Clinical Immunology recommends against using tweezers to remove ticks but rather to kill the tick first by using a product to rapidly freeze the tick to prevent it from injecting more allergen-containing saliva.

In a tick allergic person, the tick should be killed and removed in a safe place (e.g. an emergency department of a hospital).[138] Preventive antibiotics The risk of infectious transmission increases with the duration of tick attachment.[139] It requires between 36 and 48 hours of attachment for the bacteria that causes Lyme to travel from within the tick into its saliva.[139] If a deer tick that is sufficiently likely to be carrying Borrelia is found attached to a person and removed, and if the tick has been attached for 36 hours or is engorged, a single dose of doxycycline administered within the 72 hours after removal may reduce the risk of Lyme disease.

It is not generally recommended for all people bitten, as development of infection is rare: about 50 bitten people would have to be treated this way to prevent one case of erythema migrans (i.e. the typical rash found in about 70-80% of people infected).[2][139] Occupational exposure Outdoor workers are at risk of Lyme disease if they work at sites with infected ticks.

In 2010, the highest number of confirmed Lyme disease cases were reported from New Jersey, Pennsylvania, Wisconsin, New York, Massachusetts, Connecticut, Minnesota, Maryland, Virginia, New Hampshire, Delaware, and Maine.

S. workers in the northeastern and north-central States are at highest risk of exposure to infected ticks.

Ticks may also transmit other tick-borne diseases to workers in these and other regions of the country.

Worksites with woods, bushes, high grass, or leaf litter are likely to have more ticks.

Outdoor workers should be most careful to protect themselves in the late spring and summer when young ticks are most active.[140] Treatment Antibiotics are the primary treatment.[2][139] The specific approach to their use is dependent on the individual affected and the stage of the disease.[139] For most people with early localized infection, oral administration of doxycycline is widely recommended as the first choice, as it is effective against not only Borrelia bacteria but also a variety of other illnesses carried by ticks.[139] Doxycycline is contraindicated in children younger than eight years of age and women who are pregnant or breastfeeding;[139] alternatives to doxycycline are amoxicillin, cefuroxime axetil, and azithromycin.[139] Individuals with early disseminated or late infection may have symptomatic cardiac disease, refractory Lyme arthritis, or neurologic symptoms like meningitis or encephalitis.[139] Intravenous administration of ceftriaxone is recommended as the first choice in these cases;[139] cefotaxime and doxycycline are available as alternatives.[139] These treatment regimens last from one to four weeks.[139] If joint swelling persists or returns, a second round of antibiotics may be considered.[139] Outside of that, a prolonged antibiotic regimen lasting more than 28 days is not recommended as no clinical evidence shows it to be effective.[139][141] IgM and IgG antibody levels may be elevated for years even after successful treatment with antibiotics.[139] As antibody levels are not indicative of treatment success, testing for them is not recommended.[139] Prognosis For early cases, prompt[specify] treatment is usually curative.[142] However, the severity and treatment of Lyme disease may be complicated due to late diagnosis, failure of antibiotic treatment, and simultaneous infection with other tick-borne diseases (coinfections), including ehrlichiosis, babesiosis, and immune suppression[citation needed] in the patient.

It is believed that less than 5% of people have lingering symptoms of fatigue, pain, or joint and muscle aches at the time they finish treatment.[143] These symptoms can last for more than 6 months.

This condition is called post-treatment lyme disease syndrome.

As of 2016 the reason for the lingering symptoms was not known; the condition is generally managed similarly to fibromyalgia or chronic fatigue syndrome.[144] In dogs, a serious long-term prognosis may result in glomerular disease,[145] which is a category of kidney damage that may cause chronic kidney disease.[133] Dogs may also experience chronic joint disease if the disease is left untreated.

However, the majority of cases of Lyme disease in dogs result in a complete recovery with, and sometimes without, treatment with antibiotics.[146][verification needed] In rare cases, Lyme disease can be fatal to both humans and dogs.[147] Epidemiology Countries with reported Lyme disease cases.

Lyme disease occurs regularly in Northern Hemisphere temperate regions.[148] Africa In northern Africa, B. burgdorferi sensu lato has been identified in Morocco, Algeria, Egypt and Tunisia.[149][150][151] Lyme disease in sub-Saharan Africa is presently unknown, but evidence indicates it may occur in humans in this region.

The abundance of hosts and tick vectors would favor the establishment of Lyme infection in Africa.[152] In East Africa, two cases of Lyme disease have been reported in Kenya.[153] Asia B. burgdorferi sensu lato-infested ticks are being found more frequently in Japan, as well as in northwest China, Nepal, Thailand and far eastern Russia.[154][155] Borrelia has also been isolated in Mongolia.[156] Europe In Europe, Lyme disease is caused by infection with one or more pathogenic European genospecies of the spirochaete B. burgdorferi sensu lato, mainly transmitted by the tick Ixodes ricinus.[157] Cases of B. burgdorferi sensu lato-infected ticks are found predominantly in central Europe, particularly in Slovenia and Austria, but have been isolated in almost every country on the continent.[158] Incidence in southern Europe, such as Italy and Portugal, is much lower.[159] United Kingdom In the United Kingdom the number of laboratory confirmed cases of Lyme disease has been rising steadily since voluntary reporting was introduced in 1986[160] when 68 cases were recorded in the UK and Republic of Ireland combined.[161] In the UK there were 23 confirmed cases in 1988 and 19 in 1990,[162] but 973 in 2009[160] and 953 in 2010.[163] Provisional figures for the first 3 quarters of 2011 show a 26% increase on the same period in 2010.[164] It is thought, however, that the actual number of cases is significantly higher than suggested by the above figures, with the UK's Health Protection Agency estimating that there are between 2,000 and 3,000 cases per year,[163] (with an average of around 15% of the infections acquired overseas[160]), while Dr Darrel Ho-Yen, Director of the Scottish Toxoplasma Reference Laboratory and National Lyme Disease Testing Service, believes that the number of confirmed cases should be multiplied by 10 "to take account of wrongly diagnosed cases, tests giving false results, sufferers who weren't tested, people who are infected but not showing symptoms, failures to notify and infected individuals who don't consult a doctor."[165][166] Despite Lyme disease (Borrelia burgdorferi infection) being a notifiable disease in Scotland[167] since January 1990[168] which should therefore be reported on the basis of clinical suspicion, it is believed that many GPs are unaware of the requirement.[169] Mandatory reporting, limited to laboratory test results only, was introduced throughout the UK in October 2010, under the Health Protection (Notification) Regulations 2010.[160] Although there is a greater incidence of Lyme disease in the New Forest, Salisbury Plain, Exmoor, the South Downs, parts of Wiltshire and Berkshire, Thetford Forest[170] and the West coast and islands of Scotland[171] infected ticks are widespread, and can even be found in the parks of London.[162][172] A 1989 report found that 25% of forestry workers in the New Forest were seropositive, as were between 2% and 4-5% of the general local population of the area.[173][174] Tests on pet dogs, carried out throughout the country in 2009 indicated that around 2.

5% of ticks in the UK may be infected, considerably higher than previously thought.[175][176] It is thought that global warming may lead to an increase in tick activity in the future, as well as an increase in the amount of time that people spend in public parks, thus increasing the risk of infection.[177] North America Many studies in North America have examined ecological and environmental correlates of Lyme disease prevalence.

A 2005 study using climate suitability modelling of I. scapularis projected that climate change would cause an overall 213% increase in suitable vector habitat by the year 2080, with northward expansions in Canada, increased suitability in the central U.

S., and decreased suitable habitat and vector retraction in the southern U.

S.[178] A 2008 review of published studies concluded that the presence of forests or forested areas was the only variable that consistently elevated the risk of Lyme disease whereas other environmental variables showed little or no concordance between studies.[179] The authors argued that the factors influencing tick density and human risk between sites are still poorly understood, and that future studies should be conducted over longer time periods, become more standardized across regions, and incorporate existing knowledge of regional Lyme disease ecology.[179] Canada Owing to changing climate, the range of ticks able to carry Lyme disease has expanded from a limited area of Ontario to include areas of southern Quebec, Manitoba, northern Ontario, southern New Brunswick, southwest Nova Scotia and limited parts of Saskatchewan and Alberta, as well as British Columbia.

Cases have been reported as far east as the island of Newfoundland.[180][181][182] A model-based prediction by Leighton et al. (2012) suggests that the range of the I. scapularis tick will expand into Canada by 46 km/year over the next decade, with warming climatic temperatures as the main driver of increased speed of spread.[183] Mexico A 2007 study suggests Borrelia burgdorferi infections are endemic to Mexico, from four cases reported between 1999 and 2000.[184] United States CDC map showing the risk of Lyme disease in the United States, particularly its concentration in the Northeast Megalopolis and western Wisconsin.

Each year, approximately 30,000 new cases are reported to the CDC however, this number is likely underestimated.

The CDC is currently conducting research on evaluation and diagnostics of the disease and preliminary results suggest the number of new cases to be around 300,000.[185][186] Lyme disease is the most common tick-borne disease in North America and Europe, and one of the fastest-growing infectious diseases in the United States.

Of cases reported to the United States CDC, the ratio of Lyme disease infection is 7.

In the ten states where Lyme disease is most common, the average was 31.

6 cases for every 100,000 persons for the year 2005.[187][188][189] Although Lyme disease has been reported in all states[185][190] about 99% of all reported cases are confined to just five geographic areas (New England, Mid-Atlantic, East-North Central, South Atlantic, and West North-Central).[191] New 2011 CDC Lyme case definition guidelines are used to determine confirmed CDC surveillance cases.[192] Effective January 2008, the CDC gives equal weight to laboratory evidence from 1) a positive culture for B. burgdorferi; 2) two-tier testing (ELISA screening and Western blot confirming); or 3) single-tier IgG (old infection) Western blot.[193] Previously, the CDC only included laboratory evidence based on (1) and (2) in their surveillance case definition.

The case definition now includes the use of Western blot without prior ELISA screen.[193] The number of reported cases of the disease has been increasing, as are endemic regions in North America.

For example, B. burgdorferi sensu lato was previously thought to be hindered in its ability to be maintained in an enzootic cycle in California, because it was assumed the large lizard population would dilute the prevalence of B. burgdorferi in local tick populations; this has since been brought into question, as some evidence has suggested lizards can become infected.[194] Except for one study in Europe,[195] much of the data implicating lizards is based on DNA detection of the spirochete and has not demonstrated lizards are able to infect ticks feeding upon them.[194][196][197][198] As some experiments suggest lizards are refractory to infection with Borrelia, it appears likely their involvement in the enzootic cycle is more complex and species-specific.[55] While B. burgdorferi is most associated with ticks hosted by white-tailed deer and white-footed mice, Borrelia afzelii is most frequently detected in rodent-feeding vector ticks, and Borrelia garinii and Borrelia valaisiana appear to be associated with birds.

Both rodents and birds are competent reservoir hosts for B. burgdorferi sensu stricto.

The resistance of a genospecies of Lyme disease spirochetes to the bacteriolytic activities of the alternative complement pathway of various host species may determine its reservoir host association.[citation needed] Several similar but apparently distinct conditions may exist, caused by various species or subspecies of Borrelia in North America.

A regionally restricted condition that may be related to Borrelia infection is southern tick-associated rash illness (STARI), also known as Masters' disease.

Amblyomma americanum, known commonly as the lone-star tick, is recognized as the primary vector for STARI.

In some parts of the geographical distribution of STARI, Lyme disease is quite rare (e.g., Arkansas), so patients in these regions experiencing Lyme-like symptoms—especially if they follow a bite from a lone-star tick—should consider STARI as a possibility.

It is generally a milder condition than Lyme and typically responds well to antibiotic treatment.[citation needed] In recent years there have been 5 to 10 cases a year of a disease similar to Lyme occurring in Montana.

It occurs primarily in pockets along the Yellowstone River in central Montana.

People have developed a red bull's-eye rash around a tick bite followed by weeks of fatigue and a fever.[190] Lyme disease prevalence is comparable among males and females.

A wide range of age groups is affected, though the number of cases is highest among 10- to 19-year-olds.

For unknown reasons, Lyme disease is seven times more common among Asians.[199] South America In South America, tick-borne disease recognition and occurrence is rising.

In Brazil, a Lyme-like disease known as Baggio–Yoshinari syndrome was identified, caused by microorganisms that do not belong to the B. burgdorferi sensu lato complex and transmitted by ticks of the Amblyomma and Rhipicephalus genera.[200] The first reported case of BYS in Brazil was made in 1992 in Cotia, São Paulo.[201] B. burgdorferi sensu stricto antigens in patients have been identified in Colombia and Bolivia.[citation needed] History The evolutionary history of Borrelia burgdorferi genetics has been the subject of recent studies.

One study has found that prior to the reforestation that accompanied post-colonial farm abandonment in New England and the wholesale migration into the mid-west that occurred during the early 19th century, Lyme disease was present for thousands of years in America and had spread along with its tick hosts from the Northeast to the Midwest.[202] John Josselyn, who visited New England in 1638 and again from 1663–1670, wrote "there be infinite numbers of tikes hanging upon the bushes in summer time that will cleave to man's garments and creep into his breeches eating themselves in a short time into the very flesh of a man.

I have seen the stockins of those that have gone through the woods covered with them."[203] This is also confirmed by the writings of Peter Kalm, a Swedish botanist who was sent to America by Linnaeus, and who found the forests of New York "abound" with ticks when he visited in 1749.

When Kalm's journey was retraced 100 years later, the forests were gone and the Lyme bacterium had probably become isolated to a few pockets along the northeast coast, Wisconsin, and Minnesota.[204] Perhaps the first detailed description of what is now known as Lyme disease appeared in the writings of Reverend Dr.

John Walker after a visit to the Island of Jura (Deer Island) off the west coast of Scotland in 1764.[205] He gives a good description both of the symptoms of Lyme disease (with "exquisite pain [in] the interior parts of the limbs") and of the tick vector itself, which he describes as a "worm" with a body which is "of a reddish colour and of a compressed shape with a row of feet on each side" that "penetrates the skin".

Many people from this area of Great Britain emigrated to North America between 1717 and the end of the 18th century.

The examination of preserved museum specimens has found Borrelia DNA in an infected Ixodes ricinus tick from Germany that dates back to 1884, and from an infected mouse from Cape Cod that died in 1894.[204] The 2010 autopsy of Ötzi the Iceman, a 5,300-year-old mummy, revealed the presence of the DNA sequence of Borrelia burgdorferi making him the earliest known human with Lyme disease.[206] The early European studies of what is now known as Lyme disease described its skin manifestations.

The first study dates to 1883 in Breslau, Germany (now Wrocław, Poland), where physician Alfred Buchwald described a man who had suffered for 16 years with a degenerative skin disorder now known as acrodermatitis chronica atrophicans.[207] At a 1909 research conference, Swedish dermatologist Arvid Afzelius presented a study about an expanding, ring-like lesion he had observed in an older woman following the bite of a sheep tick.

He named the lesion erythema migrans.[207] The skin condition now known as borrelial lymphocytoma was first described in 1911.[208] The modern history of medical understanding of the disease, including its cause, diagnosis, and treatment, has been difficult.[209] Neurological problems following tick bites were recognized starting in the 1920s.

French physicians Garin and Bujadoux described a farmer with a painful sensory radiculitis accompanied by mild meningitis following a tick bite.

A large, ring-shaped rash was also noted, although the doctors did not relate it to the meningoradiculitis.

In 1930, the Swedish dermatologist Sven Hellerström was the first to propose EM and neurological symptoms following a tick bite were related.[210] In the 1940s, German neurologist Alfred Bannwarth described several cases of chronic lymphocytic meningitis and polyradiculoneuritis, some of which were accompanied by erythematous skin lesions.

Carl Lennhoff, who worked at the Karolinska Institute in Sweden, believed many skin conditions were caused by spirochetes.

In 1948, he used a special stain to microscopically observe what he believed were spirochetes in various types of skin lesions, including EM.[211] Although his conclusions were later shown to be erroneous, interest in the study of spirochetes was sparked.

In 1949, Nils Thyresson, who also worked at the Karolinska Institute, was the first to treat ACA with penicillin.[212] In the 1950s, the relationship among tick bite, lymphocytoma, EM and Bannwarth's syndrome was recognized throughout Europe leading to the widespread use of penicillin for treatment in Europe.[213][214] In 1970, a dermatologist in Wisconsin named Rudolph Scrimenti recognized an EM lesion in a patient after recalling a paper by Hellerström that had been reprinted in an American science journal in 1950.

This was the first documented case of EM in the United States.

Based on the European literature, he treated the patient with penicillin.[215] The full syndrome now known as Lyme disease was not recognized until a cluster of cases originally thought to be juvenile rheumatoid arthritis was identified in three towns in southeastern Connecticut in 1975, including the towns Lyme and Old Lyme, which gave the disease its popular name.[216] This was investigated by physicians David Snydman and Allen Steere of the Epidemic Intelligence Service, and by others from Yale University, including Dr.

Stephen Malawista, who is credited as a co-discover of the disease.[217] The recognition that the patients in the United States had EM led to the recognition that "Lyme arthritis" was one manifestation of the same tick-borne condition known in Europe.[218] Before 1976, the elements of B. burgdorferi sensu lato infection were called or known as tick-borne meningopolyneuritis, Garin-Bujadoux syndrome, Bannwarth syndrome, Afzelius' disease,[219] Montauk Knee or sheep tick fever.

Since 1976 the disease is most often referred to as Lyme disease,[220][221] Lyme borreliosis or simply borreliosis.[citation needed] In 1980, Steere, et al., began to test antibiotic regimens in adult patients with Lyme disease.[222] In the same year, New York State Health Dept. epidemiologist Jorge Benach provided Willy Burgdorfer, a researcher at the Rocky Mountain Biological Laboratory, with collections of I. dammini [scapularis] from Shelter Island, NY, a known Lyme-endemic area as part of an ongoing investigation of Rocky Mountain spotted fever.

In examining the ticks for rickettsiae, Burgdorfer noticed "poorly stained, rather long, irregularly coiled spirochetes." Further examination revealed spirochetes in 60% of the ticks.

Burgdorfer credited his familiarity with the European literature for his realization that the spirochetes might be the "long-sought cause of ECM and Lyme disease." Benach supplied him with more ticks from Shelter Island and sera from patients diagnosed with Lyme disease.

University of Texas Health Science Center researcher Alan Barbour "offered his expertise to culture and immunochemically characterize the organism." Burgdorfer subsequently confirmed his discovery by isolating, from patients with Lyme disease, spirochetes identical to those found in ticks.[223] In June 1982, he published his findings in Science, and the spirochete was named Borrelia burgdorferi in his honor.[224] After the identification of B. burgdorferi as the causative agent of Lyme disease, antibiotics were selected for testing, guided by in vitro antibiotic sensitivities, including tetracycline antibiotics, amoxicillin, cefuroxime axetil, intravenous and intramuscular penicillin and intravenous ceftriaxone.[225][226] The mechanism of tick transmission was also the subject of much discussion.

B. burgdorferi spirochetes were identified in tick saliva in 1987, confirming the hypothesis that transmission occurred via tick salivary glands.[227] Society and culture Urbanization and other anthropogenic factors can be implicated in the spread of Lyme disease to humans.

In many areas, expansion of suburban neighborhoods has led to gradual deforestation of surrounding wooded areas and increased border contact between humans and tick-dense areas.

Human expansion has also resulted in a reduction of predators that hunt deer as well as mice, chipmunks and other small rodents—the primary reservoirs for Lyme disease.

As a consequence of increased human contact with host and vector, the likelihood of transmission of the disease has greatly increased.[228][229] Researchers are investigating possible links between global warming and the spread of vector-borne diseases, including Lyme disease.[230] Controversy The term "chronic Lyme disease" is controversial and not recognized in the medical literature,[231] and most medical authorities advise against long-term antibiotic treatment for Lyme disease.[91][232][233] Studies have shown that most people diagnosed with "chronic Lyme disease" either have no objective evidence of previous or current infection with B. burgdorferi or are people who should be classified as having post-treatment Lyme disease syndrome (PTLDS), which is defined as continuing or relapsing non-specific symptoms (such as fatigue, musculoskeletal pain, and cognitive complaints) in a person previously treated for Lyme disease.[234] Other animals Prevention of Lyme disease is an important step in keeping dogs safe in endemic areas.

Prevention education and a number of preventative measures are available.

First, for dog owners who live near or who often frequent tick-infested areas, routine vaccinations of their dogs is an important step.[235] Another crucial preventive measure is the use of persistent acaricides, such as topical repellents or pesticides that contain triazapentadienes (Amitraz), phenylpyrazoles (Fipronil), or permethrin (pyrethroids).[236] These acaricides target primarily the adult stages of Lyme-carrying ticks and reduce the number of reproductively active ticks in the environment.[235] Formulations of these ingredients are available in a variety of topical forms, including spot-ons, sprays, powders, impregnated collars, solutions, and shampoos.[236] Examination of a dog for ticks after being in a tick-infested area is an important precautionary measure to take in the prevention of Lyme disease.

Key spots to examine include the head, neck, and ears.[237] Research The National Institutes of Health have supported research into bacterial persistence.[238]  This article incorporates public domain material from the Centers for Disease Control and Prevention document "Post-Treatment Lyme Disease Syndrome".Symptoms of Lyme disease Lyme disease occurs in three stages: early localized, early disseminated, and late disseminated.

The symptoms you experience will depend on which stage the disease is in.

Stage 1: Early localized disease Symptoms of Lyme disease start one to two weeks after the tick bite.

One of the earliest signs is a “bull’s-eye” rash, which is a sign that bacteria are multiplying in the bloodstream.

The rash occurs at the site of the tick bite as a central red spot surrounded by a clear spot with an area of redness at the edge.

It may be warm to the touch, but it isn’t painful and doesn’t itch.

The formal name for this rash is erythema migrans.

Erythema migrans is said to be characteristic of Lyme disease.

Some people have a rash that is solid red, while people with dark complexions may have a rash that resembles a bruise.

Stage 2: Early disseminated Lyme disease Early disseminated Lyme disease occurs several weeks after the tick bite.

During this stage bacteria are beginning to spread throughout the body.

It’s characterized by flu-like symptoms, such as: During early disseminated Lyme disease you’ll have a general feeling of being unwell.

A rash may appear in areas other than the tick bite, and neurological signs such as numbness, tingling, and Bell’s palsy can also occur.

This stage of Lyme disease can be complicated by meningitis and cardiac conduction disturbances.

Stage 3: Late disseminated Lyme disease Late disseminated Lyme disease occurs when the infection hasn’t been treated in stages 1 and 2.

Stage 3 can occur weeks, months, or years after the tick bite.

This stage is characterized by: severe headaches arthritis of one or more large joints disturbances in heart rhythm brain disorders (encephalopathy) involving memory, mood, and sleep short-term memory loss difficulty concentrating mental fogginess problems following conversations numbness in the arms, legs, hands, or feet Contact your doctor immediately if you have any of these symptoms.Lyme Disease History Lyme disease, sometimes referred to as Lyme infection or borreliosis, is a bacterial illness, transmitted to humans by the bite of deer ticks (Ixodes ticks) carrying a bacterium known as Borrelia burgdorferi.

The disease has been reported in the Northeast, Mid-Atlantic, North Central, and Pacific coastal regions of the United States (see map) and in Europe, where it was first described almost 100 years ago.

It is most prevalent in the northeastern and Midwestern states of the U.

S., with about 96% of reported cases occurring in 14 states, including Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.

Doctors at New Haven's Yale Medical Center first described and named Lyme disease in the U.

S. in 1977, after an unexpected number of residents in Lyme, Conn., were found to have a "new" and unusual illness.

Take the Lyme Disease Quiz Lyme Disease Slideshow Pictures Lyme Disease Target Rash What Are Lyme Disease Causes and Risk Factors?

The bacteria have a complex life cycle, spending part of their life in the deer tick and part in some mammals such as mice and deer.

Humans are not a part of the bacterium's life cycle but can become infected when bitten by the tick.

Lyme disease is not contagious and cannot be passed from person to person.

While dogs and cats can get Lyme disease, there are no reported cases of these animals spreading the disease to their owners.

However, dogs and cats can bring the infected ticks into the home, which is one reason why tick protection for pets is important.

Talk to a veterinarian about the right type of tick control for any pets.

Risk factors for getting Lyme disease include the following: Living in the northeastern or Midwestern U.

S. states where the disease is most prevalent Being outdoors in the woods or areas that have tall grass, shrubs, or brush Fishing, camping, hunting, yard work, hiking, and other outdoor activities in tick-infested areas Having bare, unprotected skin when outdoors in high-risk areas Pets who are not protected against ticks may bring them indoors.

Not removing attached ticks promptly Lyme Disease Pictures See photos of the ticks that cause Lyme disease, and view images of tick bites and the bull's-eye rash.

See more pictures of Lyme disease » YOU MAY ALSO LIKE VIEW Lyme Disease Pictures, Symptoms and Treatment What Are Signs and Symptoms of Lyme Disease?

Early signs and symptoms of Lyme disease occur from three to 30 days after a tick bite and include the following: Fever Chills Headache Fatigue Muscle and joint aches Swollen lymph nodes General feeling of being unwell (malaise) The initial infection can occur with minimal or no signs or symptoms.

But many people experience a flu-like primary illness or a characteristic rash several days to a few weeks following a tick bite.

This rash may feel warm to the touch but is rarely itchy or painful.

The flu-like illness usually occurs in the warm weather months when flu (influenza) does not occur.

It is called erythema migrans and occurs in about 70%-80% of infected individuals.

Centers for Disease Control and Prevention (CDC) defines this rash as a skin lesion that typically begins as a red spot and expands over a period of days to weeks to form a large round lesion, at least 5 cm (about 2 inches) across, and up to 30 cm (12 inches).

A red circular spot that begins within hours and is smaller is usually a reaction to the tick bite.

When the rash occurs at the site of the tick bite, it is called a primary lesion.

Multiple secondary lesions can occur that are a reaction to the infection and are not due to multiple tick bites.

All of these lesions can enlarge to the size of a football.

This growth in size of the red spots on the skin is characteristic of Lyme disease.

As it grows, the rash can remain red throughout, although it often can develop a clear central area.

In a minority, it may take on the appearance of a target with multiple rings (alternating red with clear skin), called a bull's-eye lesion.

Symptoms and signs in children are similar, though younger children are more likely to have skin lesions occur on the head or neck and older children on the extremities.

Left untreated, signs and symptoms of the primary illness usually will go away on their own within a few weeks, although the rash may recur.

Days to months later, additional symptoms of Lyme disease may occur.

The organs affected later in the course of the disease may lead to the following conditions and complications: Facial palsy (Bell's palsy) is paralysis of the facial nerve that causes the facial muscles to be uneven and droop.

Meningitis causes headache, fever, and stiff neck.

Nerve inflammation causes pain, numbness, and tingling in the arms or legs.

Shooting pains may interfere with sleep and cause insomnia.

Muscle weakness Brain swelling (encephalitis) causes learning difficulties, confusion, and dementia.

Intermittent episodes of arthritis last about a week and usually involve the knee or wrist.

This involves severe joint pain, stiffness, and swelling.

These may recur over periods of weeks to months, and if the Lyme disease remains untreated, about 10% of people who have these episodes develop persistent arthritis in the knee.

Occasionally, people with Lyme disease can present with an acute arthritis in the knee without a clear history of a rash or other joint complaints.

Inflammation of the heart (carditis) results in heart palpitations or an irregular heartbeat (Lyme carditis), which can also result in dizziness or passing out.

Inflammation of the brain and spinal cord Difficulty with short-term memory Is Lyme Disease Contagious?

Lyme disease is not contagious and cannot be transmitted from person to person.

The only way humans can get Lyme disease is through the bite of an infected blacklegged tick.

A primary-care provider (PCP) such as a family practitioner, internist, or child's pediatrician may initially diagnose Lyme disease.

In areas where Lyme disease is common, these physicians often treat the illness, as well.

However, you may be referred to a specialist for treatment.

Rheumatologists specialize in diseases that affect the joints and muscles, including infectious diseases such as Lyme disease.

You may also see a neurologist if you experience nerve problems or an infectious disease specialist who can help treat Lyme disease in the later stages.

Take the Lyme Disease Quiz Lyme Disease Slideshow Pictures Lyme Disease Target Rash When Should Someone Seek Medical Care for Lyme Disease?

Seek immediate medical attention if you live in or have visited an area where Lyme disease is common and you experience a flu-like illness or develop a red or target-like (bull's eye) rash anytime from late spring to early fall.

Prompt treatment at this early stage reduces the risk of further symptoms of Lyme disease.

Remove any attached ticks by pulling them off your body.

The CDC recommends the following tick-removal process: Grasp the tick with fine-tipped tweezers as close to the skin's surface as possible.

Don't twist or jerk the tick or mouth-parts may break off and remain in the skin.

If this happens, remove the mouth-parts with tweezers.

If you are cannot remove the mouth easily with tweezers, leave it alone and let the skin heal.

After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water.

If the tick is still alive, dispose of it by submersing it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet.

However, removing ticks promptly is more important than how you remove them.

If you cannot remove an attached tick, see a doctor, who will remove it.

You do not need to save the tick to get it tested.

The CDC states this is generally not useful because even if the tick contains disease-causing organisms, it does not necessarily mean you have been infected with the bacteria that cause Lyme disease; and if you have been infected, symptoms will likely develop before tick testing results come back and you should be treated as soon as possible.

Following tick removal, see a doctor if any flu-like symptoms or rash develop within the next three weeks.

If a rash develops, draw a line around it with ink that does not wash off (such as a Magic Marker or Sharpie) each day to see if it is growing.

Young children with fever and severe headache should see a doctor immediately, because these may be their only symptoms.

Outdoor workers and anyone whose hobbies or recreational activities place them in wooded or brush areas should be particularly aware of these symptoms because their environmental exposure increases contact with the deer tick and is a risk factor for contracting Lyme disease.

See a doctor or go to a hospital's emergency department immediately.

When the initial disease is not treated, your symptoms may go away, but additional late stage symptoms and complications of Lyme disease can occur months later.

When this happens, Lyme disease can affect the heart, muscles and joints, or the nervous system.

Since these symptoms can occur with other diseases, be sure to tell a doctor about travel to areas with a high tick population or if you have any possible exposures to ticks (from pets, gardening, walking, or camping in wooded areas, etc.).

If you are pregnant and are bitten by a tick, see a doctor immediately.

If you become infected with Lyme disease during pregnancy, the illness can infect the placenta and may result in stillbirth.

Lyme disease is not transmitted through breast milk.

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Questions to Ask the Doctor About Lyme Disease If you have an identifiable tick bite but no symptoms have begun, there is a question as to whether preventive treatment should be started.

If the symptoms of Lyme disease have started, the question is what antibiotic treatment will be used, by which route it will be administered, and how long it should be taken.

Doctors base a diagnosis of Lyme disease on a careful and detailed history and a complete physical examination supported by laboratory testing when appropriate.

The doctor will ask whether you know if a tick has bitten you and will gather information about your outdoor exposure in an area with a high tick population.

Physical examination findings are important, especially the presence of erythema migrans.

If there is doubt whether a rash is due to Lyme disease, the doctor might measure its size and then remeasure one to two days later.

Erythema migrans usually exhibits an increase in size of the rash, often expanding by about ½ inch every day.

Some physical findings help to distinguish Lyme disease from other infectious ailments.

Doctors may perform blood tests to examine for antibodies to the bacteria.

Antibodies can be absent early in the course of a Lyme infection (in the first few weeks), so a negative test result may be misleading at that time.

There are two tiers of blood tests used to diagnose Lyme disease, a screening test (Lyme ELISA or IFA) and, if that test is positive or equivocal, a more specific test (Western blot).

A positive Western blot test result confirms current or past infection.

Especially in regions of the country where Lyme disease is very common, patients can have positive test results for Lyme disease but have clinical problems that are explained by another condition.

A screening test (a Lyme titer) is not considered sufficient to make a diagnosis of Lyme disease; the Western blot has to be positive also.

The accuracy of these tests is very good, but it depends on the stage of the disease.

In early stages, a negative test is expected; however, after a few weeks, the ELISA and IFA tests have good sensitivity and accuracy.

Once a Lyme blood test is positive, it will remain positive for a long time even with successful treatment.

Repeat blood tests after treatment are not helpful in determining further care.

Ixodes ticks can carry other organisms in addition to B. burgdorferi, and these can cause illnesses that can mimic Lyme disease or can even occur along with Lyme disease.

The two most important infections are ehrlichiosis (HGE) and babesiosis.

Doctors also may perform liver function tests and blood counts to examine the red blood cells and other tests for these two conditions.

Another tick-borne illness called Rocky Mountain spotted fever can cause a rash but is not the same illness as Lyme disease.

People with severe headaches may need a spinal tap to determine if there is inflammation in the nervous system (meningitis, encephalitis) and to test for Lyme antibodies in the spinal fluid.

Doctors may perform an ECG if you have possible heart complications.

CT scans and MRI of the brain may be performed to rule out other conditions that can cause similar symptoms.

Take the Lyme Disease Quiz Lyme Disease Slideshow Pictures Lyme Disease Target Rash Are There Lyme Disease Home Remedies?

Health departments in areas with high rates of infection have undertaken campaigns to raise public awareness and educate the public on facts about Lyme disease.

It is known that certain outdoor areas are highly infested with deer ticks and should be avoided if possible -- these include woods and brush areas.

Generally, the tick counts on suburban lawns are much lower.

Lyme disease should never be treated with home remedies alone.

Antibiotics are needed to cure the illness, however, some home remedies may help ease symptoms as you recover.

Consult a doctor before taking an herbal supplement or natural remedy as they may interact with medications you already take or may cause unwanted side effects.

Nattokinase is an enzyme made from fermented soybeans that some believe can help treat their Lyme disease symptoms.

Probiotics (such as Lactobacillus acidophilus) can be taken to help reduce diarrhea or yeast infections that are side effects of prescribed antibiotics.

Beta-glucan is a type of fiber believed to stimulate the immune system, though there are no studies that prove this.

One small study showed it was effective as a tick repellant when used on properties where ticks tend to live.

Another small study showed that people who took garlic as a supplement reported fewer tick bites.

More study is needed to determine if garlic is an effective tick repellant.

Essiac is an herbal formula that contains burdock root (Arctium lappa), sheep sorrel (Rumex acetosella), slippery elm (Ulmus fulva), and rhubarb (Rheum palmatum) and is reported to help treat Lyme disease, but there are no studies that prove it is effective, or whether it will interact with medications.

What Are Lyme Disease Treatments and Medications?

Doctors will treat primary or early Lyme disease with oral antibiotics, including doxycycline (Vibramycin), cefuroxime (Ceftin), penicillins, amoxicillin (Amoxil), or erythromycin (Ilotycin, Ery-Ped, Ery-Tab).

In early stages, the disease can be curable with just this antibiotic treatment.

Pregnant women are usually treated with penicillins or erythromycin.

Doxycycline is generally avoided as it may affect the development of the fetus.

Doctors may treat late-stage cases of neurological, heart, or arthritic Lyme disease with intravenous antibiotics (usually ceftriaxone [Rocephin]) in the hospital or as an outpatient.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve) may be recommended to help relieve pain and inflammation.

Follow-up for Lyme Disease Follow-up with continued care is important for people who have early Lyme disease but who fail to improve rapidly and completely.

Doctors must consider other treatment options and rule out other illnesses that may be mistaken for Lyme disease.

People with later-stage disease who require IV antibiotics or hospitalization must be monitored in the weeks following their treatment.

Improvement in the symptoms of Lyme disease, particularly in the heart and nervous system, may occur gradually over a period of months.

Lack of immediate improvement in all your symptoms is not a sign of unsuccessful treatment.

Take the Lyme Disease Quiz Lyme Disease Slideshow Pictures Lyme Disease Target Rash How Can People Prevent Lyme Disease?

There is currently no vaccine available to prevent Lyme disease; however, there are three approaches to preventing Lyme disease.

Tick Avoidance Try to stay out of woodlands and brush areas where the tick thrives, especially during the peak season of summer and early fall.

Wear garments that will create barriers to the tick attaching to the skin and biting.

Tuck pant legs into socks so ticks cannot easily crawl the short distance from the ground to just above the sock line.

Wear light-colored clothing to better identify ticks.

The application of the insecticide DEET (low-concentration preparations are recommended) to clothing and skin (This should be limited in children to prevent absorption of too much DEET.) has been found to decrease tick bites and the chance for Lyme disease infections.

Tick Removal Deer ticks need to remain attached to the skin for about 24-48 hours to transmit the Borrelia bacteria to the skin.

Inspect all areas of the body after outdoor activity.

If you notice a bite, it is very important to watch for symptoms, which usually show up in about three weeks.

Ticks attach to areas that are warm and moist, such as the groin, the armpits, the underside of a woman's breasts, and the neck and hairline.

If you see a tick, promptly remove it (see previous section on When Should Seek Medical Care for Lyme Disease for instructions on tick removal).

This greatly reduces the likelihood of an infection.

Disinfect the bite site thoroughly with alcohol or other skin antiseptic solution.

Use of gasoline, petroleum, and other organic solvents to suffocate ticks, as well as burning the tick with a match, should be avoided.

Antibiotic Treatment Treatment of tick bites within 72 hours of a bite with a single dose of doxycycline has been reported to prevent Lyme disease.

This may be appropriate if you live in an endemic area and have removed an engorged tick or multiple ticks.

When treated early, the prognosis for most people with Lyme disease is rapid improvement and minimal complications from the disease.

Later stages of illness are avoided by effective treatment of early Lyme disease.

People with later stages of the disease may also do well when they are diagnosed soon after their later-stage symptoms first occur.

A small percentage of people with Lyme disease do not fully recover, or recover very slowly, and have a condition called post-treatment Lyme disease syndrome (PTLDS), in which symptoms of fatigue, pain, or joint and muscle aches last for more than six months following treatment.

Long-term effects of Lyme disease may include residual facial palsy or residual knee pain.

Other people develop chronic muscle and joint pains, fatigue, and concentration difficulties that seem to have arisen from the time of the original Lyme disease infection.

While these chronic and recurring symptoms have been called chronic Lyme disease, recent studies have not shown any evidence of Borrelial infection in the blood or spinal fluid, and further antibiotic therapy does not appear to have a durable effect in relieving the condition.

For the present, patients with this problem are being treated with supportive measures aimed at symptomatic relief.

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Zernel, Pfizer Labs Picture of the bull's-eye shape of the Lyme rash, which may grow in size.

Picture of magnified ticks at different stages of development.

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And as it continues to expand its range into the southern and western U.

S. and into Canada, it’s likely that the number of Lyme disease cases in North America will climb, experts say.

A recent CDC study found that cases of Lyme increased more than 80% between 2004 and 2016 -- from 19,804 to 36,429.

The CDC estimates there are more than 300,000 cases of Lyme infection in the U.

S. each year -- or 10 times as many as what is reported. “There’s obviously year-to-year bouncing around, but the trend line is upward,” says John Aucott, MD, director of the Johns Hopkins Lyme Disease Clinical Research Center in Baltimore. “It won’t stop in the foreseeable future.” Most cases are clustered in 14 states in the Northeast and Upper Midwest, but Lyme has been reported as far south as Florida and Mexico, and increasingly, in Canada.

The black-legged tick (Ixodes scapularis), also known as the deer tick, carries the bacteria that causes Lyme infection.

The same tick also can spread other diseases, including babesiosis, anaplasmosis, and Powassan virus -- other diseases on the rise in the U.

Here’s more about the disease and what to expect this year and beyond.

Lyme disease is caused by bacteria, Borrelia burgdorferi that are transmitted to humans through a bite from an infected black-legged or deer tick.

Symptoms can occur anywhere from 3 to 30 days after the bite and can be wide-ranging, depending on the stage of the infection.

In some cases, symptoms can appear months after the bite.

The chances you might get Lyme disease from a tick bite depend on the kind of tick, where you were when the bite occurred, and how long the tick was attached to you, the CDC says.

Black-legged ticks must be attached to you for 36 to 48 hours to transmit Lyme disease.

If you remove the tick or ticks within 48 hours, you aren’t likely to get infected, says Cleveland Clinic infectious disease specialist Alan Taege, MD.

Early signs and symptoms include fever, chills, headache, fatigue, muscle and joint pain, and swollen lymph nodes -- all common in the flu.

In up to 80% of Lyme infections, a rash is one of the first symptoms, Aucott says.

They might include: Severe headache or neck stiffness Rashes on other areas of the body Arthritis with severe joint pain and swelling, particularly in the knees Loss of muscle tone or “drooping” on one or both sides of the face.

Heart palpitation or an irregular heartbeat Inflammation of the brain and spinal cord Shooting pains, numbness, or tingling in the hands or feet What does the rash look like?

About 20% to 30% of Lyme rashes have a “bull's-eye” appearance -- concentric circles around a center point -- but most are round and uniformly red and at least 5 centimeters (about 2 inches) across, Aucott says. “Most are just red,” he says. “They do not have the classic ring within a ring like the Target logo.” The rash expands gradually over a period of days and can grow to about 12 inches across, the CDC says.

It may feel warm to the touch, but it rarely itches or is painful, and it can appear on any part of the body.

TIcks come in three sizes, depending on their stage of life.

Larvae are the size of grains of sand, nymphs the size of poppy seeds, and adults the size of an apple seed.  How is Lyme disease diagnosed?

Doctors diagnose it based on symptoms and a history of tick exposure.

Two-step blood tests are helpful if used correctly.

But the accuracy of the test depends on when you got infected.

In the first few weeks of infection, the test may be negative, as antibodies take a few weeks to develop.

Tests aren’t recommended for patients who don’t have Lyme disease symptoms.

Aucott says the most promising development in the fight against Lyme disease are better diagnostic tests that are accurate in the first few weeks after exposure.

The earlier the treatment, the less likely the disease will progress.

Aucott says he expects the tests to be available soon.

Doctors may not recognize symptoms, especially those who practice in areas where Lyme infection isn’t prevalent, and up to 30% of the infections are not accompanied by a rash.

There are three stages: Early localized Lyme: Flu-like symptoms such as fever, chills, headache, swollen lymph nodes, sore throat, and typically a rash that has a “bull's-eye” appearance or is uniformly round and red and at least 5 centimeters in size Early disseminated Lyme: Flu-like symptoms that now include pain, weaknessor numbness in the arms and legs, vision changes, heart palpitations and chest pain, a rash, and facial paralysis (Bell’s palsy) Late disseminated Lyme: This can occur weeks, months, or years after the tick bite.

Symptoms might include arthritis, severe fatigue and headaches, vertigo, sleep disturbances, and mental confusion.

While experts don’t understand it, roughly 10% of people treated for Lyme infection do not shake the disease.

They may go on to have three core symptoms -- joint or muscle pain, fatigue, and short-term memory loss or mental confusion This is called post-treatment Lyme disease syndrome.

It’s considered controversial because its symptoms are shared with other diseases and there isn’t a blood test to diagnose it, Aucott says.

There are theories as to why Lyme symptoms become chronic.

One is that the body continues fighting the infection long after the bacteria are gone, much like an autoimmune disorder.

Antibiotics are used to treat early stage Lyme infection.

Patients typically take doxycycline for 10 days to 3 weeks, or amoxicillin and cefuroxime for 2 to 3 weeks.

In up to 90% of cases, the antibiotic cures the infection.

If it doesn’t, patients might get other antibiotics either by mouth or intravenously.

For early disseminated Lyme disease, which may happen when a Lyme infection goes untreated, oral antibiotics are recommended for symptoms such as facial palsy and abnormal heart rhythm.

Intravenous antibiotics are recommended if a person has meningitis, inflammation of the lining of the brain and spinal cord, or more severe heart problems.

In late-stage Lyme, a patient may receive oral or intravenous antibiotics.

Patients with lingering arthritis would receive standard arthritis treatment.

There is no treatment for post-treatment Lyme disease syndrome. “Ten percent of people don’t get better after antibiotics,” Aucott says. “We think it’s very significant if 30,000 people a year don’t get better.” What areas are more likely to have it?

Mainly New England, the Mid-Atlantic states, and part of the Upper Midwest.

The CDC says 95% of confirmed cases in 2016 were in 14 states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.

From 2006 to 2016, case numbers have increased in Ohio, Indiana, and Michigan as the tick’s range expands westward.

In 2016, the highest number of confirmed Lyme infection cases -- 9,000 -- was reported in Pennsylvania, followed by New Jersey, with more than 3,300 cases.

S., which is more prone to hot weather, ticks tend to stay under leaf litter and don’t come up higher to feed much, Aucott says -- “ticks don’t like to dry out.” This means Southern ticks don’t transmit Lyme as frequently because they don’t tend to feed on humans.

Infection is more common in males up to age 15 and between the ages of 40 and 60, says Taege. “These are people who are more likely to play outside, and go camping, hunting, and hiking,” he says.

Aucott adds that Lyme infection drops off in older teens and those in their 20s “because they’re inside on their computers.” Older adults, he says, tend to have more time to work in their backyards, which is where most Lyme infection is transmitted.

Scientists point to a variety of causes for the spread of Lyme infection.

Among them are reforestation, especially in the Northeast U.

S., where Lyme disease is more prevalent; climate change and temperature extremes; suburbanization; and more exposure to the white-tailed deer, which is the black-legged tick’s favorite mode of travel.

Development led to record low numbers of deer early in the last century, says CDC epidemiologist Paul Mead, MD.

But the deer population has rebounded as reforestation took place over several decades, meaning the tick population has risen and expanded as well. “Ticks have a pretty long life cycle, lasting 2-3 years, and typically don’t move very far within their lifetime, so it takes a while to see large changes,” he says.

Deer and white-footed mice, which transmit Lyme disease to ticks that bite them, are moving closer to humans as their habitats disappear, says Taege.

Ticks don’t mind dogs, either, which carry them into homes and spread them to their humans.

Another reason: Warmer weather and mild winters may bring more people outside, raising their chances of being bitten, particularly in Lyme-prone areas, Taege says. “Whether you believe in global warming or not, we have longer, warmer summer months, and people are outdoors more,” says Taege. “We’ve seen an expansion [of ticks] in areas in which the vectors live, and we’ve slowly seen more Lyme disease.” That doesn’t mean you should be afraid of outdoor activities, as long as you take precautions to avoid tick bites, Aucott says.

Ticks can’t fly or jump, but instead live in shrubs and bushes, and grab onto someone when they pass by.

To avoid getting bitten: Wear pants and socks in the woods, areas with lots of trees, and while handling fallen leaves Wear a tick repellent on your skin and clothing that has DEET, lemon oil, or eucalyptus.

For even more protection, use the chemical permethrin on clothing and camping gear.

Shower within 2 hours after coming inside, if possible.

Look at your skin and wash ticks out of your hair.

Put your clothing and any exposed gear into a hot dryer to kill whatever pests might remain.

Given that the ticks are the size of a poppy seed, you’ve got to have pretty good eyes.

The CDC recommends that if you’ve been walking in the woods, in tall grass, or working in the garden, check your skin afterward, ideally in the shower or bath.

That way, you’ve removed your clothes, which may carry ticks, too.

What do you do if there’s a tick under your skin?

Remove it with a pair of fine-tipped tweezers as soon as possible, pulling upward with steady pressure.

If parts of the tick remain in the skin, also try to remove them with the tweezers.

After everything is out, clean the bite area with rubbing alcohol or soap and water.

Mead says you’re not likely to get infected if you remove the tick within 36 to 48 hours.

Some people have an allergic reaction to ticks, so they’ll notice a bite right away.

Place it in soapy water or alcohol, stick it to a piece of tape, or flush it down the toilet.

When should you see a doctor if you suspect you have Lyme?

The rash is a pretty good indication that you may have been bitten.

Take a photo of the rash and see your doctor, Aucott says.

At this stage of the illness, treatment with antibiotics will probably be successful.

If you don’t have the telltale rash but have a summer flu -- fatigue, fever, headache but no respiratory symptoms like a cough -- you may want to talk to your doctor, Aucott says.

Is there any progress on a vaccine for Lyme disease?

The FDA in July 2017 gave "fast-track" approval to French biotech company Valneva to test potential Lyme disease vaccine VLA15 on adults in the U.

Data from the first phase are expected to be released soon, and then the second phase will begin.

The more ticks in your region, the likelier it is that your furry pal will bring them home.

Dogs are much more likely than humans to be bitten by ticks, and where Lyme disease is more prevalent, up to 25% of dogs have evidence of past infection, he says. “On the flip side, low rates of exposure in dogs is a good indicator that Lyme is not a problem in the area.” And they can get sick.

About 10% of dogs with Lyme disease will become ill.

Common symptoms, which may show up 7-21 days after a tick bite, are lameness -- your dog will appear to be walking on eggshells -- a fever, lethargy, and enlarged lymph nodes.

Practice prevention habits and use a tick control product on your pet.Lyme Disease History Lyme disease, sometimes referred to as Lyme infection or borreliosis, is a bacterial illness, transmitted to humans by the bite of deer ticks (Ixodes ticks) carrying a bacterium known as Borrelia burgdorferi.

The disease has been reported in the Northeast, Mid-Atlantic, North Central, and Pacific coastal regions of the United States (see map) and in Europe, where it was first described almost 100 years ago.

It is most prevalent in the northeastern and Midwestern states of the U.

S., with about 96% of reported cases occurring in 14 states, including Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.

Doctors at New Haven's Yale Medical Center first described and named Lyme disease in the U.

S. in 1977, after an unexpected number of residents in Lyme, Conn., were found to have a "new" and unusual illness.

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The bacteria have a complex life cycle, spending part of their life in the deer tick and part in some mammals such as mice and deer.

Humans are not a part of the bacterium's life cycle but can become infected when bitten by the tick.

Lyme disease is not contagious and cannot be passed from person to person.

While dogs and cats can get Lyme disease, there are no reported cases of these animals spreading the disease to their owners.

However, dogs and cats can bring the infected ticks into the home, which is one reason why tick protection for pets is important.

Talk to a veterinarian about the right type of tick control for any pets.

Risk factors for getting Lyme disease include the following: Living in the northeastern or Midwestern U.

S. states where the disease is most prevalent Being outdoors in the woods or areas that have tall grass, shrubs, or brush Fishing, camping, hunting, yard work, hiking, and other outdoor activities in tick-infested areas Having bare, unprotected skin when outdoors in high-risk areas Pets who are not protected against ticks may bring them indoors.

Not removing attached ticks promptly Lyme Disease Pictures See photos of the ticks that cause Lyme disease, and view images of tick bites and the bull's-eye rash.

See more pictures of Lyme disease » YOU MAY ALSO LIKE VIEW Lyme Disease Pictures, Symptoms and Treatment What Are Signs and Symptoms of Lyme Disease?

Early signs and symptoms of Lyme disease occur from three to 30 days after a tick bite and include the following: Fever Chills Headache Fatigue Muscle and joint aches Swollen lymph nodes General feeling of being unwell (malaise) The initial infection can occur with minimal or no signs or symptoms.

But many people experience a flu-like primary illness or a characteristic rash several days to a few weeks following a tick bite.

This rash may feel warm to the touch but is rarely itchy or painful.

The flu-like illness usually occurs in the warm weather months when flu (influenza) does not occur.

It is called erythema migrans and occurs in about 70%-80% of infected individuals.

Centers for Disease Control and Prevention (CDC) defines this rash as a skin lesion that typically begins as a red spot and expands over a period of days to weeks to form a large round lesion, at least 5 cm (about 2 inches) across, and up to 30 cm (12 inches).

A red circular spot that begins within hours and is smaller is usually a reaction to the tick bite.

When the rash occurs at the site of the tick bite, it is called a primary lesion.

Multiple secondary lesions can occur that are a reaction to the infection and are not due to multiple tick bites.

All of these lesions can enlarge to the size of a football.

This growth in size of the red spots on the skin is characteristic of Lyme disease.

As it grows, the rash can remain red throughout, although it often can develop a clear central area.

In a minority, it may take on the appearance of a target with multiple rings (alternating red with clear skin), called a bull's-eye lesion.

Symptoms and signs in children are similar, though younger children are more likely to have skin lesions occur on the head or neck and older children on the extremities.

Left untreated, signs and symptoms of the primary illness usually will go away on their own within a few weeks, although the rash may recur.

Days to months later, additional symptoms of Lyme disease may occur.

The organs affected later in the course of the disease may lead to the following conditions and complications: Facial palsy (Bell's palsy) is paralysis of the facial nerve that causes the facial muscles to be uneven and droop.

Meningitis causes headache, fever, and stiff neck.

Nerve inflammation causes pain, numbness, and tingling in the arms or legs.

Shooting pains may interfere with sleep and cause insomnia.

Muscle weakness Brain swelling (encephalitis) causes learning difficulties, confusion, and dementia.

Intermittent episodes of arthritis last about a week and usually involve the knee or wrist.

This involves severe joint pain, stiffness, and swelling.

These may recur over periods of weeks to months, and if the Lyme disease remains untreated, about 10% of people who have these episodes develop persistent arthritis in the knee.

Occasionally, people with Lyme disease can present with an acute arthritis in the knee without a clear history of a rash or other joint complaints.

Inflammation of the heart (carditis) results in heart palpitations or an irregular heartbeat (Lyme carditis), which can also result in dizziness or passing out.

Inflammation of the brain and spinal cord Difficulty with short-term memory Is Lyme Disease Contagious?

Lyme disease is not contagious and cannot be transmitted from person to person.

The only way humans can get Lyme disease is through the bite of an infected blacklegged tick.

A primary-care provider (PCP) such as a family practitioner, internist, or child's pediatrician may initially diagnose Lyme disease.

In areas where Lyme disease is common, these physicians often treat the illness, as well.

However, you may be referred to a specialist for treatment.

Rheumatologists specialize in diseases that affect the joints and muscles, including infectious diseases such as Lyme disease.

You may also see a neurologist if you experience nerve problems or an infectious disease specialist who can help treat Lyme disease in the later stages.

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Seek immediate medical attention if you live in or have visited an area where Lyme disease is common and you experience a flu-like illness or develop a red or target-like (bull's eye) rash anytime from late spring to early fall.

Prompt treatment at this early stage reduces the risk of further symptoms of Lyme disease.

Remove any attached ticks by pulling them off your body.

The CDC recommends the following tick-removal process: Grasp the tick with fine-tipped tweezers as close to the skin's surface as possible.

Don't twist or jerk the tick or mouth-parts may break off and remain in the skin.

If this happens, remove the mouth-parts with tweezers.

If you are cannot remove the mouth easily with tweezers, leave it alone and let the skin heal.

After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water.

If the tick is still alive, dispose of it by submersing it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet.

However, removing ticks promptly is more important than how you remove them.

If you cannot remove an attached tick, see a doctor, who will remove it.

You do not need to save the tick to get it tested.

The CDC states this is generally not useful because even if the tick contains disease-causing organisms, it does not necessarily mean you have been infected with the bacteria that cause Lyme disease; and if you have been infected, symptoms will likely develop before tick testing results come back and you should be treated as soon as possible.

Following tick removal, see a doctor if any flu-like symptoms or rash develop within the next three weeks.

If a rash develops, draw a line around it with ink that does not wash off (such as a Magic Marker or Sharpie) each day to see if it is growing.

Young children with fever and severe headache should see a doctor immediately, because these may be their only symptoms.

Outdoor workers and anyone whose hobbies or recreational activities place them in wooded or brush areas should be particularly aware of these symptoms because their environmental exposure increases contact with the deer tick and is a risk factor for contracting Lyme disease.

See a doctor or go to a hospital's emergency department immediately.

When the initial disease is not treated, your symptoms may go away, but additional late stage symptoms and complications of Lyme disease can occur months later.

When this happens, Lyme disease can affect the heart, muscles and joints, or the nervous system.

Since these symptoms can occur with other diseases, be sure to tell a doctor about travel to areas with a high tick population or if you have any possible exposures to ticks (from pets, gardening, walking, or camping in wooded areas, etc.).

If you are pregnant and are bitten by a tick, see a doctor immediately.

If you become infected with Lyme disease during pregnancy, the illness can infect the placenta and may result in stillbirth.

Lyme disease is not transmitted through breast milk.

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Questions to Ask the Doctor About Lyme Disease If you have an identifiable tick bite but no symptoms have begun, there is a question as to whether preventive treatment should be started.

If the symptoms of Lyme disease have started, the question is what antibiotic treatment will be used, by which route it will be administered, and how long it should be taken.

Doctors base a diagnosis of Lyme disease on a careful and detailed history and a complete physical examination supported by laboratory testing when appropriate.

The doctor will ask whether you know if a tick has bitten you and will gather information about your outdoor exposure in an area with a high tick population.

Physical examination findings are important, especially the presence of erythema migrans.

If there is doubt whether a rash is due to Lyme disease, the doctor might measure its size and then remeasure one to two days later.

Erythema migrans usually exhibits an increase in size of the rash, often expanding by about ½ inch every day.

Some physical findings help to distinguish Lyme disease from other infectious ailments.

Doctors may perform blood tests to examine for antibodies to the bacteria.

Antibodies can be absent early in the course of a Lyme infection (in the first few weeks), so a negative test result may be misleading at that time.

There are two tiers of blood tests used to diagnose Lyme disease, a screening test (Lyme ELISA or IFA) and, if that test is positive or equivocal, a more specific test (Western blot).

A positive Western blot test result confirms current or past infection.

Especially in regions of the country where Lyme disease is very common, patients can have positive test results for Lyme disease but have clinical problems that are explained by another condition.

A screening test (a Lyme titer) is not considered sufficient to make a diagnosis of Lyme disease; the Western blot has to be positive also.

The accuracy of these tests is very good, but it depends on the stage of the disease.

In early stages, a negative test is expected; however, after a few weeks, the ELISA and IFA tests have good sensitivity and accuracy.

Once a Lyme blood test is positive, it will remain positive for a long time even with successful treatment.

Repeat blood tests after treatment are not helpful in determining further care.

Ixodes ticks can carry other organisms in addition to B. burgdorferi, and these can cause illnesses that can mimic Lyme disease or can even occur along with Lyme disease.

The two most important infections are ehrlichiosis (HGE) and babesiosis.

Doctors also may perform liver function tests and blood counts to examine the red blood cells and other tests for these two conditions.

Another tick-borne illness called Rocky Mountain spotted fever can cause a rash but is not the same illness as Lyme disease.

People with severe headaches may need a spinal tap to determine if there is inflammation in the nervous system (meningitis, encephalitis) and to test for Lyme antibodies in the spinal fluid.

Doctors may perform an ECG if you have possible heart complications.

CT scans and MRI of the brain may be performed to rule out other conditions that can cause similar symptoms.

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Health departments in areas with high rates of infection have undertaken campaigns to raise public awareness and educate the public on facts about Lyme disease.

It is known that certain outdoor areas are highly infested with deer ticks and should be avoided if possible -- these include woods and brush areas.

Generally, the tick counts on suburban lawns are much lower.

Lyme disease should never be treated with home remedies alone.

Antibiotics are needed to cure the illness, however, some home remedies may help ease symptoms as you recover.

Consult a doctor before taking an herbal supplement or natural remedy as they may interact with medications you already take or may cause unwanted side effects.

Nattokinase is an enzyme made from fermented soybeans that some believe can help treat their Lyme disease symptoms.

Probiotics (such as Lactobacillus acidophilus) can be taken to help reduce diarrhea or yeast infections that are side effects of prescribed antibiotics.

Beta-glucan is a type of fiber believed to stimulate the immune system, though there are no studies that prove this.

One small study showed it was effective as a tick repellant when used on properties where ticks tend to live.

Another small study showed that people who took garlic as a supplement reported fewer tick bites.

More study is needed to determine if garlic is an effective tick repellant.

Essiac is an herbal formula that contains burdock root (Arctium lappa), sheep sorrel (Rumex acetosella), slippery elm (Ulmus fulva), and rhubarb (Rheum palmatum) and is reported to help treat Lyme disease, but there are no studies that prove it is effective, or whether it will interact with medications.

What Are Lyme Disease Treatments and Medications?

Doctors will treat primary or early Lyme disease with oral antibiotics, including doxycycline (Vibramycin), cefuroxime (Ceftin), penicillins, amoxicillin (Amoxil), or erythromycin (Ilotycin, Ery-Ped, Ery-Tab).

In early stages, the disease can be curable with just this antibiotic treatment.

Pregnant women are usually treated with penicillins or erythromycin.

Doxycycline is generally avoided as it may affect the development of the fetus.

Doctors may treat late-stage cases of neurological, heart, or arthritic Lyme disease with intravenous antibiotics (usually ceftriaxone [Rocephin]) in the hospital or as an outpatient.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve) may be recommended to help relieve pain and inflammation.

Follow-up for Lyme Disease Follow-up with continued care is important for people who have early Lyme disease but who fail to improve rapidly and completely.

Doctors must consider other treatment options and rule out other illnesses that may be mistaken for Lyme disease.

People with later-stage disease who require IV antibiotics or hospitalization must be monitored in the weeks following their treatment.

Improvement in the symptoms of Lyme disease, particularly in the heart and nervous system, may occur gradually over a period of months.

Lack of immediate improvement in all your symptoms is not a sign of unsuccessful treatment.

Take the Lyme Disease Quiz Lyme Disease Slideshow Pictures Lyme Disease Target Rash How Can People Prevent Lyme Disease?

There is currently no vaccine available to prevent Lyme disease; however, there are three approaches to preventing Lyme disease.

Tick Avoidance Try to stay out of woodlands and brush areas where the tick thrives, especially during the peak season of summer and early fall.

Wear garments that will create barriers to the tick attaching to the skin and biting.

Tuck pant legs into socks so ticks cannot easily crawl the short distance from the ground to just above the sock line.

Wear light-colored clothing to better identify ticks.

The application of the insecticide DEET (low-concentration preparations are recommended) to clothing and skin (This should be limited in children to prevent absorption of too much DEET.) has been found to decrease tick bites and the chance for Lyme disease infections.

Tick Removal Deer ticks need to remain attached to the skin for about 24-48 hours to transmit the Borrelia bacteria to the skin.

Inspect all areas of the body after outdoor activity.

If you notice a bite, it is very important to watch for symptoms, which usually show up in about three weeks.

Ticks attach to areas that are warm and moist, such as the groin, the armpits, the underside of a woman's breasts, and the neck and hairline.

If you see a tick, promptly remove it (see previous section on When Should Seek Medical Care for Lyme Disease for instructions on tick removal).

This greatly reduces the likelihood of an infection.

Disinfect the bite site thoroughly with alcohol or other skin antiseptic solution.

Use of gasoline, petroleum, and other organic solvents to suffocate ticks, as well as burning the tick with a match, should be avoided.

Antibiotic Treatment Treatment of tick bites within 72 hours of a bite with a single dose of doxycycline has been reported to prevent Lyme disease.

This may be appropriate if you live in an endemic area and have removed an engorged tick or multiple ticks.

When treated early, the prognosis for most people with Lyme disease is rapid improvement and minimal complications from the disease.

Later stages of illness are avoided by effective treatment of early Lyme disease.

People with later stages of the disease may also do well when they are diagnosed soon after their later-stage symptoms first occur.

A small percentage of people with Lyme disease do not fully recover, or recover very slowly, and have a condition called post-treatment Lyme disease syndrome (PTLDS), in which symptoms of fatigue, pain, or joint and muscle aches last for more than six months following treatment.

Long-term effects of Lyme disease may include residual facial palsy or residual knee pain.

Other people develop chronic muscle and joint pains, fatigue, and concentration difficulties that seem to have arisen from the time of the original Lyme disease infection.

While these chronic and recurring symptoms have been called chronic Lyme disease, recent studies have not shown any evidence of Borrelial infection in the blood or spinal fluid, and further antibiotic therapy does not appear to have a durable effect in relieving the condition.

For the present, patients with this problem are being treated with supportive measures aimed at symptomatic relief.

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Zernel, Pfizer Labs Picture of the bull's-eye shape of the Lyme rash, which may grow in size.

Picture of magnified ticks at different stages of development.

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Post View 8 Comments Lyme Disease - Treatment What was the treatment for your lyme disease?Lyme Disease Pictures, Symptoms and Treatment Lyme disease is caused by spiral-shaped bacteria called Borrelia burgdorferi (found in the U.

Two different species of ticks, Ixodes scapularis and Ixodes pacificus, transmit the bacteria to humans via bites.

Some ticks carried by deer transmit the bacteria that cause Lyme disease.

Lyme disease is not contagious from person to person.

Lyme disease can affect many areas of the body including the heart, skin, joints, and nervous system.

Lyme disease came to light in 1975 when children living in the community of Lyme, Connecticut became afflicted with what was at first thought to be rheumatoid arthritis.

The disease was named after the town where these children lived.

Researchers eventually identified the bacteria that caused the illness in 1982.

Lyme disease is present in all 50 states, but the illness is most commonly found in the Northeastern part of the U.

Lyme disease is prevalent in areas with a high population of ticks, especially ticks infected with the Lyme disease bacteria.

More than 50% of ticks in New York State carry the bacteria that cause Lyme disease.

The illness has been reported all over the world including Australia, China, Europe, Japan, and in countries that were once part of the Soviet Union.

Early localized disease causes skin rashes and redness.

Early disseminated disease affects the nervous system and heart.

People in this stage may have palsies that cause paralysis and tremors.

A rare but potentially life-threatening bacterial infection called meningitis may occur in this stage.

Meningitis affects the tissue surrounding the brain and spinal cord (meninges).

Late disease involves arthritis and neurological issues.

During this stage damage to nerves of sensation and movement can occur.

A characteristic flat, red ring or bull's-eye rash develops in 75% of those who have been bitten by a tick infected with Lyme disease.

The rash appears days to weeks after the bite and spreads outward.

The bull's-eye rash is called "erythema migrans." Some people don't notice or remember being bitten by a tick either because the tick was too small or a rash never appeared.

Someone with newly acquired Lyme disease may suffer from fatigue, headache, joint and muscle stiffness, and swollen glands.

Later stages of the disease affect the heart, joints, and nervous system.

Untreated, skin redness associated with early localized Lyme disease resolves in about one month.

The second stage occurs weeks or months after the appearance of the red rash.

During this time, bacteria affect other parts of the body including the heart, joints, and nervous system.

Late-stage Lyme disease can inflame the heart and lead to heart rhythm disorders and even heart failure.

Nervous system problems associated with late disease may include facial paralysis (Bell's palsy), meningitis, confusion, and abnormal function of the nerves outside of the spinal cord (peripheral neuropathy).

Joint inflammation can occur -- typically in just one to a few joints (often the knees) -- resulting in pain, stiffness, and swelling.

Arthritis associated with Lyme disease can become chronic and may mimic other forms of inflammatory arthritis.

Doctors use a variety of methods to diagnose Lyme disease.

Different approaches may be used depending on the stage of the disease.

Early Lyme disease is easily diagnosed if a person has the characteristic red, bull's-eye rash.

The diagnosis is considered when a person has recently been in an area known to have ticks that harbor the bacteria.

The doctor may perform a physical exam and order tests to exclude other potential problems with the heart, joints, and nervous system.

Antibody tests are available for Lyme disease, but they are not useful in the early stage.

They are more helpful in the diagnosis of later stages.

A test called the ELISA assay is used to detect Lyme disease antibodies.

However, there's a possibility of a false positive diagnosis because Lyme disease antibodies may be present in the body for years after the illness has resolved.

The most reliable test available to confirm the diagnosis of Lyme disease is called the Western Blot assay.

Different stages of disease may be treated with different antibiotics.

Treatment choices also depend on the areas of the body involved.

Oral amoxicillin (Amoxil), cefuroxime axetil (Ceftin), and doxycycline (Vibramycin) are often used to treat the early stages of Lyme disease.

A bull's-eye skin rash after a tick bite is a reason to see the doctor urgently for treatment.

The rash typically resolves in about 1 or 2 weeks with antibiotic treatment.

Intravenous medications such as ceftriaxone (Rocephin) may be necessary to treat later stages of Lyme disease.

There are a few options to treat the joint pain and swelling associated with Lyme disease.

Pain-relievers and anti-inflammatories – such as ibuprofen (Motrin, Nuprin) – can help relieve symptoms.

An in-office procedure called arthrocentesis can be used to withdraw fluid from swollen joints.

Rarely, arthritis persists after antibiotic treatment.

Some scientists believe that chronic joint inflammation can be triggered by the infection even after the successful elimination of Lyme bacteria.

The best way to avoid Lyme disease is to prevent it!

Take the following measures to reduce the risk of a tick bites and illness.

Wear shirts with long sleeves and pants to protect the skin.

Apply bug repellant containing DEET to exposed areas.

Examine clothing, kids, and pets for ticks after excursions to areas known to harbor ticks.

If a tick bites, use tweezers to remove it from the skin.

Place the tick in a closed container and provide it to health professionals for identification.

Remove clothes and bathe -- washing the entire body and scalp -- to help prevent tick bites and the transmission of Lyme disease.

Currently, there is no vaccine available to prevent Lyme disease.

The LYMErixTM Lyme disease vaccine was withdrawn from the market in 2002.

Prevention is the best weapon against Lyme disease.

Sources: IMAGES PROVIDED BY: CDC / James Gathny © 2007 Interactive Medical Media LLC.

All rights reserved. iStockPhoto / Igor Balasanov Courtesy of CDC MedicineNet Image reprinted with permission from eMedicine.com, 2008.

CDC / James Gathany BigStockPhoto / Linda Bucklin iStockPhoto / Sebastian Kaulitzki Photo courtesy of Jellono at en.wikipedia Image reprinted with permission from eMedicine.com, 2008. iStockPhoto / Ncholas Monu iStockPhoto / Visual Field Image reprinted with permission from eMedicine.com, 2008. iStockPhoto / Ana Abejon iStockPhoto / Freeze Frame Studio REFERENCES: Centers for Disease Control and Prevention: "Lyme Disease." Centers for Disease Control and Prevention: "Lyme Disease Diagnosis and Testing." Centers for Disease Control and Prevention: "Lyme Disease: What You Need to Know." Centers for Disease Control and Prevention: "Lyme Disease Transmission." Centers for Disease Control and Prevention: "Lyme Disease Treatment." Centers for Disease Control and Prevention: "Preventing Tick Bites." Centers for Disease Control and Prevention: "Signs and Symptoms of Lyme Disease." Todar’s Textbook of Online Bacteriology: "Borrelia burgdorferi and Lyme Disease." UpToDate: Hu, L., et al. "Patient Information - Lyme Disease Treatment (Beyond the Basics).Since they can’t always explain what feels wrong, they may just come across as cranky and irritable.

They suffer when their bodies hurt, when their illness disrupts their sleep at night, when they struggle in school, when they don’t even feel like playing.

They may feel confused, lost and betrayed by parents and teachers who fail to recognize that they are sick and need help.

Mothers and fathers may not understand what the child’s normal baseline is.

Is this the “terrible twos” or “the nine-year-old change” or is something really wrong?

Because the symptoms of Lyme disease can be non-specific, vague and changeable, adults may not even realize these children are ill.

They may suspect them of making things up to gain attention or to avoid school.

Children with Lyme often have trouble in the classroom, because the disease can contribute to learning disabilities and behavioral problems.

Children are especially vulnerable to tick-borne diseases because they are physically low to the ground, where the ticks are.

They play in leaves, roll on grass, cuddle with pets and otherwise increase their exposure to ticks.

Lyme pediatric specialist Charles Ray Jones, MD, compiled a list of common symptoms of infection in his young patients: severe fatigue unrelieved by rest insomnia headaches nausea, abdominal pain impaired concentration poor short-term memory inability to sustain attention difficulty thinking and expressing thoughts difficulty reading and writing being overwhelmed by schoolwork difficulty making decisions confusion uncharacteristic behavior outbursts and mood swings fevers/chills joint pain dizziness noise and light sensitivity Among Jones’ patients, only half have had a known tick attachment.

Fewer than 10% have had an erythema migrans rash (bull’s-eye).

Jones has also documented congenital, or gestational, Lyme disease in some children he thinks were infected in utero or by breastfeeding.

In these patients his suspicion is raised when the child has: frequent fevers increased incidence of ear and throat infections increased incidence of pneumonia irritability joint and body pain poor muscle tone gastroesophageal reflux small windpipe (tracheomalacia) cataracts and other eye problems developmental delay learning disabilities psychiatric manifestations If you believe your child may have Lyme or other tick-borne diseases, we highly recommend that he or she be evaluated by an ILADS-affiliated health care provider.

Charles Ray Jones is the world’s foremost expert on pediatric tick-borne diseases, having treated more than 12,000 children.

Click here for his paper, “Rationale on Long Term Antibiotic Therapy in Treating Lyme Disease.” Dorothy Pietrucha, MD, a pediatric neurologist, presents an overview of diagnosis and treatment with case histories in “Neurological Manifestations of Lyme Disease in Children.” Ann Corson, MD, board-certified family practitioner, has a full time Lyme and tick-borne disease practice in Chester County, PA, with a special interest in children and pregnant women.

View her slideshows on pediatric Lyme disease, neuropsychiatric presentations of Lyme disease, and Lyme and Pregnancy: Psychotherapist Sandy Berenbaum, LCSW, BCD, has devoted much of her career to children and adolescents with Lyme disease.

Click here to read her story “Kids and Lyme Disease – How It Affects Their Learning.” Pennsylvania psychiatrist Virgina Sherr, MD, has treated many children with Lyme disease.

Read her poignant story of two different young people with Lyme disease who ended up in jail: “The Pillaging of Personalities: Our Lost Kids are Being Highjacked by Spirochetes.So this part can be really tricky, as symptoms for Lyme are vast and vary from person to person, which is why Lyme disease is often misdiagnosed as something else.

The symptoms for Lyme can range from slight fatigue, to joint pain, to depression, seizures, and even cardiac failure.

The following is a superb comprehensive list of Lyme disease symptoms from The Canadian Lyme Disease Foundation: Lyme Disease (commonly misspelled as Lime or Lymes ) symptoms may show up fast, with a bang, or very slowly and innocuously.

There may be initial flu-like symptoms with fever, headache, nausea, jaw pain, light sensitivity, red eyes, muscle ache and stiff neck.

Many write this off as a flu and because the nymph stage of the tick is so tiny many do not recall a tick bite.

Lyme Disease, SYMPTOMS & CHARACTERISTICS, a compilation of peer-reviewed literature reports The classic rash may only occur or have been seen in as few as 30% of cases (many rashes in body hair and indiscreet areas go undetected).

The Lyme Rash If left untreated or treated insufficiently symptoms may creep into ones life over weeks, months or even years.

They wax and wane and may even go into remission only to come out at a later date…even years later.

With symptoms present, a negative lab result means very little as they are very unreliable.

The diagnosis, with today’s limitations in the lab, must be clinical.

Many Lyme patients were firstly diagnosed with other illnesses such as Juvenile Arthritis, Rheumatoid Arthritis, Reactive Arthritis, Infectious Arthritis, Osteoarthritis, Fibromyalgia, Raynaud’s Syndrome, Chronic Fatigue Syndrome, Interstitial Cystis, Gastroesophageal Reflux Disease, Fifth Disease, Multiple Sclerosis, scleroderma, lupus, early ALS, early Alzheimers Disease, crohn’s disease, ménières syndrome, reynaud’s syndrome, sjogren’s syndrome, irritable bowel syndrome, colitis, prostatitis, psychiatric disorders (bipolar, depression, etc.), encephalitis, sleep disorders, thyroid disease and various other illnesses.

If you have received one of these diagnoses please scroll down and see if you recognize a broader range of symptoms.

If you are a doctor please re-examine these diagnoses, incorporating Lyme in the differential diagnoses.

The one common thread with Lyme Disease is the number of systems affected (brain, central nervous system, autonomic nervous system, cardiovascular, digestive, respiratory, musco-skeletal, etc.) and sometimes the hourly/daily/weekly/monthly changing of symptoms.

No one will have all symptoms but if many are present serious consideration must be given by any physician to Lyme as the possible culprit.

The infection rate with Lyme in the tick population is exploding in North America and as the earth’s temperature warms this trend is expected to continue.

Symptoms may come and go in varying degrees with fluctuation from one symptom to another.

There may be a period of what feels like remission only to be followed by another onset of symptoms.

PRINT AND CIRCLE ALL YES ANSWERS ( 20 yes represents a serious potential and Lyme should be included in diagnostic workup ) Symptoms of Lyme Disease The Tick Bite (fewer than 50% recall a tick bite or get/see the rash) Rash at site of bite Rashes on other parts of your body Rash basically circular, oval and spreading out (more generalized) Raised rash, disappearing and recurring Head, Face, Neck Unexplained hair loss Headache, mild or severe, Seizures Pressure in head, white matter lesions in brain (MRI) Twitching of facial or other muscles Facial paralysis (Bell’s Palsy, Horner’s syndrome) Tingling of nose, (tip of) tongue, cheek or facial flushing Stiff or painful neck Jaw pain or stiffness Dental problems (unexplained) Sore throat, clearing throat a lot, phlegm ( flem ), hoarseness, runny nose Eyes/Vision Double or blurry vision Increased floating spots Pain in eyes, or swelling around eyes Oversensitivity to light Flashing lights/Peripheral waves/phantom images in corner of eyes Ears/Hearing Decreased hearing in one or both ears, plugged ears Buzzing in ears Pain in ears, oversensitivity to sounds Ringing in one or both ears Digestive and Excretory Systems Diarrhea Constipation Irritable bladder (trouble starting, stopping) or Interstitial cystitis Upset stomach (nausea or pain) or GERD (gastroesophageal reflux disease) Musculoskeletal System Bone pain, joint pain or swelling, carpal tunnel syndrome Stiffness of joints, back, neck, tennis elbow Muscle pain or cramps, (Fibromyalgia) Respiratory and Circulatory Systems Shortness of breath, can’t get full/satisfying breath, cough Chest pain or rib soreness Night sweats or unexplained chills Heart palpitations or extra beats Endocarditis, Heart blockage Neurologic System Tremors or unexplained shaking Burning or stabbing sensations in the body Fatigue, Chronic Fatigue Syndrome, Weakness, peripheral neuropathy or partial paralysis Pressure in the head Numbness in body, tingling, pinpricks Poor balance, dizziness, difficulty walking Increased motion sickness Lightheadedness, wooziness Psychological well-being Mood swings, irritability, bi-polar disorder Unusual depression Disorientation (getting or feeling lost) Feeling as if you are losing your mind Over-emotional reactions, crying easily Too much sleep, or insomnia Difficulty falling or staying asleep Narcolepsy, sleep apnea Panic attacks, anxiety Mental Capability Memory loss (short or long term) Confusion, difficulty in thinking Difficulty with concentration or reading Going to the wrong place Speech difficulty (slurred or slow) Stammering speech Forgetting how to perform simple tasks Reproduction and Sexuality Loss of sex drive Sexual dysfunction Unexplained menstral pain, irregularity Unexplained breast pain, discharge Testicular or pelvic pain General Well-being Phantom smells Unexplained weight gain, loss Extreme fatigue Swollen glands/lymph nodes Unexplained fevers (high or low grade) Continual infections (sinus, kidney, eye, etc.) Symptoms seem to change, come and go Pain migrates (moves) to different body parts Early on, experienced a “flu-like” illness, after which you have not since felt well.Lyme Disease in Children Not what you're looking for?

Start New Search ABOUT CAUSES DIAGNOSIS TREATMENT What is Lyme disease in children?

Lyme disease is an infection caused by bacteria called Borrelia burgdorferi. The bacteria are usually spread by tick bites.

Lyme disease is a year-round problem, but it peaks during the spring and summer months.

It can cause short-term symptoms, and may cause long-term problems.

Lyme disease is caused by bacteria that are spread to people by tick bites.

The ticks that carry the bacteria are: Black-legged deer tick. These are found in the Northeastern, Mid-Atlantic, and North-Central U.

Western black-legged tick. These are found on the West Coast of the U.

Depending on the location, less than 1 in 100 to more than half of ticks in that area may be infected with Lyme.

A child is more at risk for Lyme disease in certain parts of the U.

S. during the spring and summer months, when ticks are more active.

Ticks live in wooded areas, low-growing grasslands, and yards.

A child is more at risk outdoors in these places, or around a pet that has been in these areas.

The most cases have been reported in: Northeastern states, such as Massachusetts and Connecticut Mid-Atlantic states, such as New Jersey and Pennsylvania Wisconsin and Minnesota Northern California Many cases have also been reported in Asia and Europe.

What are the symptoms of Lyme disease in a child?

Symptoms can occur a bit differently in each child.

They usually appear within 3 to 30 days after a tick bite.

Lyme disease has early and late-stage symptoms. Early stage Lyme disease is more easily cured with antibiotics than late-stage disease.

Most cases of late-stage disease occur when if early stage disease is not treated.

One of the most common symptoms is a ring-shaped rash that looks like a bull's-eye.

It may be pink in the center and have a darker red ring around it.

If it does occur, the rash may: Appear several days after infection Last up to several weeks Be very small or very large, up to 12 inches across Look like other skin problems such as hives, eczema, sunburn, poison ivy, or flea bites Itch or feel hot, or not be felt at all Go away and come back several weeks later Several days or weeks after a bite from an infected tick, your child may have flu-like symptoms such as: Headache Stiff neck Aches and pains in muscles and joints Low fever and chills Tiredness Loss of appetite Swollen glands Weeks to months after the bite, these symptoms may develop: Nervous system symptoms.

Examples are inflammation of the nervous system (meningitis) and weakness and paralysis of the facial muscles (Bell palsy) Heart problems, such as inflammation of the heart (myopericarditis) and problems with heart rate Eye problems, such as inflammation of the eyes Skin disorders Severe tiredness Weakness Months to a few years after a bite, these symptoms may occur: Inflammation of the joints (arthritis) Nervous system symptoms such as numbness in the arms and legs, tingling and pain, and trouble with speech, memory, and concentration The symptoms of Lyme disease can be like other health conditions.

Make sure your child sees his or her healthcare provider for a diagnosis.

The healthcare provider will ask about your child’s symptoms and health history.

Lyme may be difficult to diagnose because the symptoms are like other conditions.

The main symptom is often a rash, but more than 1 in 5 people infected with Lyme don’t have the rash.

Diagnosis is usually based on symptoms and a history of a tick bite.

Your child may have blood tests to help diagnose Lyme, and to check for other illnesses that can cause similar symptoms.

Researchers are working on more ways to diagnose Lyme.

Lyme disease is usually treated with antibiotic medicine. Early stage Lyme disease is more easily cured with antibiotics than late-stage disease. Your child’s healthcare provider will discuss the best treatment plan with you based on: Your child’s symptoms and test results If your child had a recent tick bite If the tick tests positive for bacteria that cause Lyme If your child lives in an area where the ticks are known to be infected Talk with your child’s healthcare providers about the risks, benefits, and possible side effects of all medicines.

What are possible complications of Lyme disease in a child?

Some children may develop post-Lyme disease syndrome (PLDS).

This means that some symptoms last longer than 6 months.

Symptoms can include: Ongoing muscle and nerve pain Tiredness Problems with memory How can I help prevent Lyme disease in a child?

A child who has had the disease doesn’t build up immunity and can get it again.

But you can help prevent Lyme disease by protecting your child from tick bites.

Ticks can’t bite through clothing, so dress your child and family in: Long-sleeved shirts tucked into pants Socks and closed-toe shoes Long pants with legs tucked into socks Choose light-colored clothing so that ticks can be easily seen.

Check your child often for ticks, including: Behind the knees, between fingers and toes, in underarms, and in the groin In the belly button In and behind the ears, on the neck, in the hairline, and on top of the head Where underwear elastic touches the skin Where bands from pants or skirts touch the skin Anywhere else clothing presses on the skin All other areas of the body and hair Run fingers gently over the skin.

Run a fine-toothed comb through your child's hair to check for ticks.

Other helpful tips include: When possible, use cleared or paved paths when walking through wooded areas and fields.

Shower after outdoor activities are done for the day.

It may take up to 4 to 6 hours for ticks to attach firmly to skin.

The most common used against ticks are: DEET. This is for skin.

Products that contain DEET repel ticks, but may not kill the tick and are not 100% effective.

Use a children's insect repellent with no more than 30% DEET.

Products that contain DEET should not be used on babies less than 2 months old. Don't put insect repellent near your child's mouth, nose, or eyes, or on open cuts or sores.  Permethrin. This is for clothing, tents, and other fabric.

Treat fabric with small amounts of a product that contains permethrin.

Talk with your pet’s veterinarian about tick repellent medicine.

When should I call my child's healthcare provider?

Call the healthcare provider if your child has: Symptoms that don’t get better, or get worse New symptoms Key points about Lyme disease in children Lyme disease is an infection caused by bacteria.

Lyme disease is a year-round problem, but it peaks during the spring and summer months.

Ticks live in wooded areas, low-growing grasslands, and yards.

A child is more at risk outdoors in these places, or around a pet who has been in these areas.

One of the most common symptoms is a ring-shaped rash that looks like a bulls-eye.

It may be pink in the center and have a darker red ring around it.

Diagnosis is usually based on symptoms and a history of a tick bite.

Your child may have blood tests to help diagnose Lyme.

Lyme disease is usually treated with antibiotic medicine. Early stage Lyme disease is more easily cured with antibiotics than late-stage disease.

But you can help prevent Lyme disease by protecting your child from tick bites.

Next steps Tips to help you get the most from a visit to your child’s healthcare provider: Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests.

Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child.

Ask if your child’s condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child’s provider after office hours.

This is important if your child becomes ill and you have questions or need advice.Lyme disease, also known as Lyme borreliosis, is an infectious disease caused by bacteria of the Borrelia type which is spread by ticks.[2] The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans, that begins at the site of a tick bite about a week after it has occurred.[1] The rash is typically neither itchy nor painful.[1] Approximately 25–50% of infected people do not develop a rash.[1] Other early symptoms may include fever, headache and feeling tired.[1] If untreated, symptoms may include loss of the ability to move one or both sides of the face, joint pains, severe headaches with neck stiffness, or heart palpitations, among others.[1] Months to years later, repeated episodes of joint pain and swelling may occur.[1] Occasionally, people develop shooting pains or tingling in their arms and legs.[1] Despite appropriate treatment, about 10 to 20% of people develop joint pains, memory problems, and feel tired for at least six months.[1][5] Lyme disease is transmitted to humans by the bite of infected ticks of the genus Ixodes.[6] Usually, the tick must be attached for 36 to 48 hours before the bacteria can spread.[7] In North America, Borrelia burgdorferi and Borrelia mayonii are the cause.[2][8] In Europe and Asia, the bacteria Borrelia afzelii and Borrelia garinii are also causes of the disease.[2] The disease does not appear to be transmissible between people, by other animals, or through food.[7] Diagnosis is based upon a combination of symptoms, history of tick exposure, and possibly testing for specific antibodies in the blood.[3][9] Blood tests are often negative in the early stages of the disease.[2] Testing of individual ticks is not typically useful.[10] Prevention includes efforts to prevent tick bites such as by wearing long pants and using DEET.[2] Using pesticides to reduce tick numbers may also be effective.[2] Ticks can be removed using tweezers.[11] If the removed tick was full of blood, a single dose of doxycycline may be used to prevent development of infection, but is not generally recommended since development of infection is rare.[2] If an infection develops, a number of antibiotics are effective, including doxycycline, amoxicillin, and cefuroxime.[2] Standard treatment usually lasts for two or three weeks.[2] Some people develop a fever and muscle and joint pains from treatment which may last for one or two days.[2] In those who develop persistent symptoms, long-term antibiotic therapy has not been found to be useful.[2][12] Lyme disease is the most common disease spread by ticks in the Northern Hemisphere.[13] It is estimated to affect 300,000 people a year in the United States and 65,000 people a year in Europe.[2][4] Infections are most common in the spring and early summer.[2] Lyme disease was diagnosed as a separate condition for the first time in 1975 in Old Lyme, Connecticut.[14] It was originally mistaken for juvenile rheumatoid arthritis.[14] The bacterium involved was first described in 1981 by Willy Burgdorfer.[15] Chronic symptoms following treatment are well described and are known as post-treatment Lyme disease syndrome (PTLDS).[12] PTLDS is different to chronic Lyme disease; a no longer supported term used in different ways by different groups.[12] Some healthcare providers claim that it is due to ongoing infection; however, this is not believed to be true, due to the inability to detect infectious organisms after standard treatment.[16] A Lyme vaccine was marketed in the US between 1998 and 2002; it was withdrawn from the market due to poor sales, originally due to lack of reimbursement by insurance companies and then due to rumors about adverse effects.[2][17] Research is ongoing to develop new vaccines.[2] Contents Signs and symptoms This "classic" bull's-eye rash is also called erythema migrans.

A rash caused by Lyme does not always look like this and approximately 25% of those infected with Lyme disease may have no rash. [1] [18] Raised, red borders around indurated central portion Lyme disease can affect multiple body systems and produce a broad range of symptoms.

Not all patients with Lyme disease have all symptoms, and many of the symptoms are not specific to Lyme disease, but can occur with other diseases, as well.

The incubation period from infection to the onset of symptoms is usually one to two weeks, but can be much shorter (days), or much longer (months to years).[19] Symptoms most often occur from May to September, because the nymphal stage of the tick is responsible for most cases.[19] Asymptomatic infection exists, but occurs in less than 7% of infected individuals in the United States.[20] Asymptomatic infection may be much more common among those infected in Europe.[21] Early localized infection Early localized infection can occur when the infection has not yet spread throughout the body.

Only the site where the infection has first come into contact with the skin is affected.

The classic sign of early local infection with Lyme disease is a circular, outwardly expanding rash called erythema chronicum migrans (EM), which occurs at the site of the tick bite three to 32 days after the tick bite.[2] The rash is red, and may be warm, but is generally painless.

Classically, the innermost portion remains dark red and becomes indurated (is thicker and firmer), the outer edge remains red, and the portion in between clears, giving the appearance of a bull's eye.

However, partial clearing is uncommon, and the bull's-eye pattern more often involves central redness.[2] The EM rash associated with early infection is found in about 70–80% of people infected.[1] It can have a range of appearances including the classic target bull's-eye lesion and nontarget appearing lesions.

The 20–30% without the EM and the nontarget lesions can often cause misidentification of Lyme disease.[22] Affected individuals can also experience flu-like symptoms, such as headache, muscle soreness, fever, and malaise.[23] Lyme disease can progress to later stages even in people who do not develop a rash.[21][24] Early disseminated infection Within days to weeks after the onset of local infection, the Borrelia bacteria may begin to spread through the bloodstream.

EM may develop at sites across the body that bear no relation to the original tick bite.[25] Another skin condition, apparently absent in North American patients, but found in Europe, is borrelial lymphocytoma, a purplish lump that develops on the ear lobe, nipple, or scrotum.[26] Various acute neurological problems, termed neuroborreliosis, appear in 10–15% of untreated people.[23][27] These include facial palsy, which is the loss of muscle tone on one or both sides of the face, as well as meningitis, which involves severe headaches, neck stiffness, and sensitivity to light.

Inflammation of the spinal cord's nerve roots can cause shooting pains that may interfere with sleep, as well as abnormal skin sensations.

Mild encephalitis may lead to memory loss, sleep disturbances, or mood changes.

In addition, some case reports have described altered mental status as the only symptom seen in a few cases of early neuroborreliosis.[28] The disease may adversely impact the heart's electrical conduction system and can cause abnormal heart rhythms such as atrioventricular block.[29] Late disseminated infection After several months, untreated or inadequately treated patients may go on to develop severe and chronic symptoms that affect many parts of the body, including the brain, nerves, eyes, joints, and heart.

Many disabling symptoms can occur, including permanent impairment of motor or sensory function of the lower extremities in extreme cases.[21] The associated nerve pain radiating out from the spine is termed Bannwarth syndrome,[30] named after Alfred Bannwarth.

The late disseminated stage is where the infection has fully spread throughout the body.

Chronic neurologic symptoms occur in up to 5% of untreated patients.[23] A polyneuropathy that involves shooting pains, numbness, and tingling in the hands or feet may develop.

A neurologic syndrome called Lyme encephalopathy is associated with subtle cognitive difficulties, insomnia, a general sense of feeling unwell, and changes in personality.[31] Other problems, however, such as depression and fibromyalgia, are no more common in people with Lyme disease than in the general population.[32][33] Chronic encephalomyelitis, which may be progressive, can involve cognitive impairment, brain fog, migraines, balance issues, weakness in the legs, awkward gait, facial palsy, bladder problems, vertigo, and back pain.

In rare cases, untreated Lyme disease may cause frank psychosis, which has been misdiagnosed as schizophrenia or bipolar disorder.

Panic attacks and anxiety can occur; also, delusional behavior may be seen, including somatoform delusions, sometimes accompanied by a depersonalization or derealization syndrome, where the patients begin to feel detached from themselves or from reality.[34][35] Lyme arthritis usually affects the knees.[36] In a minority of patients, arthritis can occur in other joints, including the ankles, elbows, wrists, hips, and shoulders.

Pain is often mild or moderate, usually with swelling at the involved joint.

Acrodermatitis chronica atrophicans (ACA) is a chronic skin disorder observed primarily in Europe among the elderly.[26] ACA begins as a reddish-blue patch of discolored skin, often on the backs of the hands or feet.

The lesion slowly atrophies over several weeks or months, with the skin becoming first thin and wrinkled and then, if untreated, completely dry and hairless.[37] Cause Deer tick life cycle Borrelia bacteria, the causative agent of Lyme disease, magnified Ixodes scapularis, the primary vector of Lyme disease in eastern North America Tick Ixodes ricinus, developmental stages Lyme disease is caused by spirochetal bacteria from the genus Borrelia.

Spirochetes are surrounded by peptidoglycan and flagella, along with an outer membrane similar to other Gram-negative bacteria.

Because of their double-membrane envelope, Borrelia bacteria are often mistakenly described as Gram negative despite the considerable differences in their envelope components from Gram-negative bacteria.[38] The Lyme-related Borrelia species are collectively known as Borrelia burgdorferi sensu lato, and show a great deal of genetic diversity.

B. burgdorferi sensu lato is made up of 21 closely related species, but only three clearly cause Lyme disease: B. burgdorferi sensu stricto (predominant in North America, but also present in Europe), B. afzelii, and B. garinii (both predominant in Eurasia).[39][40] Some studies have also proposed B. bissettii and B. valaisiana may sometimes infect humans, but these species do not seem to be important causes of disease.[41][42] Transmission Lyme disease is classified as a zoonosis, as it is transmitted to humans from a natural reservoir among small mammals and birds by ticks that feed on both sets of hosts.[43] Hard-bodied ticks of the genus Ixodes are the main vectors of Lyme disease (also the vector for Babesia).[44] Most infections are caused by ticks in the nymphal stage, because they are very small and thus may feed for long periods of time undetected.[43] Larval ticks are very rarely infected.[45] Although deer are the preferred hosts of the adult stage of deer ticks, and tick populations are much lower in the absence of deer, ticks generally do not acquire Lyme disease spirochetes from deer.

Rather, deer ticks acquire Borrelia microbes from infected small mammals and occasionally birds, including the white-footed mouse, Peromyscus leucopus.[46] Within the tick midgut, the Borrelia's outer surface protein A (OspA) binds to the tick receptor for OspA, known as TROSPA.

When the tick feeds, the Borrelia downregulates OspA and upregulates OspC, another surface protein.

After the bacteria migrate from the midgut to the salivary glands, OspC binds to Salp15, a tick salivary protein that appears to have immunosuppressive effects that enhance infection.[47] Successful infection of the mammalian host depends on bacterial expression of OspC.[48] Tick bites often go unnoticed because of the small size of the tick in its nymphal stage, as well as tick secretions that prevent the host from feeling any itch or pain from the bite.

However, transmission is quite rare, with only about 1% of recognized tick bites resulting in Lyme disease.

In Europe, the vector is Ixodes ricinus, which is also called the sheep tick or castor bean tick.[49] In China, Ixodes persulcatus (the taiga tick) is probably the most important vector.[50] In North America, the black-legged tick or deer tick (Ixodes scapularis) is the main vector on the East Coast.[45] The lone star tick (Amblyomma americanum), which is found throughout the Southeastern United States as far west as Texas, is unlikely to transmit the Lyme disease spirochetes,[51] though it may be implicated in a related syndrome called southern tick-associated rash illness, which resembles a mild form of Lyme disease.[52] On the West Coast of the United States, the main vector is the western black-legged tick (Ixodes pacificus).[53] The tendency of this tick species to feed predominantly on host species such as lizards that are resistant to Borrelia infection appears to diminish transmission of Lyme disease in the West.[54][55] Transmission across the placenta during pregnancy has not been demonstrated, and no consistent pattern of teratogenicity or specific "congenital Lyme borreliosis" has been identified.

As with a number of other spirochetal diseases, adverse pregnancy outcomes are possible with untreated infection; prompt treatment with antibiotics reduces or eliminates this risk.[56][57] While Lyme spirochetes have been found in insects, as well as ticks,[58] reports of actual infectious transmission appear to be rare.[59] Lyme spirochete DNA has been found in semen[60] and breast milk.[61] However, according to the CDC, live spirochetes have not been found in breast milk, urine, or semen and thus is not sexually transmitted.[62] Tick-borne coinfections Ticks that transmit B. burgdorferi to humans can also carry and transmit several other parasites, such as Theileria microti and Anaplasma phagocytophilum, which cause the diseases babesiosis and human granulocytic anaplasmosis (HGA), respectively.[63] Among early Lyme disease patients, depending on their location, 2–12% will also have HGA and 2–40% will have babesiosis.[64] Ticks in certain regions, including the lands along the eastern Baltic Sea, also transmit tick-borne encephalitis.[65] Coinfections complicate Lyme symptoms, especially diagnosis and treatment.

It is possible for a tick to carry and transmit one of the coinfections and not Borrelia, making diagnosis difficult and often elusive.

The Centers for Disease Control and Prevention studied 100 ticks in rural New Jersey, and found 55% of the ticks were infected with at least one of the pathogens.[66] Pathophysiology B. burgdorferi can spread throughout the body during the course of the disease, and has been found in the skin, heart, joints, peripheral nervous system, and central nervous system.[48][67] Many of the signs and symptoms of Lyme disease are a consequence of the immune response to the spirochete in those tissues.[23] B. burgdorferi is injected into the skin by the bite of an infected Ixodes tick.

Tick saliva, which accompanies the spirochete into the skin during the feeding process, contains substances that disrupt the immune response at the site of the bite.[68] This provides a protective environment where the spirochete can establish infection.

The spirochetes multiply and migrate outward within the dermis.

The host inflammatory response to the bacteria in the skin causes the characteristic circular EM lesion.[48] Neutrophils, however, which are necessary to eliminate the spirochetes from the skin, fail to appear in the developing EM lesion.

This allows the bacteria to survive and eventually spread throughout the body.[69] Days to weeks following the tick bite, the spirochetes spread via the bloodstream to joints, heart, nervous system, and distant skin sites, where their presence gives rise to the variety of symptoms of the disseminated disease.

The spread of B. burgdorferi is aided by the attachment of the host protease plasmin to the surface of the spirochete.[70] If untreated, the bacteria may persist in the body for months or even years, despite the production of B. burgdorferi antibodies by the immune system.[71] The spirochetes may avoid the immune response by decreasing expression of surface proteins that are targeted by antibodies, antigenic variation of the VlsE surface protein, inactivating key immune components such as complement, and hiding in the extracellular matrix, which may interfere with the function of immune factors.[72][73] In the brain, B. burgdorferi may induce astrocytes to undergo astrogliosis (proliferation followed by apoptosis), which may contribute to neurodysfunction.[74] The spirochetes may also induce host cells to secrete quinolinic acid, which stimulates the NMDA receptor on nerve cells, which may account for the fatigue and malaise observed with Lyme encephalopathy.[75] In addition, diffuse white matter pathology during Lyme encephalopathy may disrupt gray matter connections, and could account for deficits in attention, memory, visuospatial ability, complex cognition, and emotional status.

White matter disease may have a greater potential for recovery than gray matter disease, perhaps because the neuronal loss is less common.

Resolution of MRI white matter hyperintensities after antibiotic treatment has been observed.[76] Tryptophan, a precursor to serotonin, appears to be reduced within the central nervous system in a number of infectious diseases that affect the brain, including Lyme.[77] Researchers are investigating if this neurohormone secretion is the cause of neuropsychiatric disorders developing in some patients with borreliosis.[78] Immunological studies Exposure to the Borrelia bacterium during Lyme disease possibly causes a long-lived and damaging inflammatory response,[79] a form of pathogen-induced autoimmune disease.[80] The production of this reaction might be due to a form of molecular mimicry, where Borrelia avoids being killed by the immune system by resembling normal parts of the body's tissues.[81][82] Chronic symptoms from an autoimmune reaction could explain why some symptoms persist even after the spirochetes have been eliminated from the body.

This hypothesis may explain why chronic arthritis persists after antibiotic therapy, similar to rheumatic fever, but its wider application is controversial.[83][84] Diagnosis Lyme disease is diagnosed clinically based on symptoms, objective physical findings (such as EM, facial palsy, or arthritis), or a history of possible exposure to infected ticks, as well as serological blood tests.

The EM rash is not always a bull's eye, i.e., it can be solid red.

When making a diagnosis of Lyme disease, health care providers should consider other diseases that may cause similar illnesses.

Not all individuals infected with Lyme disease develop the characteristic bull's-eye rash, and many may not recall a tick bite.[85] Because of the difficulty in culturing Borrelia bacteria in the laboratory, diagnosis of Lyme disease is typically based on the clinical exam findings and a history of exposure to endemic Lyme areas.[44] The EM rash, which does not occur in all cases, is considered sufficient to establish a diagnosis of Lyme disease even when serologic blood tests are negative.[86][87] Serological testing can be used to support a clinically suspected case, but is not diagnostic by itself.[44] Diagnosis of late-stage Lyme disease is often complicated by a multifaceted appearance and nonspecific symptoms, prompting one reviewer to call Lyme the new "great imitator".[88] Lyme disease may be misdiagnosed as multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, lupus, Crohn's disease, HIV, or other autoimmune and neurodegenerative diseases.

As all people with later-stage infection will have a positive antibody test, simple blood tests can exclude Lyme disease as a possible cause of a person's symptoms.[89] Laboratory testing Several forms of laboratory testing for Lyme disease are available, some of which have not been adequately validated.

The most widely used tests are serologies, which measure levels of specific antibodies in a patient's blood.

These tests may be negative in early infection as the body may not have produced a significant quantity of antibodies, but they are considered a reliable aid in the diagnosis of later stages of Lyme disease.[90] Serologic tests for Lyme disease are of limited use in people lacking objective signs of Lyme disease because of false positive results and cost.[91] The serological laboratory tests most widely available and employed are the Western blot and ELISA.

A two-tiered protocol is recommended by the Centers for Disease Control and Prevention: the sensitive ELISA test is performed first, and if it is positive or equivocal, then the more specific Western blot is run.[92] The reliability of testing in diagnosis remains controversial.[44] Studies show the Western blot IgM has a specificity of 94–96% for people with clinical symptoms of early Lyme disease.[93][94] The initial ELISA test has a sensitivity of about 70%, and in two-tiered testing, the overall sensitivity is only 64%, although this rises to 100% in the subset of people with disseminated symptoms, such as arthritis.[95] Erroneous test results have been widely reported in both early and late stages of the disease, and can be caused by several factors, including antibody cross-reactions from other infections, including Epstein–Barr virus and cytomegalovirus,[96] as well as herpes simplex virus.[97] The overall rate of false positives is low, only about 1 to 3%, in comparison to a false-negative rate of up to 36% in the early stages of infection using two-tiered testing.[95] Polymerase chain reaction (PCR) tests for Lyme disease have also been developed to detect the genetic material (DNA) of the Lyme disease spirochete.

PCR tests are susceptible to false positive results from poor laboratory technique.[98] Even when properly performed, PCR often shows false negative results with blood and cerebrospinal fluid specimens.[99] Hence, PCR is not widely performed for diagnosis of Lyme disease, but it may have a role in the diagnosis of Lyme arthritis because it is a highly sensitive way of detecting ospA DNA in synovial fluid.[100] Culture or PCR are the current means for detecting the presence of the organism, as serologic studies only test for antibodies of Borrelia.

OspA antigens, shedded by live Borrelia bacteria into urine, are a promising technique being studied.[101] The use of nanotrap particles for their detection is being looked at and the OspA has been linked to active symptoms of Lyme.[102][103] High titers of either immunoglobulin G (IgG) or immunoglobulin M (IgM) antibodies to Borrelia antigens indicate disease, but lower titers can be misleading, because the IgM antibodies may remain after the initial infection, and IgG antibodies may remain for years.[104] Western blot, ELISA, and PCR can be performed by either blood test via venipuncture or cerebrospinal fluid (CSF) via lumbar puncture.

Though lumbar puncture is more definitive of diagnosis, antigen capture in the CSF is much more elusive; reportedly, CSF yields positive results in only 10–30% of affected individuals cultured.

The diagnosis of neurologic infection by Borrelia should not be excluded solely on the basis of normal routine CSF or negative CSF antibody analyses.[105] New techniques for clinical testing of Borrelia infection have been developed, such as LTT-MELISA,[106] although the results of studies are contradictory.

The first peer reviewed study assessing the diagnostic sensitivity and specificity of the test was presented in 2012 and demonstrated potential for LTT to become a supportive diagnostic tool.[107] In 2014, research of LTT-MELISA concluded that it is "sensible" to include the LTT test in the diagnostic protocol for putative European-acquired Lyme borreliosis infections.[108] Other diagnostic techniques, such as focus floating microscopy, are under investigation.[109] New research indicates chemokine CXCL13 may also be a possible marker for neuroborreliosis.[110] Some laboratories offer Lyme disease testing using assays whose accuracy and clinical usefulness have not been adequately established.

These tests include urine antigen tests, PCR tests on urine, immunofluorescent staining for cell-wall-deficient forms of B. burgdorferi, and lymphocyte transformation tests.

The CDC does not recommend these tests, and stated their use is "of great concern and is strongly discouraged".[99] Imaging Neuroimaging is controversial in whether it provides specific patterns unique to neuroborreliosis, but may aid in differential diagnosis and in understanding the pathophysiology of the disease.[111] Though controversial, some evidence shows certain neuroimaging tests can provide data that are helpful in the diagnosis of a patient.

Magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) are two of the tests that can identify abnormalities in the brain of a patient affected with this disease.

Neuroimaging findings in an MRI include lesions in the periventricular white matter, as well as enlarged ventricles and cortical atrophy.

The findings are considered somewhat unexceptional because the lesions have been found to be reversible following antibiotic treatment.

Images produced using SPECT show numerous areas where an insufficient amount of blood is being delivered to the cortex and subcortical white matter.

However, SPECT images are known to be nonspecific because they show a heterogeneous pattern in the imaging.

The abnormalities seen in the SPECT images are very similar to those seen in people with cerebral vacuities and Creutzfeldt–Jakob disease, which makes them questionable.[112] Prevention Protective clothing includes a hat, long-sleeved shirt, and long pants tucked into socks or boots.

Light-colored clothing makes the tick more easily visible before it attaches itself.

People should use special care in handling and allowing outdoor pets inside homes because they can bring ticks into the house.

People who work in areas with woods, bushes, leaf litter, and tall grass are at risk of becoming infected with Lyme at work.

Employers can reduce the risk for employees by providing education on Lyme transmission and infection risks, and about how to check themselves for ticks on the groin, armpits, and hair.

Work clothing used in risky areas should be washed in hot water and dried in a hot dryer to kill any ticks.[113] Permethrin sprayed on clothing kills ticks on contact, and is sold for this purpose.

According to the CDC, only DEET is effective at repelling ticks.[114] Host animals Lyme and other deer tick-borne diseases can sometimes be reduced by greatly reducing the deer population on which the adult ticks depend for feeding and reproduction.

Lyme disease cases fell following deer eradication on an island, Monhegan, Maine[115] and following deer control in Mumford Cove, Connecticut.[116] It is worth noting that eliminating deer may lead to a temporary increase in tick density.[117] For example, in the U.

S., reducing the deer population to levels of 8 to 10 per square mile (from the current levels of 60 or more deer per square mile in the areas of the country with the highest Lyme disease rates), may reduce tick numbers and reduce the spread of Lyme and other tick-borne diseases.[118] However, such a drastic reduction may be very difficult to implement in many areas, and low to moderate densities of deer or other large mammal hosts may continue to feed sufficient adult ticks to maintain larval densities at high levels.

Routine veterinary control of ticks of domestic animals, including livestock, by use of acaricides can contribute to reducing exposure of humans to ticks.

Action can be taken to avoid getting bitten by ticks by using insect repellants, for example, those that contain DEET.

DEET-containing repellants are thought to be moderately effective in the prevention of tick bites.[119] In Europe known reservoirs of Borrelia burgdorferi were 9 small mammals, 7 medium-sized mammals and 16 species of birds (including passerines, sea-birds and pheasants).[120] These animals seem to transmit spirochetes to ticks and thus participate in the natural circulation of B. burgdorferi in Europe.

The house mouse is also suspected as well as other species of small rodents, particularly in Eastern Europe and Russia.[120] "The reservoir species that contain the most pathogens are the European roe deer Capreolus capreolus;[121] "it does not appear to serve as a major reservoir of B. burgdorferi" thought Jaenson & al. (1992)[122] (incompetent host for B. burgdorferi and TBE virus) but it is important for feeding the ticks,[123] as red deer and wild boars (Sus scrofa),[124] in which one Rickettsia and three Borrelia species were identified",[121] with high risks of coinfection in roe deer.[125] Nevertheless, in the 2000s, in roe deer in Europe " two species of Rickettsia and two species of Borrelia were identified".[124] Vaccination A recombinant vaccine against Lyme disease, based on the outer surface protein A (ospA) of B. burgdorferi, was developed by SmithKline Beecham.

In clinical trials involving more than 10,000 people, the vaccine, called LYMErix, was found to confer protective immunity to Borrelia in 76% of adults and 100% of children with only mild or moderate and transient adverse effects.[126] LYMErix was approved on the basis of these trials by the Food and Drug Administration (FDA) on 21 December 1998.

Following approval of the vaccine, its entry in clinical practice was slow for a variety of reasons, including its cost, which was often not reimbursed by insurance companies.[127] Subsequently, hundreds of vaccine recipients reported they had developed autoimmune and other side effects.

Supported by some patient advocacy groups, a number of class-action lawsuits were filed against GlaxoSmithKline, alleging the vaccine had caused these health problems.

These claims were investigated by the FDA and the Centers for Disease Control, which found no connection between the vaccine and the autoimmune complaints.[128] Despite the lack of evidence that the complaints were caused by the vaccine, sales plummeted and LYMErix was withdrawn from the U.

S. market by GlaxoSmithKline in February 2002,[129] in the setting of negative media coverage and fears of vaccine side effects.[128][130] The fate of LYMErix was described in the medical literature as a "cautionary tale";[130] an editorial in Nature cited the withdrawal of LYMErix as an instance in which "unfounded public fears place pressures on vaccine developers that go beyond reasonable safety considerations."[17] The original developer of the OspA vaccine at the Max Planck Institute told Nature: "This just shows how irrational the world can be...

There was no scientific justification for the first OspA vaccine LYMErix being pulled."[128] New vaccines are being researched using outer surface protein C (OspC) and glycolipoprotein as methods of immunization.[131][132] Vaccines have been formulated and approved for prevention of Lyme disease in dogs.

Currently, three Lyme disease vaccines are available.

LymeVax, formulated by Fort Dodge Laboratories, contains intact dead spirochetes which expose the host to the organism.

Galaxy Lyme, Intervet-Schering-Plough's vaccine, targets proteins OspC and OspA.

The OspC antibodies kill any of the bacteria that have not been killed by the OspA antibodies.

Canine Recombinant Lyme, formulated by Merial, generates antibodies against the OspA protein so a tick feeding on a vaccinated dog draws in blood full of anti-OspA antibodies, which kill the spirochetes in the tick's gut before they are transmitted to the dog.[133] Valneva's hexavalent (OspA) protein subunit-based vaccine candidate VLA15 was granted fast track designation by the U.

Food and Drug Administration in July 2017 which will allow further study.[134] Tick removal Removal of a tick using tweezers Attached ticks should be removed promptly, as removal within 36 hours can reduce transmission rates.[135] Folk remedies for tick removal tend to be ineffective, offer no advantages in preventing the transfer of disease, and may increase the risks of transmission or infection.[136] The best method is simply to pull the tick out with tweezers as close to the skin as possible, without twisting, and avoiding crushing the body of the tick or removing the head from the tick's body.[137] The risk of infection increases with the time the tick is attached, and if a tick is attached for less than 24 hours, infection is unlikely.

However, since these ticks are very small, especially in the nymph stage, prompt detection is quite difficult.[135] The Australian Society of Clinical Immunology recommends against using tweezers to remove ticks but rather to kill the tick first by using a product to rapidly freeze the tick to prevent it from injecting more allergen-containing saliva.

In a tick allergic person, the tick should be killed and removed in a safe place (e.g. an emergency department of a hospital).[138] Preventive antibiotics The risk of infectious transmission increases with the duration of tick attachment.[139] It requires between 36 and 48 hours of attachment for the bacteria that causes Lyme to travel from within the tick into its saliva.[139] If a deer tick that is sufficiently likely to be carrying Borrelia is found attached to a person and removed, and if the tick has been attached for 36 hours or is engorged, a single dose of doxycycline administered within the 72 hours after removal may reduce the risk of Lyme disease.

It is not generally recommended for all people bitten, as development of infection is rare: about 50 bitten people would have to be treated this way to prevent one case of erythema migrans (i.e. the typical rash found in about 70-80% of people infected).[2][139] Occupational exposure Outdoor workers are at risk of Lyme disease if they work at sites with infected ticks.

In 2010, the highest number of confirmed Lyme disease cases were reported from New Jersey, Pennsylvania, Wisconsin, New York, Massachusetts, Connecticut, Minnesota, Maryland, Virginia, New Hampshire, Delaware, and Maine.

S. workers in the northeastern and north-central States are at highest risk of exposure to infected ticks.

Ticks may also transmit other tick-borne diseases to workers in these and other regions of the country.

Worksites with woods, bushes, high grass, or leaf litter are likely to have more ticks.

Outdoor workers should be most careful to protect themselves in the late spring and summer when young ticks are most active.[140] Treatment Antibiotics are the primary treatment.[2][139] The specific approach to their use is dependent on the individual affected and the stage of the disease.[139] For most people with early localized infection, oral administration of doxycycline is widely recommended as the first choice, as it is effective against not only Borrelia bacteria but also a variety of other illnesses carried by ticks.[139] Doxycycline is contraindicated in children younger than eight years of age and women who are pregnant or breastfeeding;[139] alternatives to doxycycline are amoxicillin, cefuroxime axetil, and azithromycin.[139] Individuals with early disseminated or late infection may have symptomatic cardiac disease, refractory Lyme arthritis, or neurologic symptoms like meningitis or encephalitis.[139] Intravenous administration of ceftriaxone is recommended as the first choice in these cases;[139] cefotaxime and doxycycline are available as alternatives.[139] These treatment regimens last from one to four weeks.[139] If joint swelling persists or returns, a second round of antibiotics may be considered.[139] Outside of that, a prolonged antibiotic regimen lasting more than 28 days is not recommended as no clinical evidence shows it to be effective.[139][141] IgM and IgG antibody levels may be elevated for years even after successful treatment with antibiotics.[139] As antibody levels are not indicative of treatment success, testing for them is not recommended.[139] Prognosis For early cases, prompt[specify] treatment is usually curative.[142] However, the severity and treatment of Lyme disease may be complicated due to late diagnosis, failure of antibiotic treatment, and simultaneous infection with other tick-borne diseases (coinfections), including ehrlichiosis, babesiosis, and immune suppression[citation needed] in the patient.

It is believed that less than 5% of people have lingering symptoms of fatigue, pain, or joint and muscle aches at the time they finish treatment.[143] These symptoms can last for more than 6 months.

This condition is called post-treatment lyme disease syndrome.

As of 2016 the reason for the lingering symptoms was not known; the condition is generally managed similarly to fibromyalgia or chronic fatigue syndrome.[144] In dogs, a serious long-term prognosis may result in glomerular disease,[145] which is a category of kidney damage that may cause chronic kidney disease.[133] Dogs may also experience chronic joint disease if the disease is left untreated.

However, the majority of cases of Lyme disease in dogs result in a complete recovery with, and sometimes without, treatment with antibiotics.[146][verification needed] In rare cases, Lyme disease can be fatal to both humans and dogs.[147] Epidemiology Countries with reported Lyme disease cases.

Lyme disease occurs regularly in Northern Hemisphere temperate regions.[148] Africa In northern Africa, B. burgdorferi sensu lato has been identified in Morocco, Algeria, Egypt and Tunisia.[149][150][151] Lyme disease in sub-Saharan Africa is presently unknown, but evidence indicates it may occur in humans in this region.

The abundance of hosts and tick vectors would favor the establishment of Lyme infection in Africa.[152] In East Africa, two cases of Lyme disease have been reported in Kenya.[153] Asia B. burgdorferi sensu lato-infested ticks are being found more frequently in Japan, as well as in northwest China, Nepal, Thailand and far eastern Russia.[154][155] Borrelia has also been isolated in Mongolia.[156] Europe In Europe, Lyme disease is caused by infection with one or more pathogenic European genospecies of the spirochaete B. burgdorferi sensu lato, mainly transmitted by the tick Ixodes ricinus.[157] Cases of B. burgdorferi sensu lato-infected ticks are found predominantly in central Europe, particularly in Slovenia and Austria, but have been isolated in almost every country on the continent.[158] Incidence in southern Europe, such as Italy and Portugal, is much lower.[159] United Kingdom In the United Kingdom the number of laboratory confirmed cases of Lyme disease has been rising steadily since voluntary reporting was introduced in 1986[160] when 68 cases were recorded in the UK and Republic of Ireland combined.[161] In the UK there were 23 confirmed cases in 1988 and 19 in 1990,[162] but 973 in 2009[160] and 953 in 2010.[163] Provisional figures for the first 3 quarters of 2011 show a 26% increase on the same period in 2010.[164] It is thought, however, that the actual number of cases is significantly higher than suggested by the above figures, with the UK's Health Protection Agency estimating that there are between 2,000 and 3,000 cases per year,[163] (with an average of around 15% of the infections acquired overseas[160]), while Dr Darrel Ho-Yen, Director of the Scottish Toxoplasma Reference Laboratory and National Lyme Disease Testing Service, believes that the number of confirmed cases should be multiplied by 10 "to take account of wrongly diagnosed cases, tests giving false results, sufferers who weren't tested, people who are infected but not showing symptoms, failures to notify and infected individuals who don't consult a doctor."[165][166] Despite Lyme disease (Borrelia burgdorferi infection) being a notifiable disease in Scotland[167] since January 1990[168] which should therefore be reported on the basis of clinical suspicion, it is believed that many GPs are unaware of the requirement.[169] Mandatory reporting, limited to laboratory test results only, was introduced throughout the UK in October 2010, under the Health Protection (Notification) Regulations 2010.[160] Although there is a greater incidence of Lyme disease in the New Forest, Salisbury Plain, Exmoor, the South Downs, parts of Wiltshire and Berkshire, Thetford Forest[170] and the West coast and islands of Scotland[171] infected ticks are widespread, and can even be found in the parks of London.[162][172] A 1989 report found that 25% of forestry workers in the New Forest were seropositive, as were between 2% and 4-5% of the general local population of the area.[173][174] Tests on pet dogs, carried out throughout the country in 2009 indicated that around 2.

5% of ticks in the UK may be infected, considerably higher than previously thought.[175][176] It is thought that global warming may lead to an increase in tick activity in the future, as well as an increase in the amount of time that people spend in public parks, thus increasing the risk of infection.[177] North America Many studies in North America have examined ecological and environmental correlates of Lyme disease prevalence.

A 2005 study using climate suitability modelling of I. scapularis projected that climate change would cause an overall 213% increase in suitable vector habitat by the year 2080, with northward expansions in Canada, increased suitability in the central U.

S., and decreased suitable habitat and vector retraction in the southern U.

S.[178] A 2008 review of published studies concluded that the presence of forests or forested areas was the only variable that consistently elevated the risk of Lyme disease whereas other environmental variables showed little or no concordance between studies.[179] The authors argued that the factors influencing tick density and human risk between sites are still poorly understood, and that future studies should be conducted over longer time periods, become more standardized across regions, and incorporate existing knowledge of regional Lyme disease ecology.[179] Canada Owing to changing climate, the range of ticks able to carry Lyme disease has expanded from a limited area of Ontario to include areas of southern Quebec, Manitoba, northern Ontario, southern New Brunswick, southwest Nova Scotia and limited parts of Saskatchewan and Alberta, as well as British Columbia.

Cases have been reported as far east as the island of Newfoundland.[180][181][182] A model-based prediction by Leighton et al. (2012) suggests that the range of the I. scapularis tick will expand into Canada by 46 km/year over the next decade, with warming climatic temperatures as the main driver of increased speed of spread.[183] Mexico A 2007 study suggests Borrelia burgdorferi infections are endemic to Mexico, from four cases reported between 1999 and 2000.[184] United States CDC map showing the risk of Lyme disease in the United States, particularly its concentration in the Northeast Megalopolis and western Wisconsin.

Each year, approximately 30,000 new cases are reported to the CDC however, this number is likely underestimated.

The CDC is currently conducting research on evaluation and diagnostics of the disease and preliminary results suggest the number of new cases to be around 300,000.[185][186] Lyme disease is the most common tick-borne disease in North America and Europe, and one of the fastest-growing infectious diseases in the United States.

Of cases reported to the United States CDC, the ratio of Lyme disease infection is 7.

In the ten states where Lyme disease is most common, the average was 31.

6 cases for every 100,000 persons for the year 2005.[187][188][189] Although Lyme disease has been reported in all states[185][190] about 99% of all reported cases are confined to just five geographic areas (New England, Mid-Atlantic, East-North Central, South Atlantic, and West North-Central).[191] New 2011 CDC Lyme case definition guidelines are used to determine confirmed CDC surveillance cases.[192] Effective January 2008, the CDC gives equal weight to laboratory evidence from 1) a positive culture for B. burgdorferi; 2) two-tier testing (ELISA screening and Western blot confirming); or 3) single-tier IgG (old infection) Western blot.[193] Previously, the CDC only included laboratory evidence based on (1) and (2) in their surveillance case definition.

The case definition now includes the use of Western blot without prior ELISA screen.[193] The number of reported cases of the disease has been increasing, as are endemic regions in North America.

For example, B. burgdorferi sensu lato was previously thought to be hindered in its ability to be maintained in an enzootic cycle in California, because it was assumed the large lizard population would dilute the prevalence of B. burgdorferi in local tick populations; this has since been brought into question, as some evidence has suggested lizards can become infected.[194] Except for one study in Europe,[195] much of the data implicating lizards is based on DNA detection of the spirochete and has not demonstrated lizards are able to infect ticks feeding upon them.[194][196][197][198] As some experiments suggest lizards are refractory to infection with Borrelia, it appears likely their involvement in the enzootic cycle is more complex and species-specific.[55] While B. burgdorferi is most associated with ticks hosted by white-tailed deer and white-footed mice, Borrelia afzelii is most frequently detected in rodent-feeding vector ticks, and Borrelia garinii and Borrelia valaisiana appear to be associated with birds.

Both rodents and birds are competent reservoir hosts for B. burgdorferi sensu stricto.

The resistance of a genospecies of Lyme disease spirochetes to the bacteriolytic activities of the alternative complement pathway of various host species may determine its reservoir host association.[citation needed] Several similar but apparently distinct conditions may exist, caused by various species or subspecies of Borrelia in North America.

A regionally restricted condition that may be related to Borrelia infection is southern tick-associated rash illness (STARI), also known as Masters' disease.

Amblyomma americanum, known commonly as the lone-star tick, is recognized as the primary vector for STARI.

In some parts of the geographical distribution of STARI, Lyme disease is quite rare (e.g., Arkansas), so patients in these regions experiencing Lyme-like symptoms—especially if they follow a bite from a lone-star tick—should consider STARI as a possibility.

It is generally a milder condition than Lyme and typically responds well to antibiotic treatment.[citation needed] In recent years there have been 5 to 10 cases a year of a disease similar to Lyme occurring in Montana.

It occurs primarily in pockets along the Yellowstone River in central Montana.

People have developed a red bull's-eye rash around a tick bite followed by weeks of fatigue and a fever.[190] Lyme disease prevalence is comparable among males and females.

A wide range of age groups is affected, though the number of cases is highest among 10- to 19-year-olds.

For unknown reasons, Lyme disease is seven times more common among Asians.[199] South America In South America, tick-borne disease recognition and occurrence is rising.

In Brazil, a Lyme-like disease known as Baggio–Yoshinari syndrome was identified, caused by microorganisms that do not belong to the B. burgdorferi sensu lato complex and transmitted by ticks of the Amblyomma and Rhipicephalus genera.[200] The first reported case of BYS in Brazil was made in 1992 in Cotia, São Paulo.[201] B. burgdorferi sensu stricto antigens in patients have been identified in Colombia and Bolivia.[citation needed] History The evolutionary history of Borrelia burgdorferi genetics has been the subject of recent studies.

One study has found that prior to the reforestation that accompanied post-colonial farm abandonment in New England and the wholesale migration into the mid-west that occurred during the early 19th century, Lyme disease was present for thousands of years in America and had spread along with its tick hosts from the Northeast to the Midwest.[202] John Josselyn, who visited New England in 1638 and again from 1663–1670, wrote "there be infinite numbers of tikes hanging upon the bushes in summer time that will cleave to man's garments and creep into his breeches eating themselves in a short time into the very flesh of a man.

I have seen the stockins of those that have gone through the woods covered with them."[203] This is also confirmed by the writings of Peter Kalm, a Swedish botanist who was sent to America by Linnaeus, and who found the forests of New York "abound" with ticks when he visited in 1749.

When Kalm's journey was retraced 100 years later, the forests were gone and the Lyme bacterium had probably become isolated to a few pockets along the northeast coast, Wisconsin, and Minnesota.[204] Perhaps the first detailed description of what is now known as Lyme disease appeared in the writings of Reverend Dr.

John Walker after a visit to the Island of Jura (Deer Island) off the west coast of Scotland in 1764.[205] He gives a good description both of the symptoms of Lyme disease (with "exquisite pain [in] the interior parts of the limbs") and of the tick vector itself, which he describes as a "worm" with a body which is "of a reddish colour and of a compressed shape with a row of feet on each side" that "penetrates the skin".

Many people from this area of Great Britain emigrated to North America between 1717 and the end of the 18th century.

The examination of preserved museum specimens has found Borrelia DNA in an infected Ixodes ricinus tick from Germany that dates back to 1884, and from an infected mouse from Cape Cod that died in 1894.[204] The 2010 autopsy of Ötzi the Iceman, a 5,300-year-old mummy, revealed the presence of the DNA sequence of Borrelia burgdorferi making him the earliest known human with Lyme disease.[206] The early European studies of what is now known as Lyme disease described its skin manifestations.

The first study dates to 1883 in Breslau, Germany (now Wrocław, Poland), where physician Alfred Buchwald described a man who had suffered for 16 years with a degenerative skin disorder now known as acrodermatitis chronica atrophicans.[207] At a 1909 research conference, Swedish dermatologist Arvid Afzelius presented a study about an expanding, ring-like lesion he had observed in an older woman following the bite of a sheep tick.

He named the lesion erythema migrans.[207] The skin condition now known as borrelial lymphocytoma was first described in 1911.[208] The modern history of medical understanding of the disease, including its cause, diagnosis, and treatment, has been difficult.[209] Neurological problems following tick bites were recognized starting in the 1920s.

French physicians Garin and Bujadoux described a farmer with a painful sensory radiculitis accompanied by mild meningitis following a tick bite.

A large, ring-shaped rash was also noted, although the doctors did not relate it to the meningoradiculitis.

In 1930, the Swedish dermatologist Sven Hellerström was the first to propose EM and neurological symptoms following a tick bite were related.[210] In the 1940s, German neurologist Alfred Bannwarth described several cases of chronic lymphocytic meningitis and polyradiculoneuritis, some of which were accompanied by erythematous skin lesions.

Carl Lennhoff, who worked at the Karolinska Institute in Sweden, believed many skin conditions were caused by spirochetes.

In 1948, he used a special stain to microscopically observe what he believed were spirochetes in various types of skin lesions, including EM.[211] Although his conclusions were later shown to be erroneous, interest in the study of spirochetes was sparked.

In 1949, Nils Thyresson, who also worked at the Karolinska Institute, was the first to treat ACA with penicillin.[212] In the 1950s, the relationship among tick bite, lymphocytoma, EM and Bannwarth's syndrome was recognized throughout Europe leading to the widespread use of penicillin for treatment in Europe.[213][214] In 1970, a dermatologist in Wisconsin named Rudolph Scrimenti recognized an EM lesion in a patient after recalling a paper by Hellerström that had been reprinted in an American science journal in 1950.

This was the first documented case of EM in the United States.

Based on the European literature, he treated the patient with penicillin.[215] The full syndrome now known as Lyme disease was not recognized until a cluster of cases originally thought to be juvenile rheumatoid arthritis was identified in three towns in southeastern Connecticut in 1975, including the towns Lyme and Old Lyme, which gave the disease its popular name.[216] This was investigated by physicians David Snydman and Allen Steere of the Epidemic Intelligence Service, and by others from Yale University, including Dr.

Stephen Malawista, who is credited as a co-discover of the disease.[217] The recognition that the patients in the United States had EM led to the recognition that "Lyme arthritis" was one manifestation of the same tick-borne condition known in Europe.[218] Before 1976, the elements of B. burgdorferi sensu lato infection were called or known as tick-borne meningopolyneuritis, Garin-Bujadoux syndrome, Bannwarth syndrome, Afzelius' disease,[219] Montauk Knee or sheep tick fever.

Since 1976 the disease is most often referred to as Lyme disease,[220][221] Lyme borreliosis or simply borreliosis.[citation needed] In 1980, Steere, et al., began to test antibiotic regimens in adult patients with Lyme disease.[222] In the same year, New York State Health Dept. epidemiologist Jorge Benach provided Willy Burgdorfer, a researcher at the Rocky Mountain Biological Laboratory, with collections of I. dammini [scapularis] from Shelter Island, NY, a known Lyme-endemic area as part of an ongoing investigation of Rocky Mountain spotted fever.

In examining the ticks for rickettsiae, Burgdorfer noticed "poorly stained, rather long, irregularly coiled spirochetes." Further examination revealed spirochetes in 60% of the ticks.

Burgdorfer credited his familiarity with the European literature for his realization that the spirochetes might be the "long-sought cause of ECM and Lyme disease." Benach supplied him with more ticks from Shelter Island and sera from patients diagnosed with Lyme disease.

University of Texas Health Science Center researcher Alan Barbour "offered his expertise to culture and immunochemically characterize the organism." Burgdorfer subsequently confirmed his discovery by isolating, from patients with Lyme disease, spirochetes identical to those found in ticks.[223] In June 1982, he published his findings in Science, and the spirochete was named Borrelia burgdorferi in his honor.[224] After the identification of B. burgdorferi as the causative agent of Lyme disease, antibiotics were selected for testing, guided by in vitro antibiotic sensitivities, including tetracycline antibiotics, amoxicillin, cefuroxime axetil, intravenous and intramuscular penicillin and intravenous ceftriaxone.[225][226] The mechanism of tick transmission was also the subject of much discussion.

B. burgdorferi spirochetes were identified in tick saliva in 1987, confirming the hypothesis that transmission occurred via tick salivary glands.[227] Society and culture Urbanization and other anthropogenic factors can be implicated in the spread of Lyme disease to humans.

In many areas, expansion of suburban neighborhoods has led to gradual deforestation of surrounding wooded areas and increased border contact between humans and tick-dense areas.

Human expansion has also resulted in a reduction of predators that hunt deer as well as mice, chipmunks and other small rodents—the primary reservoirs for Lyme disease.

As a consequence of increased human contact with host and vector, the likelihood of transmission of the disease has greatly increased.[228][229] Researchers are investigating possible links between global warming and the spread of vector-borne diseases, including Lyme disease.[230] Controversy The term "chronic Lyme disease" is controversial and not recognized in the medical literature,[231] and most medical authorities advise against long-term antibiotic treatment for Lyme disease.[91][232][233] Studies have shown that most people diagnosed with "chronic Lyme disease" either have no objective evidence of previous or current infection with B. burgdorferi or are people who should be classified as having post-treatment Lyme disease syndrome (PTLDS), which is defined as continuing or relapsing non-specific symptoms (such as fatigue, musculoskeletal pain, and cognitive complaints) in a person previously treated for Lyme disease.[234] Other animals Prevention of Lyme disease is an important step in keeping dogs safe in endemic areas.

Prevention education and a number of preventative measures are available.

First, for dog owners who live near or who often frequent tick-infested areas, routine vaccinations of their dogs is an important step.[235] Another crucial preventive measure is the use of persistent acaricides, such as topical repellents or pesticides that contain triazapentadienes (Amitraz), phenylpyrazoles (Fipronil), or permethrin (pyrethroids).[236] These acaricides target primarily the adult stages of Lyme-carrying ticks and reduce the number of reproductively active ticks in the environment.[235] Formulations of these ingredients are available in a variety of topical forms, including spot-ons, sprays, powders, impregnated collars, solutions, and shampoos.[236] Examination of a dog for ticks after being in a tick-infested area is an important precautionary measure to take in the prevention of Lyme disease.

Key spots to examine include the head, neck, and ears.[237] Research The National Institutes of Health have supported research into bacterial persistence.[238]  This article incorporates public domain material from the Centers for Disease Control and Prevention document "Post-Treatment Lyme Disease Syndrome".Children can contract Lyme disease from a tick bite, and there are three stages of Lyme disease that develop after an infected tick bites a child.

Within the first three to 30 days, the signs of Lyme disease are quite obvious, the University of Michigan Health System reports.

The earliest symptoms may be attributed to general illness, but the characteristic signs of Lyme disease soon appear.

Video of the Day Stage 1 The first symptoms of Lyme disease can appear between three and 30 days after a bite form an infected tick.

The most characteristic symptom is a bull's-eye rash that develops at the site of the wound.

It affects about 80 percent of individuals who have been bitten.

The outer edge of the rash consists of a large red ring that expands out from the bite.

It can become larger than 2 inches across, the University of Michigan states.

Anything small, such as the size of a dime or quarter, is not a rash from Lyme disease.

The rash does not cause any discomfort or irritation.

Children may develop smaller spots scattered about the body.

Flu-like symptoms often accompany a rash in a child.

These symptoms include a fever, chills, sore throat and a headache that persists for several days.

Stage 2 In most cases, treatment of Lyme disease will occur before it progresses to stage 2.

Without treatment, about 15 percent of people will develop stage 2 signs.

Children's Hospital Boston reports that testing usually does not reveal Lyme disease but observation of the characteristic signs can help make a proper diagnosis.

These more serious symptoms include nervous system issues, such as a stiff neck, weakened facial muscles or hand and foot weakness and numbness.

Some children can experience irregular heartbeat.

Stage 3 Without proper treatment, 60 percent will develop symptoms associated with stage 3 of Lyme disease.

Those affected may not have had any symptoms of stage 2 illness.

During this stage, the symptoms can consist of recurrent swelling of the joints, as in arthritis.

The University of Michigan points out that 10 percent of children will develop chronic arthritis from Lyme disease.Lyme disease (LD) is a multistage, multisystem bacterial infection caused by Borrelia burgdorferi bacteria. These are usually transmitted by tick bites.

The disease takes its name from Lyme, Connecticut, where the illness was first identified in the United States in 1975.

Lyme disease continues to be a rapidly emerging infectious disease. It is the leading cause of all insect-borne illness in the U.

S. LD cases more than doubled during the surveillance period of 1992 to 2006.

In 2010, there were nearly 23,000 confirmed cases and more than 7,000 probable cases of LD.  Lyme disease is a year-round problem, although April through October is considered tick season.

The chance of encountering a tick infected with the bacteria is more likely during this time.

Cases of LD have been reported in nearly all states in this country, with most cases occurring in: The coastal northeast The mid-Atlantic states Wisconsin and Minnesota Northern California Many cases have also been identified in large areas of Asia and Europe.

The list of possible symptoms for Lyme disease is nonspecific.

Symptoms usually appear within 3 to 30 days after a tick bite.

The following are the most common symptoms of LD.

However, each child may experience symptoms differently.

One of the primary symptoms is often a circular-shaped rash that can be pink in the center and a deeper red on the surrounding skin.

The rash: Can appear several days after infection, or not at all.

Can be very small or very large (up to 12 inches across).

Can mimic such skin problems as hives, eczema, sunburn, poison ivy, and flea bites.

Several days or weeks after a bite from an infected tick, flu-like symptoms can appear, including the following: Headache Stiff neck Aches and pains in muscles and joints Low-grade fever and chills Fatigue Poor appetite Swollen glands After several months, painful and swollen joints may occur.

Other possible symptoms may include the following: Neurological symptoms Heart problems Skin disorders Eye problems Hepatitis Severe fatigue Weakness Problems with coordination Symptoms of LD may resemble other conditions or medical problems.

Always consult your health care provider for a diagnosis.

It is possible that your child may be one of the 10% to 20% of people with LD who have posttreatment Lyme disease syndrome. This means that symptoms linger after 6 months.

LD may be difficult to diagnose because the symptoms may resemble other conditions.

The primary symptom is a rash, but it may not be present in more than 20% of cases.

Diagnosis is usually based on symptoms and a history of a tick bite.

Diagnosis of Lyme disease must be made by an experienced health care provider.

Blood and laboratory tests may be performed to help diagnose LD and to rule out other conditions.

Research is under way to develop and improve methods for diagnosing LD.

Your health care provider will determine the best treatment plan, based on your individual situation.

Lyme disease is usually treated with antibiotics.

Treatment will be considered based on these and other factors: Your symptoms and test results.

If you are bitten by a tick that tests positive for spirochetes.

If you are bitten by a tick and have any of the symptoms.

If you are bitten by a tick and live in an area where the ticks are known to be infected.

Check your family often for ticks, including: All parts of the body that bend: behind the knees, between fingers and toes, underarms, and groin.

Other areas where ticks are commonly found: belly button, in and behind the ears, neck, hairline, and top of the head.

Areas of pressure points, including: Where underwear elastic waistbands touch the skin.

Anywhere else where clothing presses on the skin.

Visually check all other areas of the body and hair, and run fingers gently over skin.

Run a fine-toothed comb through your child's hair to check for ticks daily.

Other helpful measures include the following: Walk on cleared paths and pavement through wooded areas and fields when possible.

Shower after all outdoor activities are over for the day.

It may take up to 4 to 6 hours for ticks to attach firmly to skin.

Use insect repellents safely: Products that contain DEET are tick repellents, but do not always kill the tick and are not 100 percent effective.

Use a children's insect repellent (10% to 30% DEET) for your child.

Do not use repellent for infants younger than age 2 months.

Do not apply to the area around your child's nose, mouth, and eyes.

Do not apply over any cuts or open sores.  Treat clothing with a product that contains permethrin. This is known to kill ticks on contact.Approach Considerations Antibiotic selection, route of administration, and duration of therapy for Lyme disease are guided by the patient’s clinical manifestations and stage of disease, as well as the presence of any concomitant medical conditions or allergies.

Prompt treatment increases the likelihood of therapeutic success.

Of great importance, doxycycline is contraindicated in patients younger than 8 years and in pregnant women.

Clinical presentation and therapy for the stages of Lyme disease (Open Table in a new window) Table 2.

Adult and pediatric treatment options, dosages, and routes of administration (Open Table in a new window) In most patients with carditis, prompt institution of appropriate antibiotics is the only treatment needed.

However, occasional patients with Lyme disease–related atrioventricular (AV) block may require hospitalization for temporary cardiac pacing.

The indications for cardiac pacing are the same as for any other patient with varying degrees of heart block.

Symptoms of arthritis may persist for a few weeks beyond adequate therapy.

Repeat treatment usually is not necessary unless symptoms worsen or persist beyond 2 months.

Persistent arthritis after clearance of the infection is most likely related to autoimmunity and is more prevalent among individuals with HLA-DR2, HLA-DR3, or HLA-DR4 allotypes.

These patients should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), plus hydroxychloroquine if necessary.

As a last resort, such patients may need a synovectomy to eradicate the inflammatory arthritis in the involved joint.

Neurologic manifestations of Lyme disease in both adults and children respond well to penicillin, ceftriaxone, cefotaxime, and doxycycline.

Although most studies of neuroborreliosis have used intravenous antibiotics, European studies support use of oral doxycycline in adults with meningitis, cranial neuritis, or radiculitis, with intravenous regimens reserved for patients with parenchymal central nervous system (CNS) involvement, other severe neurologic symptomatology, or failure to respond to oral treatment. [48] Borrelial lymphocytoma is sufficiently uncommon that no comparative trials address the ideal duration of treatment, route of administration of the antibiotic, or the choice of medication.

Treatment is usually with 14-21 days of oral antibiotics.

When symptoms of dissemination are noted, however, parenteral therapy sometimes is used.

Physicians should observe patients closely for possible Jarisch-Herxheimer reactions after the institution of therapy.

This allergic/inflammatory response may manifest in the skin, mucous membranes, viscera, or nervous system.

In endemic areas, antibiotic prophylaxis may be appropriate for selected patients with a recognized tick bite (see Prevention).

Prophylactic antibiotics are not routinely recommended, however, as tick bites rarely result in Lyme disease, and if infection does develop, early antibiotic treatment has excellent efficacy.

Several groups have published Lyme disease guidelines.

The Infectious Diseases Society of America (IDSA) has released clinical practice guidelines for the assessment, treatment, and prevention of Lyme disease. [44] The American Academy of Neurology has established guidelines for the treatment of nervous system Lyme disease. [48] The International Lyme and Associated Diseases Society (ILADS) issued updated recommendations for the management of Lyme disease in 2014. [53] The recommendations are all based on "very low quality evidence" and use patient preference as major portion of the support for the recommendations.

In addition, the recommendations are limited to three specific aspects of Lyme disease.

The differences between the IDSA and ILADS recommendations are outlined in the table below.

Comparison of Infectious Diseases Society of America (IDSA) and International Lyme and Associated Diseases Society (ILADS) recommendations for Lyme disease treatment (Open Table in a new window) Controversy regarding the treatment of Lyme disease abounds, including an antitrust investigation initiated in 2008 by the Connecticut Attorney General (CAG) into the development process for the 2006 IDSA Lyme disease treatment guidelines.

The CAG claimed the process was tainted by suppression of scientific evidence and conflicts of interest. [54] In April 2008, the CAG and the IDSA reached an agreement to end the investigation.

In 2010, a review panel convened as part of that agreement concluded that “the IDSA’s 2006 Lyme disease guidelines were based on the highest-quality medical and scientific evidence available at the time and are supported by evidence that has been published in more recent years.” [55] Next: Treatment of Early Lyme Disease Early localized Lyme disease refers to isolated erythema migrans and to an undifferentiated febrile illness.

In endemic areas, patients with erythema migrans and a recent history of possible or proven tick exposure can be treated empirically, without laboratory confirmation of the diagnosis.

Serologic testing is appropriate for patients who present more than 3 weeks after tick exposure.

Doxycycline, amoxicillin, or cefuroxime axetil is recommended for the treatment of adult patients with early localized or early disseminated Lyme disease associated with erythema migrans, in the absence of specific neurologic manifestations or third-degree heart block.

Antibiotics recommended for children include amoxicillin and cefuroxime axetil; in children 8 years and older, doxycycline may be used.

Because of its cost, cefuroxime axetil is reserved for patients unable to take amoxicillin or doxycycline Macrolides are alternative agents, but they are used only when the first-line agents are not tolerated or are contraindicated.

Those macrolides that have been compared with other antimicrobials in clinical trials of Lyme disease have been found to be less effective. [44] Treatment for 14 days is recommended (range, 10-21 d for doxycycline and 14-21 d for amoxicillin or cefuroxime axetil).

Longer treatment was previously recommended, but several studies have shown similar efficacy between 10-day and longer courses (20-21 d). [56, 57] Erythema migrans typically shows improvement within a few days after the institution of appropriate antibiotic therapy.

Patients with other manifestations who are treated with oral formulations should be treated for 30 days because, with these manifestations, accurately pinpointing the date of infection is not always possible.

This regimen may also be effective for neurologic disease.

Neurologic Lyme disease is effectively treated with a 2-week course of parenteral penicillin, ceftriaxone, or cefotaxime. [48, 58] Oral doxycycline is as efficacious as parenteral antibiotics in patients who have Lyme-associated meningitis, facial nerve palsy, or radiculitis. [48] Pregnancy For pregnant women with erythema migrans, some physicians recommend parenteral therapy, although data on this are limited.

Isolated reports exist of transplacental transmission from the mother to fetus.

One European descriptive study showed good results of parenteral ceftriaxone in pregnant women with erythema migrans. [59] Pregnant women who develop Lyme disease should not be treated with doxycycline or another tetracycline.

Risks to the fetus include permanent discoloration of the teeth, enamel hypoplasia, and retardation of skeletal development.

Previous Next: Lyme Arthritis In patients without neurologic disease, Lyme arthritis can usually be treated successfully with oral antibiotics, with an extended treatment time of 28 days.

Recommended regimens for adult patients are as follows [44] : Doxycycline, 100 mg twice daily Amoxicillin, 500 mg three times daily Cefuroxime axetil, 500 mg twice daily per day Recommended regimens for pediatric patients are as follows [44] : Amoxicillin, 50 mg/kg/day in three divided doses (maximum of 500 mg/dose) Cefuroxime axetil, 30 mg/kg/day in two divided doses (maximum of 500 mg/dose) Doxycycline, 4 mg/kg/day in two divided doses (maximum of 100 mg/dose), if the patient is 8 years of age or older Patients with mild residual joint swelling after a recommended course of oral antibiotic therapy can be re-treated with another 4-week course of oral antibiotics.

Patients whose arthritis fails to improve or worsens can be re-treated with a 2- to 4-week course of intravenous ceftriaxone.

IDSA guidelines suggest that clinicians consider waiting several months before starting a second round of antibiotics, as joint inflammation tends to resolve slowly even when the infection has been eliminated. [44] In patients with persistent arthritis despite intravenous therapy, polymerase chain reaction (PCR) of synovial fluid (and synovial tissue, if available) can be done.

PCR results may remain positive for several weeks after the eradication of Borrelia burgdorferi; nevertheless, if PCR is positive for B burgdorferi DNA, the patient can be treated with oral antibiotic therapy for another month. [20] If PCR is negative, the patient should be given symptomatic treatment with nonsteroidal anti-inflammatory drugs NSAIDs).

If necessary, NSAID treatment can be supplemented with oral hydroxychloroquine, 20 mg twice daily. [20, 44] Consultation with a rheumatologist is recommended in these cases.

Eventual resolution of chronic Lyme arthritis can be expected in all patients.

However, patients who continue to have significant pain or limitation of function after 3-6 months of symptomatic therapy can be considered for arthroscopic synovectomy. [20, 44] Intra-articular corticosteroids should not be given before antibiotic treatment, as they may promote persistent Lyme arthritis.

Intra-articular corticosteroids are rarely indicated after antibiotic treatment. [58] Previous Next: Lyme Carditis The patient with myocarditis generally is not very ill, and significant muscle dysfunction is unusual.

Pericarditis with tamponade, while rare, has been reported.

Patients with atrioventricular (AV) heart block and/or myopericarditis associated with early Lyme disease may be treated with either oral or parenteral antibiotic therapy for 14 days (range, 14-21 days).

Hospitalization and continuous monitoring are advisable for patients with any of the following [60] : Associated symptoms (eg, syncope, dyspnea, or chest pain) Second-degree or third-degree AV block First-degree heart block with prolongation of the PR interval to more than 30 milliseconds (the degree of block may fluctuate and worsen very rapidly in such patients) For patients with advanced heart block, a temporary pacemaker may be required; consultation with a cardiologist is recommended.

Use of the pacemaker may be discontinued when the advanced heart block has resolved.

An oral antibiotic treatment regimen should be used for completion of therapy and for outpatients, as is used for patients with erythema migrans without carditis.

Previous Next: Neurologic Manifestations Although facial palsies may resolve without treatment, oral antibiotic therapy may prevent further sequelae.

Encephalitis/encephalopathy should be treated with intravenous antibiotic therapy for 28 days.

The use of ceftriaxone in early Lyme disease has been recommended for adult patients with acute meningitis or radiculopathy.

Possible satisfactory alternatives include parenteral therapy with cefotaxime or penicillin G.

For patients who are intolerant of β-lactam antibiotics, increasing evidence indicates that oral doxycycline (200-400 mg/d in two divided doses orally for 10-28 d) may be adequate. [61, 62, 63] For all patients, except those with encephalitis, oral agents may be satisfactory. [64] With any regimen, neurologic symptoms may take 6 months to reach maximum improvement.

Patients with Lyme meningitis may need to be admitted not only for pain control but also for administration of intravenous antibiotics.

If diagnostic uncertainty exists regarding the etiology of the meningitis, the antibiotic coverage may need to be extended for other more serious bacterial pathogens until the precise etiology is clarified.

Adult patients with late neurologic disease affecting the central or peripheral nervous system should be treated with intravenous medication.

Response to treatment is usually slow and may be incomplete.

Retreatment is not recommended unless relapse is shown by reliable objective measures.

Previous Next: Ocular Manifestations Conjunctivitis and photophobia in stage 1 Lyme disease require no therapy.

Bell palsy in stage 2 Lyme disease is self-limited, but patients require supportive therapy to prevent the complications of exposure keratitis.

Keratitis and episcleritis benefit from topical corticosteroids, usually a short course of prednisolone acetate 1% or fluorometholone 0.

A treatment regimen for severe neuro-ophthalmic disease (involving the optic nerve) or posterior segment disease (eg, pars planitis, vitreitis) has not been established.

Oral corticosteroids without concomitant antibiotics should not be used.

The best approach for these patients might be a trial of antibiotic therapy, in which patients receive 2-3 weeks of intravenous penicillin or ceftriaxone.

If patients respond to treatment, the trial is successful, ocular Lyme disease is diagnosed, and no further therapy is needed.

Recurrences of Lyme uveitis, once adequate intravenous therapy has been given, can be treated with judicious corticosteroids.

Previous Next: Acrodermatitis Chronica Atrophicans Acrodermatitis chronica atrophicans is usually treated with 1-month course of oral antibiotics, usually a beta-lactam or doxycycline.

One study showed fewer relapses with 30 days compared with 20 or fewer days of therapy.

In the same study, 30 days of oral antibiotics were more effective than 15 days of intravenous ceftriaxone (2 g/d). [65] It is important to ensure that no neurologic manifestations are present before embarking on oral therapy.

Previous Next: Post-Treatment Lyme Disease Syndrome Despite appropriate antibiotic treatment, patients with Lyme disease may experience lingering symptoms similar to fibromyalgia (eg, fatigue, pain, joint and muscle aches).

This condition has been termed chronic Lyme disease or, more precisely, post-treatment Lyme disease syndrome (PTLDS). [66] These symptoms have not been shown in any controlled trials to be responsive to antibiotic therapy. [58] A study by Klempner et al failed to show a benefit of treatment with 2 g of intravenous ceftriaxone daily for 30 days, followed by oral doxycycline at 200 mg/d for 60 days. [67] Long-term IV ceftriaxone therapy can result in the formation of biliary sludge, which can lead to biliary colic.

Similarly, the Persistent Lyme Empiric Antibiotic Study Europe (PLEASE) study, a double-blind, randomized, placebo-controlled trial in 280 patients, found that longer-term use of antibiotics does not improve health-related quality of life in patients with PTLDS.

In PLEASE, patients received open-label ceftriaxone for 2 weeks and were then randomized to a 12-week oral regimen of doxycycline (n = 86), clarithromycin combined with hydroxychloroquine (n = 96), or placebo (n = 98).

At the end of the treatment period, the three groups showed no significant difference in health-related quality of life, which was the study's primary outcome, or in secondary outcomes, including physical and mental aspects of health-related quality of life and fatigue. [68, 69] Extended antibiotic therapy, sometimes for longer than 6 months, has been advocated for PTLDS.

This not only can cause great harm to patients but also has resulted in one or more deaths. [70] The Centers for Disease Control and Prevention has reported five cases of serious bacterial infections in patients receiving intravenous antibiotic treatment for chronic Lyme disease, including septic shock, osteomyelitis, Clostridium difficile colitis, and paraspinal abscess. [71, 72] The existence of PTLDS has been called into question as a result of a lack of direct evidence of persistent infection. [73, 74] Hassett and colleagues reported that rates of psychiatric comorbidity and other psychological factors (eg, depression, anxiety, tendency to catastrophize pain) were higher in patients with “chronic Lyme disease” (defined as symptomatic patients with previously treated Lyme disease and patients whose symptoms were attributed to Lyme disease without good evidence for Lyme disease) than in other patients commonly seen in Lyme disease referral centers, and that those factors were related to poor functional outcomes. [75] Previous Next: Co-infection Co-infection with other tick-borne illnesses occur in roughly 10-15% of patients with Lyme disease and should be considered in patients with a poor response to conventional antimicrobial therapy or atypical clinical presentations (eg, high fever, leukopenia).

Co-transmitted infective organisms can include the following: Babesia microti, the primary cause of babesiosis Anaplasma phagocytophilum and Ehrlichia chaffeensis, which cause ehrlichiosis Flavivirus, the cause of tick-borne encephalitis Powassan or tick-borne encephalitis-like virus Previous Next: Prevention Prevention of tick-borne disease can be divided into personal and environmental measures.

Clinicians in endemic areas should provide patient education on personal measures for tick avoidance and management of tick exposure (see Patient Education).

Environmental prevention involves clearing underbrush and spraying acaricides in the spring around property sites.

These measures prevent both mice and ticks from encroaching on properties.

Studies involving the treatment of wild deer and mice have not been conclusive in reducing tick-borne diseases in humans.

Tick removal In patients in endemic areas who present with an attached tick, prompt removal can reduce the likelihood of contracting Lyme disease.

Transmission of infection is unlikely if the duration of tick attachment is less than 24 hours, but is very likely for ticks attached for longer than 72 hours.

Removal of a tick is ideally accomplished using fine-tipped forceps and wearing gloves.

Grasp the tick as close to the skin surface as possible, including the mouth parts, and pull upward with steady, even traction. (See the image below).

Do not twist or jerk the tick because this may cause the mouth parts to break off and remain in the skin; however, note that the mouth parts themselves are not infectious.

To remove a tick, use fine-tipped forceps and wear gloves.

Grasp the tick as close to the skin surface as possible, including the mouth parts, and pull upward with steady, even traction.

Do not twist or jerk the tick because this may cause the mouth parts to break off and remain in the skin; however, note that the mouth parts themselves are not infectious.

When removing, wear gloves to avoid possible infection.

View Media Gallery The use of forceps and gloves represents an optimal method of removal.

However, removal of the tick should not be delayed in order to obtain forceps and it is extremely unlikely that one can become infected by touching an engorged tick even if the tick is carrying Borrelia (which most of them are not, even in endemic areas).

Using lidocaine (subcutaneously or topically) may actually irritate the tick and prompt it to regurgitate its stomach contents.

Once the tick is removed, wash the bite area with soap and water or with an antiseptic to destroy any contaminating microorganisms.

Antibiotic prophylaxis Routine prophylaxis after a recognized tick bite is not recommended.

A guideline from the Infectious Disease Society of America recommends prophylactic antibiotic therapy for adults and children older than 8 years, using a single 200-mg dose of doxycycline (in children, 4 mg/kg up to a maximum dose of 200 mg) only if all of the following criteria are met [44] : The attached tick can be reliably recognized as a nymphal or adult Ixodes scapularis The tick has been attached for at least 36 hours, as determined by the degree of engorgement of the tick or certainty about the time of exposure to the tick Prophylaxis can be started within 72 hours of the time the tick was removed The local rate of infection of these ticks with Borrelia burgdorferi is at least 20% (unlikely outside of select areas in New England, the mid-Atlantic States, Minnesota, and Wisconsin) Doxycycline treatment is not contraindicated The species of tick is important because non-Ixodes ticks (and other insects), although they can contain the organism, are highly unlikely to cause disease.

The one clinically relevant exception may be bites by Amblyomma americanum in the central and southern midwestern United States, but few data exist on treating these tick bites prophylactically.

Doxycycline is relatively contraindicated in children younger than 8 years and in pregnant women.

Amoxicillin should not be substituted for doxycycline in persons for whom doxycycline prophylaxis is contraindicated, for the following reasons [76] : The absence of data on an effective short-course regimen for prophylaxis The likely need for a multiday regimen (and its associated adverse effects) The excellent efficacy of antibiotic treatment of Lyme disease if infection develops The extremely low risk that a person with a recognized bite will develop a serious complication of Lyme disease Even in areas where about 15-30% of ticks are infected with Borrelia burgdorferi, tick bites rarely result in Lyme disease.

Nevertheless, appropriate prophylaxis can significantly reduce that risk. [77] In a 2010 meta-analysis of trials in which patients with no clinical evidence of Lyme disease were randomly allocated to treatment or placebo groups within 72 hours after an Ixodes tick bite, the risk of Lyme disease in the control group was 2.

2% in the antibiotic-treated group. [78] Vaccination In December 1998, the FDA approved a vaccine (LYMErix Lyme disease vaccine [recombinant OspA]) directed against the outer surface protein A of B burgdorferi, after trials indicated efficacy.

In 2002, this vaccine was pulled off the market by the manufacturer because of poor demand. [79] Patients who received this vaccine are no longer protected against Lyme disease, because the vaccine’s effect was not long lasting.

Previous Next: Consultations In most patients with erythema migrans, no consultation is needed.

However, consultation with appropriate specialists (eg, rheumatologist, neurologist, cardiologist) may be indicated to ensure that other diseases are not the cause of unusual presenting symptoms in a patient with a positive Lyme titer.

Difficulties can arise in choosing the appropriate antibiotic treatment regimen, especially in children or potentially pregnant women.

An infectious disease consult is helpful in these situations. [80] Consultation with a rheumatologist may be helpful in the evaluation and treatment of patients with persistent arthritis despite conventional antimicrobial therapy and those who present with fibromyalgia occurring after treated Lyme disease.

Consultation with a neurologist is recommended in patients with persistent or chronic manifestations of Lyme disease, such as chronic fatigue syndrome.

In addition, in patients with acrodermatitis chronica atrophicans, neurologic disease is not uncommon and its presence alters the treatment plan; therefore, consultation is appropriate if neurologic signs or symptoms are present.

Consultation with a cardiologist may be indicated in patients with coexisting cardiac disease.

Previous Next: Long-Term Monitoring Follow-up monitoring until all signs and symptoms have completely resolved is indicated for all patients with Lyme disease.

In early Lyme disease, lack of prompt resolution should lead the physician to question the original diagnosis.

Later manifestations tend to resolve much more slowly than early ones.

Follow-up monitoring by the primary care physician or an appropriate specialist is indicated for patients with extracutaneous manifestations.

Patients with Lyme disease whose specific symptoms of Lyme disease (not symptoms of fibromyalgia or chronic fatigue) do not improve may need retreatment.

Patients who plateau in their improvement may also need retreatment.

Given the cost and convenience, a 30-day course of oral antibiotic therapy may be indicated before repeating intravenous therapy.

Repeat serologic testing is not indicated, because IgM titers may persist with treatment, and changes in IgG titers do not reflect the efficacy of treatment.

That is, the standard serologic tests, with initial positive results, may remain positive for long periods and should not be used as a test of cure.

Data suggest that C6-peptide may return negative results after treatment with antibiotics.

Follow-up may be of particular importance in patients with the chronic sequelae of the controversial post-Lyme disease syndrome.

These patients’ condition may be refractory to conventional therapies.It is caused by a spirochete (bacteria) species of the Borrelia burgdorferi group.

When infection leads to disease in dogs, the dominant clinical feature is recurrent lameness due to inflammation of the joints.

There may also be a lack of appetite and depression.

More serious complications include damage to the kidneys, and rarely, heart or nervous system disease.   Kidney disease appears to be more prevalent in Labrador retrievers, golden retrievers, Shetland sheepdogs, and Bernese Mountain dogs.

Experimentally, young dogs appear to be more susceptible to Lyme disease than older dogs.

Transmission of the disease has been reported in dogs throughout the United States and Europe, but is most prevalent in the upper Midwestern states, the Atlantic seaboard, and the Pacific coastal states.   Symptoms of Lyme Disease in Dogs   Many dogs who develop Lyme disease have recurrent lameness due to inflammation of the joints.

Sometimes the lameness lasts for only three to four days but recurs days to weeks later, either in the same leg or in other legs.

This is known as “shifting-leg lameness.” One or more joints may be swollen, warm, and painful.   Some dogs may also develop kidney problems.

Lyme disease sometimes leads to glomerulonephritis – inflammation and accompanying dysfunction of the kidney's glomeruli (essentially, a blood filter).

Eventually, kidney failure may set in as the dog begins to exhibit such signs as vomiting, diarrhea, lack of appetite, weight loss, increased urination and thirst, and abnormal fluid buildups.   Other symptoms associated with Lyme disease in dogs include:   Stiff walk with an arched back Sensitivity to touch Difficulty breathing Fever, lack of appetite, and depression Superficial lymph nodes close to the site of the infecting tick bite may be swollen Heart abnormalities are reported, but rare Nervous system complications (rare)   Read more about the symptoms of Lyme disease in dogs: 5 Signs of Lyme Disease in Dogs   Causes of Lyme Disease in Dogs   Borrelia burgdorferi, which is the bacteria responsible for Lyme disease in dogs, is transmitted by slow-feeding, hard-shelled deer ticks (Ixodes spp.).

Infection typically occurs after the Borrelia-carrying tick has been attached to the dog for at 2-3 days.   Diagnosing Lyme Disease in Dogs   You will need to give a thorough history of your dog's health, including a background of symptoms and possible incidents that might have precipitated them.

The history you provide may give your veterinarian clues as to which organs are being affected.

Your veterinarian may run some combination of blood chemistry tests, a complete blood cell count, a urinalysis, fecal examinations, X-rays, and tests specific to diagnosing Lyme disease (e.g., serology).

Fluid from the affected joints may also be drawn for analysis.    There are many causes for arthritis, and your veterinarian will focus on differentiating arthritis initiated by Lyme disease from other inflammatory arthritic disorders, such as trauma, degenerative joint disease, or osteochondrosis dissecans (a condition found in large, fast growing breeds of puppies).

Immune-mediated diseases will also be considered as a possible cause of the symptoms.

An X-ray of the painful joints will allow your doctor to examine the bones for abnormalities.   Treating Dog Lyme Disease   If the diagnosis is Lyme disease, your dog will be treated as an outpatient unless their condition is unstable (e.g., severe kidney disease).

Doxycycline is the most common antibiotic that is prescribed for Lyme disease, but others are also available and effective.  The recommended treatment length is usually four weeks, but longer courses may be necessary in some cases.

Your veterinarian may also prescribe an anti-inflammatory (pain reliever) if your dog is especially uncomfortable.   Unfortunately, antibiotic treatment does not always completely eliminate infection with Borrelia burgdorferi bacteria.

Symptoms may resolve but then return at a later date, and the development of kidney disease in the future is always a worry.   Living and Management   Improvement in sudden (acute) inflammation of the joints caused by Borrelia should be seen within three to five days of antibiotic treatment.

If there is no improvement within three to five days, your veterinarian will want to reevaluate your dog.   Preventing Lyme Disease in Dogs   If possible, avoid allowing your dog to roam in tick-infested environments where Lyme disease is common.

Check your dog’s coat and skin daily and remove ticks by hand.

Your veterinarian can also recommend a variety of sprays, collars, and spot-on topical products that kill and repel ticks.

Such products should be used under a veterinarian's supervision and according to the label's directions.

Lyme vaccines are available, but their use is somewhat controversial.

Talk to your veterinarian to see if Lyme vaccination is right for your dog.Find the nearest location to: What can we dig up for you?

Lyme disease is caused by a spirochete, Borrelia burgdorferi.

A spirochete is a type of bacterium. "Lyme disease is transmitted to dogs through the bite of a tick." Lyme disease is transmitted to dogs through the bite of a tick.

Once in the blood stream, the Lyme disease organism is carried to many parts of the body and is likely to localize in joints.

It was first thought that only a few types of ticks could transmit this disease, but now it appears that several common species may be involved.

The most common type of tick to carry Lyme disease is the Deer Tick.

Yes, but people do not get it directly from dogs.

They get it from being bitten by the same ticks that transmit it to dogs.

Therefore, preventing exposure to ticks is important for you and your dog.

Many people with Lyme disease develop a characteristic "bull's-eye" rash at the site of the bite within three to thirty days.

If this occurs, the disease can be easily diagnosed at an early stage.

Symptoms of Lyme disease are more difficult to detect in animals than in people.

The characteristic rash does not develop in dogs or cats.

Because the other symptoms of the disease may be delayed or go unrecognized and because the symptoms are similar to those of many other diseases, Lyme disease in animals is often not considered until other diseases have been eliminated. "Affected dogs have been described as if they were 'walking on eggshells'." Many dogs affected with Lyme disease are taken to a veterinarian because they seem to be experiencing generalized pain and have stopped eating.

Affected dogs have been described as if they were "walking on eggshells."  Often these pets have high fevers.

This painful lameness often appears suddenly and may shift from one leg to another.

If untreated, it may eventually disappear, only to recur weeks or months later.

Some pets are infected with the Lyme disease organism for over a year before they finally show symptoms.

By this time, the disease may be widespread throughout the body.

Dogs with lameness, swollen joints, and fever are suspected of having Lyme disease.

However, other diseases may also cause these symptoms.

There are two blood tests that may be used for confirmation.

This test does not detect the actual spirochete in the blood but does detect the presence of antibodies created by exposure to the organism.

A test can be falsely negative if the dog is infected but has not yet formed antibodies, or if it never forms enough antibodies to cause a positive reaction.

This may occur in animals with suppressed immune systems.

Some dogs that have been infected for long periods of time may no longer have enough antibodies present to be detected by the test.

Therefore, a positive test is meaningful, but a negative is not.

The second test is the polymerase chain reaction (PCR) test, a DNA test that is very specific and sensitive.

However, not all dogs have the spirochete in their blood cells.

If a blood sample is tested, a false negative may occur.

The best sample for PCR testing is the fluid from an affected joint.

How is Lyme disease treated? "Because the Lyme spirochete is a bacterium, it can be controlled by antibiotics." Because the Lyme spirochete is a bacterium, it can be controlled by antibiotics.

However, a lengthy course of treatment is necessary to completely eradicate the organism.

The initial antibiotic selected to treat an infected pet may not be effective against the disease, especially if the infection is long-standing.

In this situation, changing to another antibiotic is often effective.

Occasionally, the initial infection will recur, or the pet will become re-infected by being bitten by another infected tick.

How can I prevent my dog from getting Lyme disease?

The key to prevention is keeping your dog from being exposed to ticks.

Ticks are found in grassy, wooded, and sandy areas.

They find their way onto an animal by climbing to the top of a leaf, blade of grass, or short trees, especially cedar trees.

Here they wait until their sensors detect an approaching animal on which to crawl or drop.

Keeping animals from thick underbrush reduces their exposure to ticks.

Dogs should be kept on trails when walked near wooded or tall grass areas.

Vaccination against Lyme disease is recommended for pets that live in endemic areas or that travel to areas where Lyme disease is prevalent.

Check your pet immediately after it has been in a tick-infected area.

The Deer Tick is a small tick and only about pinhead size in juvenile stage, but a little more obvious in adult phase and after feeding.

If you find a tick moving on your pet, the tick has not fed.

Remove the tick promptly and place it in rubbing alcohol or crush it between two solid surfaces.

If you find a tick attached to your pet, grasp the tick with fine tweezers or your finger nails near the dog's skin and firmly pull it straight out.

Make sure you protect your fingers from exposure by using a tissue or a disposable glove.

You may need another person to help restrain your dog.

Removing the tick quickly is important since the disease does not appear to be transmitted until the tick has fed for approximately twelve hours.

If you crush the tick, do not get the tick's contents, including blood, on your skin.

The spirochete that causes Lyme disease can pass through a wound or cut in your skin.

Is there a vaccine that will protect my dog from Lyme disease?

A safe and effective vaccine is available for protecting dogs against Lyme disease.

This vaccine is initially given twice, at two- to three-week intervals. "Annual revaccination is necessary to maintain immunity." Annual revaccination is necessary to maintain immunity.

Vaccination against Lyme disease will be determined by your pet's lifestyle and individual risk assessment.

Be sure to discuss any questions you may have regarding the type and frequency of vaccination with your veterinarian.

Free First Exam Our pet care experts can't wait to welcome you.  Fetch Your Coupon Find a Local VCA We're here for you and your pet in 43 states.Lyme disease, named for a town in Connecticut where it was first properly discovered in the mid-1970s, is easier to spot and more dangerous in humans than it is in dogs.

Lyme disease in dogs is far less common, but it can be a problem, particularly in areas with high tick concentrations.

In America, problem areas for Lyme disease include New England, the upper Midwest and the West Coast.

Let’s look at Lyme disease in dogs, how it spreads and how to best prevent it!

Lyme disease in dogs is associated with deer ticks, but ticks are only a delivery system for the bacteria that actually causes the disease.

The white-footed mouse carries a corkscrew-shaped bacterium, called Borellia burgdorferi.

In the larval and nymph stages of a deer tick’s life cycle, baby ticks ingest Borellia as they feed on infected mice.

The bacteria mature in a deer tick’s gut until the tick reaches adulthood.

The fully grown deer tick, seeking a more satisfying meal, is the most common transmitter of Borellia bacteria, which causes Lyme disease in dogs.

An infected adult tick needs time to pass Borellia into its canine host.

Typically, a tick must be attached to a dog for no less than 12 hours, and usually between 24 to 48 hours, before the bacteria makes its way through the tick’s saliva into a dog’s bloodstream.

From infection to the onset of symptoms, Lyme disease in dogs can take anywhere from two to five months to develop.

Symptoms of Lyme disease in dogs When they do show up, signs of Lyme disease in dogs may include a number of symptoms held in common with other diseases and disorders, so proper diagnosis is key.

The symptoms of Lyme disease in dogs include pain and swelling in the joints.

Seemingly out of nowhere, you may see a dog start to move gingerly; over the course of several days, this arthritic pain may shift from one leg to another.

Though the lameness may appear sudden, remember that Lyme disease in dogs takes several months to develop.

Other signs of Lyme disease in dogs include increased heat and sensitivity in the affected joints, fever, diminished appetite and depression.

In the United States, Lyme disease in dogs is uncommon outside of the Northeast, Midwest and West Coast, particularly the Pacific Northwest, so dogs with these symptoms elsewhere may have other problems altogether.

Plus, don’t ignore these Lyme disease symptoms in humans >> Treating Lyme disease in dogs Fortunately, Lyme disease in dogs tends to resolve much more easily, and with far less deleterious effects, than in humans.

In many cases, the Borellia burgdorferi bacterium that causes Lyme disease in dogs presents a self-limiting problem.

This means that the symptoms noted above may only be temporary as the bacterial infection runs its course.

Treatment depends on an accurate diagnosis, which can be provided by a veterinarian.

Antibiotics are extremely effective, when recommended, in resolving cases of Lyme disease in dogs.

Vaccination against the Borellia burgdorferi bacteria is also safe and available, though it is normally only recommended in those regions where the disease is most prevalent, and even there, vaccination must be administered annually, if the veterinarian determines it to be prudent.

Preventing Lyme disease in dogs Lyme disease in dogs is much less common than it is in humans, so prevention is the best thing you can do, both for yourself and for your dogs.

How do we go about preventing those little corkscrew bacteria from making homes in ourselves and our dogs?

If you live in one of those regions where Lyme disease is endemic, or where ticks are common, make sure to check yourself and your dog on a regular basis.

Deer ticks are active during all times of year, needing only temperatures above freezing to be out in search of a blood meal.

From spring to fall, when ticks are out in force, make certain you are using all appropriate tick prevention techniques, from medicated collars to regular baths, to keep your dog tick free.

Finding a tick on your dog, refrain from touching it with your own flesh, especially if you happen to have any open wounds or sores.

Use tweezers to remove the entire tick, and, if they’re available, do so while wearing gloves.

Guinea fowl have a taste for tick meat, and find them delicious.

Of course, lovely birds though they are, and interesting to look at, keeping a brood of guinea fowl on hand to prevent Lyme disease in dogs is completely impractical.

Careful grooming, particularly in high-tick areas, and especially before you bring a dog indoors during warmer months, is both much simpler and more cost effective than taking up guinea fowl husbandry.

Neither you nor the members of your household can contract Lyme disease from an infected dog; only from the bite of a tick.

Accordingly, I never walk my dog in the forest trails around our home unless I’m kitted out in full battle regalia.

Long-sleeved sweaters and socks hiked up to my knees draw curious responses from people during the summer, but I am ever on my guard against the iniquitous deeds of parasitic arthropods.

Tell us: Has your dog ever dealt with Lyme disease?

Did it prove to be self-limiting and go away on its own?

Has your dog been treated with antibiotics, or do you vaccinate your dog annually?

Share your experiences with Lyme disease in dogs, or just let us know how much you loathe ticks in the comments!

About the author: Melvin Peña trained as a scholar and teacher of 18th-century British literature before turning his research and writing skills to puppies and kittens.

He enjoys making art, hiking, and concert-going, as well as dazzling crowds with operatic karaoke performances.

He has a one-year-old female Bluetick Coonhound mix named Idris, and his online life is conveniently encapsulated here.

It’s Flea and Tick Week sponsored by Andis on Dogster.com.

Stay tuned for more tips on how to keep your dog and household safe from fleas and ticks!Lyme disease Definition Lyme disease is an inflammatory disease transmitted through the bite of a deer tick carrying the spiral-shaped bacterium Borrelia burgdorferi .

Symptoms can include skin rash, joint inflammation, fever , headache , fatigue, and muscle pain .

Description Lyme disease is an inflammatory, systemic disease, meaning that it affects multiple body systems.

Although clinical signs of Lyme disease have been reported for more than 100 years, the disease was not recognized as a distinct illness until 1975, when a cluster of unusual arthritis cases in Lyme, Connecticut, led physicians to discover that town residents living near heavily wooded areas were most affected by arthritis and other symptoms.

Tick bites were then linked to the cause of the arthritis cases.

Borrelia burgdorferi , the spiral-shaped bacterium called a spirochete, that causes Lyme disease, was not discovered until 1981 by Willy Burgdorfer.

Although Lyme disease is easily treated, it is not easily diagnosed, since symptoms are often attributed to other conditions.

If not treated early and properly with antibiotics , Lyme disease can have long-term and disabling effects.

In its early stages, Lyme disease affects the skin and produces flu-like symptoms; the disease spreads to the joints and nervous system in its later stages.

Transmission Lyme disease is a vector-borne disease, meaning that it is transmitted from one host to another by a carrier—called a vector—that transmits but does not become infected with the disease.

In the United States, the deer tick in the genus Ixodes is the vector for Borrelia burgdorferi and Lyme disease transmission.

Lyme disease is transmitted when a tick carrying the Borrelia burgdorferi bacterium bites a human to feed on blood.

The bacterium is transferred from the intestines of the tick through the mouthparts and into the bloodstream while the tick is feeding.

Ticks are most likely to transmit Borrelia burgdorferi after remaining attached and feeding for two or more days.

In most areas, ticks are most active from April to October, but in milder climates, ticks may bite year-round.

During their two-year life cycle and three life stages (larva, nymph, and adult), deer ticks feed on a number of mammals that may carry the Borrelia burgdorferi bacterium in their blood, but the white-footed mouse is the most common source of infection.

In the summer, the larval ticks hatch from eggs laid in the ground and feed by attaching themselves to small animals and birds.

At this stage, they are not a problem for humans.

It is the next stage—the nymph—that causes most cases of Lyme disease.

Nymphs are very active from spring through early summer, at the height of outdoor activity for most people.

Because they are still quite small (less than 2 mm), they are difficult to spot, giving them ample opportunity to transmit Borrelia burgdorferi while feeding.

Although far more adult ticks than nymphs carry Borrelia burgdorferi , the adult ticks are much larger, more easily noticed, and more likely to be removed before they have fed long enough to transmit Borrelia burgdorferi .

Neither Borrelia burgdorferi nor Lyme disease can be transmitted directly from one person to another or from pets to humans.

Demographics Lyme disease is the most common vector-borne disease in the United States.

In 2002 alone, 23,763 cases were reported to the Centers for Disease Control and Prevention (CDC), a 40-percent increase over the number reported in 2001.

According to the CDC, the actual number of Lyme cases may exceed 200,000 due to underreporting and limitations in disease surveillance methods.

CDC statistics indicate that the largest proportion of Lyme disease cases occurs in children aged five to 14 years, and more than 50 percent of Lyme disease cases involve children under age 12.

Although cases of Lyme disease have been reported in 49 of the 50 states, more than 95 percent of reported cases occur in just twelve states: Connecticut, Rhode Island, New York, Pennsylvania, Delaware, New Jersey, Maryland, Maine, New Hampshire, Minnesota, Massachusetts, and Wisconsin.

In the United States, the Great Lakes region and the Pacific Northwest also have a higher incidence of Lyme disease.

The disease is also found in Scandinavia, continental Europe, the countries of the former Soviet Union, Japan, China, and Australia.

Causes and symptoms Lyme disease is caused by the Borrelia burgdorferi bacterium.

Once Borrelia burgdorferi gains entry to the body through a tick bite, it can move through the bloodstream quickly.

Only 12 hours after entering the bloodstream, Borrelia burgdorferi can be found in cerebrospinal fluid (which means it can affect the nervous system).

Treating Lyme disease early and thoroughly is important because Lyme disease can hide for long periods within the body in a clinically latent state.

That ability explains why symptoms can recur in cycles and can flare up after months, years, or decades.

Lyme disease is usually described in terms of length of infection (time since the person was bitten by a tick infected with Lyme disease) and whether Borrelia burgdorferi is localized or disseminated (spread through the body by fluids and cells carrying Borrelia burgdorferi ).

Furthermore, when and how symptoms of Lyme disease appear can vary widely from patient to patient.

People who experience recurrent bouts of symptoms over time are said to have chronic Lyme disease.

Early localized Lyme disease The most recognizable indicator of Lyme disease is a rash around the site of the tick bite.

Often, the tick exposure has not been recognized.

The rash—erythema migrans (EM)—generally develops within three to 30 days and usually begins as a round, red patch that expands outward from the tick bite.

About 80 percent of patients with Lyme disease develop EM.

Clearing may take place from the center out, leaving a bull's-eye effect; in some cases, the center gets redder instead of clearing.

On children with dark skin, the rash may look like a bruise.

Of those who develop Lyme disease, about 50 percent notice flu-like symptoms, including fatigue, headache, chills and fever, muscle and joint pain, and lymph node swelling.

Many children with Lyme disease can develop neurologic symptoms within a few weeks following a tick bite.

Neurologic symptoms in children with early Lyme disease include dizziness , stiff neck, unilateral or bilateral facial palsy, inflammation of brain membranes (a form of meningitis ), knee and/or wrist arthralgia, tingling/numbness, sleep disturbance, and difficulties with memory, concentration, and learning.

Late disseminated disease and chronic Lyme disease Weeks, months, or even years after an untreated tick bite, symptoms can appear in several forms, including the following: fatigue, forgetfulness, confusion, mood swings, irritability, numbness neurologic problems, such as pain (unexplained and not triggered by an injury), Bell's palsy (facial paralysis, usually one-sided but possibly on both sides), a mimicking of the inflammation of brain membranes known as meningitis fever, and severe headache arthritis (short episodes of pain and swelling in joints) and other musculoskeletal complaints (Arthritis eventually develops in about 60 percent of patients with untreated Lyme disease.) In adults, less common effects of Lyme disease are heart abnormalities (such as irregular rhythm or cardiac block) and eye abnormalities (such as swelling of the cornea, tissue, or eye muscles and nerves).

However, children with Lyme disease frequently complain of chest pain and have papilledema (swelling of the optic nerve).

In addition, children with late-stage Lyme disease are more likely than adults to have fever and joint swelling and pain.

When to call the doctor A child should see a doctor if an attached tick is found that is engorged with blood (usually indicating attachment for more than six hours).

Parents should remove the tick gently with tweezers.

Medical laboratories can test the tick for Borrelia burgdorferi if the tick is alive; parents should place the tick in a tightly sealed plastic bag or small bottle with a moistened cotton ball and take it to the doctor.

Most doctors will not prescribe antibiotics immediately following a tick bite but will ask parents to monitor their child for symptoms of early Lyme disease.

Less than 50 percent of children realize that they have been bitten by a tick.

And, according to pediatricians specializing in Lyme disease, many children already have chronic Lyme disease when they are first diagnosed because children have difficulties effectively verbalizing their symptoms and their symptoms may be misdiagnosed.

Any child that develops a round, bull'seye skin rash, joint pain, flu-like symptoms, and/or neurologic symptoms as described above should see a doctor.

Because many children do not develop a rash or the rash may not be readily visible (e.g., on the scalp under hair), children living in or visiting areas with a high incidence of Lyme disease and those participating in frequent outdoor activities during active tick months who develop joint pain and neurologic symptoms should see a doctor.

Diagnosis In children, symptoms of Lyme disease can mimic those of other common childhood conditions, and children may not realize they have been bitten by a tick; therefore, diagnosis of Lyme disease in children can be difficult.

Therefore, diagnosis of Lyme disease relies on information the patient and parents provide and the doctor's clinical judgment, particularly through elimination of other possible causes of the symptoms.

Differential diagnosis (distinguishing Lyme disease from other diseases) is based on clinical evaluation with laboratory tests used for clarification when necessary.

A two-test approach is common to confirm the results.

Because of the potential for misleading results (false-positive and false-negative), laboratory tests alone cannot establish the diagnosis.

In February 1999 the Food and Drug Administration (FDA) approved a new blood test for Lyme disease called PreVue.

The test, which searches for antigens (substances that stimulate the production of antibodies) produced by Borrelia burgdorferi , gives results within one hour in the doctor's office.

A positive result from the PreVue test is confirmed by a second blood test known as the Western blot, which must be done in a laboratory.

Doctors generally know which disease-causing organisms are common in their geographic area.

The most helpful piece of information is whether a tick bite or rash was noticed and whether it happened locally or while traveling.

Doctors may not consider Lyme disease if it is rare locally but will take it into account if a patient mentions vacationing in an area where the disease is commonly found.

Treatment The treatment for Lyme disease is antibiotic therapy.

If a child has strong indications of Lyme disease (symptoms and medical history), the doctor will probably begin treatment on the presumption of this disease.

The American College of Physicians recommends treatment for a patient with a rash resembling EM or who has arthritis, a history of an EM-type rash, and a previous tick bite.

The benefits of early treatment must be weighed against the risks of overtreatment.

The longer a patient is ill with Lyme disease before treatment, the longer the course of therapy must be, and the more aggressive the The first sign of lyme disease is usually an itchy bull's-eye rash around the site of the tick bite. (© 1993 Science Photo Library.

The development of opportunistic organisms may produce other symptoms.

For example, after long-term antibiotic therapy, patients can become more susceptible to yeast infections.

Treatment may also be associated with adverse drug reactions.

For most children, oral antibiotics (amoxicillin) are prescribed for 21 days.

When symptoms indicate nervous system involvement or a severe episode of Lyme disease, an intravenous antibiotic (ceftriaxone, cefotaxime, ampicillin) may be given for four to six weeks or longer.

Some physicians consider intravenous ceftriaxone the best therapy for any late manifestation of disease, but treatments for late Lyme disease are still controversial as of 2004.

Corticosteroids (oral) may be prescribed if eye abnormalities occur, but they should not be used without first consulting an eye doctor.

Nonsteroidal anti-inflammatory medications (ibuprofen) may be prescribed for joint pain and inflammation.

The doctor may have to adjust the treatment regimen or change medications based on the patient's response.

Treatment can be difficult because Borrelia burgdorferi comes in several strains (some may react to different antibiotics than others) and may even have the ability to switch forms during the course of infection.

Also, Borrelia burgdorferi can shut itself up in cell niches, allowing it to hide from antibiotics.

Finally, antibiotics can kill Borrelia burgdorferi only while it is active rather than dormant.

Alternative treatment Supportive therapies may minimize symptoms of Lyme disease or improve the immune response.

These include vitamin and nutritional supplements, mostly for chronic fatigue and increased susceptibility to infection.

For example, yogurt and Lactobacillus acidophilus preparations help fight yeast infections, which are common in patients on long-term antibiotic therapy.

In addition, botanical medicine and homeopathy can be considered to help bring the body's systems back to a state of health and well-being.

A Western herb, spilanthes ( Spilanthes spp.), may be effective in treating diseases such as Lyme disease that are caused by spirochetes (spiral-shaped bacteria).

Therapy using a low-current electrical field or magnetic pulses is also as of 2004 under research to treat bacterial infections.

It is important to note that no alternative treatments have been proven to cure Lyme disease.

Prognosis If aggressive antibiotic therapy is given early and the patient cooperates fully and sticks to the medication schedule, recovery should be complete.

Only a small percentage of Lyme disease patients fail to respond or relapse (have recurring episodes).

Most long-term effects of the disease result when diagnosis and treatment is delayed or missed.

Co-infection with other infectious organisms spread by ticks in the same areas as Borrelia burgdorferi (babesiosis and ehrlichiosis, for instance) may be responsible for treatment failures or more severe symptoms.

Most fatalities reported with Lyme disease involved patients coinfected with babesiosis.

Prevention Lyme disease can be prevented by taking the following measures to reduce exposure to tick bites: Avoid areas likely to be infested with ticks, especially during spring and summer, when tick nymphs are most likely to feed.

Areas most likely to be infested with ticks include moist and shady areas, wooded and brushy areas, overgrown grassy areas, and areas with a high rodent and deer population.

When outdoors, wear light-colored clothing, long-sleeved shirts, and long pants tucked into socks or boots.

Use insect repellents according to safety guidelines for children.

Perform a full-body "tick check" after outdoor activities and use tweezers to gently remove and dispose of ticks.

Do not try to remove the tick by using petroleum jelly, alcohol, or a lit match.

Place the tick in a closed container (for species identification later, should symptoms develop) or dispose of it by flushing or by placing the tick between scotch tape.

Check pets frequently for ticks, since ticks can migrate to children from pets.

Update on vaccination A vaccine for Lyme disease known as LYMErix was available from 1998 to 2002, when it was removed from the United States market.

The decision was influenced by reports that LYMErix may be responsible for neurologic complications in vaccinated patients.

As of late 2004, the best prevention strategy was minimizing risk of exposure to ticks and using personal protection precautions.

KEY TERMS Babesiosis —A infection transmitted by the bite of a tick and characterized by fever, headache, nausea, and muscle pain.

Bell's palsy —Facial paralysis or weakness with a sudden onset, caused by swelling or inflammation of the seventh cranial nerve, which controls the facial muscles.

Disseminated Lyme disease sometimes causes Bell's palsy.

Blood-brain barrier —An arrangement of cells within the blood vessels of the brain that prevents the passage of toxic substances, including infectious agents, from the blood and into the brain.

It also makes it difficult for certain medications to pass into brain tissue.

Cerebrospinal fluid —The clear, normally colorless fluid that fills the brain cavities (ventricles), the subarachnoid space around the brain, and the spinal cord and acts as a shock absorber.

Erythema migrans —A red skin rash that is one of the first signs of Lyme disease in about 75% of patients.

Spirochete —A type of bacterium with a long, slender, coiled shape.

Syphilis and Lyme disease are caused by spirochetes.

Vector —A carrier organism (such as a fly or mosquito) which serves to deliver a virus (or other agent of infection) to a host.

Also refers to a retrovirus that had been modified and is used to introduce specific genes into the genome of an organism.

Parental concerns Because most children do not realize they have been in tick-infested areas or been bitten by a tick and because deer ticks can be the size of a poppy seed or smaller, parents should be diligent about checking children for ticks, especially if the family lives in or visits an area with a high incidence of Lyme disease or an area near tick habitats.

Also, because Lyme disease is difficult to diagnose in children, parents who suspect Lyme disease in their children should inform their doctor about the possibility of the disease and be proactive in requesting further medical evaluation and treatment.

Resources BOOKS "Bacterial Diseases Caused by Spirochetes: Lyme Disease (Lyme Borreliosis)." Section 13, Chapter 157 in The Merck Manual of Diagnosis and Therapy.

Whitehouse Station, NJ: Merck Research Laboratories, 2002.

S. "Clinical Manifestations of Tick-Borne Infections in Children." Clinical and Diagnostic Laboratory Immunology 7 (July 2000): 523–27.

Krupp, et al. "Study and Treatment of Post Lyme Disease (STOP-LD): A Randomized Double Masked Clinical Trial." Neurology 60 (June 24, 2003): 1923–30.

Pontrelli. "Central Nervous System Lyme Disease." Seminars in Pediatric Infectious Diseases 14 (April 2003): 123–30.

S. "Current and Novel Therapies for Lyme Disease." Expert Opinion on Investigational Drugs 12 (June 2003): 1003–16.

P., et al. "Duration of Antibiotic Therapy for Early Lyme Disease: A Randomized, Double-Blind, Placebo-Controlled Trial." Annals of Internal Medicine 138 (May 6, 2003): 697–704.

ORGANIZATIONS Centers for Disease Control and Prevention.

National Institute of Allergy and Infectious Diseases (NIAID).

31 Center Drive, Room 7A50 MSC 2520, Bethesda, MD 20892.

WEB SITES "CDC Lyme Disease Home Page." Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases.

Available online at (accessed November 21, 2004). "Children's Corner." Lyme Disease Foundation.

Available online at (accessed November 21, 2004).

Edlow, Jonathan A. "Tick-Borne Diseases, Lyme." eMedicine , December 13, 2002.

Available online at (accessed November 21, 2004). "Neurological Manifestations of Lyme Disease in Children." LymeNet.

Available online at (accessed November 21, 2004).The arrival of springtime means Lyme disease is again resurfacing as a concern on the radar screens of people across the country.

So, if you go for a hike or take a walk through long grass, chances are that you'll check yourself for ticks afterward.  But our pets are constantly lounging and playing in conditions conducive to tick exposure, and how often do we thoroughly check them?

If the answer to that question isn't "every day," then experts say it's not enough.  A woman picking a tick off her dog's fur.

Kerkez/iStock "The most important thing is to stress prevention," explains Dr.

Richard Goldstein, chief medical officer at New York City's Animal Medical Center. "This is something that we want to prevent from happening the first time.

Once you're infected with these organisms, the chance is you might be infected for life.

So, you just have to really go through hair by hair.

If you do it every day, you're not going to get a big accumulation." Many nymphs feeding on a dog's ear. idmanjoe/iStock Occasionally, however, a dog can pick up hundreds of ticks on a single outing and the result can be disgusting, to say the least. "Sometimes if a dog walks through a place where ticks were molting into nymphs, you might find 200 tiny ticks on your dog," explains Dr.

Goldstein. "That's scary when that happens." But that's not the only scary reality of Lyme that pet owners should heed.

It's a year-round threat It's a common misconception that ticks die in the winter.

On the contrary, however, experts say they really just hunker down and wait for the first warm day.

So, that makes stopping your pet's tick control medicine during the winter months a risky thing to do. "There is some resistance, you know, to using medicines," explains Dr.

Joe Bloom of Harding Vet. "People don't like the expense.

People don't think that it's necessary in the colder months, which I think is really untrue.

If the temperature is 40 degrees or higher, even for just a few hours, ticks are wide awake and hungry, looking for a meal.

And we pick ticks off dogs in February all the time." Tick tweezers holding a small brown tick that has just been removed from the fur of a German shepherd dog.

Goldstein concurs. "This is not a seasonal disease," says the internationally recognized Lyme expert. "People used to say, 'Well, I'll deal with it in the summer, but I'm OK in the winter.' All you need is one warm day and the ticks are out.

And a lot of people got infected this February, as well as dogs, because we had a lot of warm days.

So, year-round diligence, year-round protection for dogs is essential." 2.

It's all across the country Likewise, the nonchalance of the past no longer applies to Lyme's regional characteristics either. "It used to be kind of a Northeast, Midwest phenomenon," explains Dr.

Goldstein, "but when you look at the latest maps, it's all over the country.

We see quite a bit of Lyme in California, in Florida, in the states that used to be relatively low in the upper West Coast.

So, yeah, it's virtually everywhere and I believe very strongly that every dog in this country should be tested annually." A map of canine Lyme Disease cases across the United States in 2017.

Companion Animal Parasite Council If you're wondering why its footprint is increasing, Dr.

Goldstein says to look no further than global warming. "That has to do with the warming climate," he tells CBS News. "It has to do with more deer that can transmit ticks from place to place, more mice.

Mice are the main reservoir for Lyme and the mice population has exploded over the last few years -- again, possibly because of mild winters.

Global warming is definitely manifesting itself in tick-borne disease in general and we see that in humans as well as in dogs.

We see diseases that exist today in areas that we just didn't have five and ten years ago." 3.

Most of the tick control products we use don't repel ticks There are many good options for flea and tick preventatives on the market.

There's the more old-school route of tick collars.

And there are — perhaps the most commonly used — monthly topical and oral options.

If you're one of the countless pet owners who gives their dog a chewable medication or squirts a preventative oil on their skin, you might be surprised to learn that neither of those tick control tactics actually repel the little bloodsuckers from your dog's body.

A topical flea and tick preventative being applied to a dog.

Tatomm/iStock "Owners come to us and say, 'Well, you know, we're using this flea and stuff, but we still see ticks on our dog,'" recalls Bloom, who practices veterinary medicine in a heavily wooded section of New Jersey. "Most of these flea and tick products will not actually repel the tick, will not keep the tick from walking onto your dog, and will not keep the tick from biting your dog.

What they'll do is they'll kill the tick after the tick has bitten." And it turns out, that's perfectly fine.

MeePoohyaphoto/iStock "If a tick bites your dog, it can transmit the bacteria, but only if it stays attached," Bloom elaborates. "If the tick is killed with less than 24 hours attachment to your dog, it won't transmit disease." If you're concerned about ticks hitching a ride into your house, though, there are some products that do physically repel ticks — a tick collar, for example.

But Goldstein argues that's not always in your family's best interest. "If you're thinking about a backyard scenario and there's the kids playing over there and the dogs playing over there," he says, motioning to opposite sides of his office, "do you really want to repel the ticks from the dog and have them climb on the kid? 'Cause we don't have any good real tick control products for children.

So maybe sucking up the ticks and killing them is not a bad thing when it's in your backyard." 4.

The symptoms aren't necessarily what you'd expect Without question, the most well-known symptom of Lyme disease in humans is the distinctive, circular bull's-eye rash that many patients develop between a week and a month after they're bitten. "That rash is great if someone recognizes that because if they get treatment at that point, they will probably not ever get a systemic infection and won't get sick," Goldstein explains. "We don't see that rash in dogs.

In dogs, the first clinical signs that we see are the pain, fever and lameness, which happen in people only months after the rash." iStock That means that by the time you spot symptoms of a tick bite on your dog, he or she will likely already be infected.

The other less-than-ideal aspect of canine Lyme symptoms is that they can easily masquerade as something else.

One of the most common symptoms dogs exhibit, for example, is joint pain.

So, if your pet is suddenly limping, you might simply assume that they've injured their paw or overworked their knee at the park.

In reality, however, they could be suffering from Lyme.

One helpful pro tip that can help you differentiate the two is to take note of whether or not your pet's joint pain shifts around.

If your dog is consistently lifting the same leg, he's likely just injured it.

If, on the other hand, he lifts his front right leg one day and his left hind leg the next, he may have contracted Lyme.

Where ticks hide You probably know that ticks are often picked up in the woods, but they don't have to be.

And there are telltale signs about your environment that can help you determine whether or not it poses a risk for tick-borne disease. "Ticks are very sensitive to dehydration," explains Goldstein. "You don't find them in, for instance, a well-cut lawn.

The joke is that there's no ticks on the green of a golf course, only in the rough.

And that's why the better golfer you are, the less chance you have of having Lyme disease." Ticks hiding between a dog's toes. showcake/iStock And with regard to where ticks will hide on dogs, experts say you'll usually find them in the more vascular areas where blood vessels are closest to the surface: the head, the neck, the ears.

They also crawl into harder-to-spot places in an attempt to hide from the dog. "Adult ticks are pretty big, and dogs will see them and try to bite them off if they can," Goldstein said. "So, in between the toes, in the ears, around the neck... places that are hidden even from the dog are where they typically will be found." 6.

The best way to remove a tick Upon discovering a live tick on your pet, your first instinct might be to pull it off immediately.

But rather than doing so with your bare hands, experts caution that patience is the safer route.

People removing ticks from a dog's ear with a pair of tweezers.

SpeedPhoto/iStock "The best way to take off every tick is with a sharpened tweezers and to kind of grab them as far down by the head as you can and pull them off," explains Goldstein. "People ideally should wear gloves when they're doing it, if they can, or just be careful.

Theoretically, if you have a cut on your finger and you squish a tick and get the blood from the tick, you could get infected with something.

Vets don't always treat Lyme disease in dogs It may seem counterintuitive, but a Lyme diagnosis for your pet doesn't always mean that the vet is going to treat your pet with antibiotics. "When we find a dog that's positive on a SNAP test for Lyme disease, then we have a conversation with the owners about whether to treat that dog or not," explains Bloom, who says he talks about Lyme with pet owners in his area three to five times a day. "You know, it's unfortunately a very complicated subject and we don't have a great understanding of it.

There are not enough studies that have been done to really explain it for us.

But in general, if a dog tests positive and doesn't show any clinical signs of Lyme disease — which would be specifically fever, lethargy, inappetence, and stiffness in joints that can change from day to day, moving from one joint to another — we typically leave them alone." 8.

Lyme affects some breeds worse than others There are a couple of notable exceptions to that rule: Labradors and golden retrievers.

There is a deadly manifestation of Lyme disease in dogs, called Lyme nephritis.

It's a fatal side effect that causes the animal's kidney to fail, and researchers have a strong suspicion that labs and golden retrievers are predisposed.

And because of this, both vets we spoke to agreed that any dogs of these two breeds who test positive for Lyme should be treated with Doxycycline immediately.

In dogs, treatment acts fact If you've ever known anyone who's contracted Lyme disease, then you probably know that treatment can be a long and complicated process in humans.

Thankfully, in dogs, it's much simpler. "Generally, and this is I think a big difference between dogs and people, within a couple of days of starting treatment with Doxycycline, they usually go into remission," Bloom tells CBS News. "And pretty much by the second day of Doxycycline, they feel so much better.

They start to eat again and they get better." 10.

How to protect your property and your pets On this last topic, Bloom commented that the majority of flea and tick control medicines on the market work fairly well.

He, however, cautioned against using more than one of them in tandem. "In my opinion, it would be overly cautious to use more than one," he says. "In other words, I wouldn't use both a collar and a topical prevention, or an oral prevention and a topical.

I think that's kind of too much poison for the dog." You can, however, combine one of the topical or oral preventatives with the Lyme vaccine.

So there is a way you can further protect your pet from contracting the disease if you live in an area where deer are prevalent.  A pit bull terrier in a field of long grass and flowers, where ticks could potentially be lurking.

Kymberlee Andersen/iStock If you're looking for an additional way to protect your yard, Bloom recommends having the perimeter sprayed by a pest control company.  Goldstein also recommended treating the perimeter of your property, but his recommendation came in the form of a physical barrier, rather than one of pesticides.  "If you're up against woods in your yard, a barrier of wood chips of pebbles will prevent at least the ticks from going across," explains Goldstein. "They can be carried across it by an animal, but at least they won't cross a barrier like that.Erika de Papp, DVM, DACVIM www.angell.org/internalmedicine internalmedicine@angell.org   Lyme disease is a very common infectious disease in the northeast United States.

It is also a very controversial topic amongst veterinarians because most dogs that test positive are not clinically ill.

This makes it difficult to determine which dogs should be treated.

Lyme disease also affects humans, so it is a topic of interest to everyone.

The purpose of this article is to answer some commonly asked questions about Lyme disease and clear up some common misconceptions.

Lyme disease is caused by the spirochete bacteria Borrelia burgdorferi.

The disease is transmitted to humans and dogs by the nymph and adult stages of the black-legged tick, Ixodes scapularis.

In New England, 50-75% of dogs tested may be positive for Lyme disease.

If my dog tests positive, does this necessitate treatment?

The answer to this will vary from dog to dog, and remains a point of controversy.

Only about 10% of positive dogs will ever develop clinical illness from infection with the Lyme organism, so many veterinarians argue that treatment is not necessary for seemingly healthy dogs.

Today we are fortunate to have two Lyme tests that assist us in determining if the infection is active / recent.

If your dog tests positive on a screening test, you should discuss additional testing with your veterinarian to determine if treatment is warranted.

In endemic areas (including Massachusetts), annual screening tests for Lyme disease are recommended.

If your dog does develop clinical illness from Lyme disease, the most common signs are lameness, fever, lethargy, and enlarged lymph nodes.

Clinical illness is expected 2-5 months after infection.

The majority of dogs respond very well to antibiotic treatment with Doxycycline or Amoxicillin.

Black-leggged ticks are small, so if I find a large tick on my dog, he/she can’t get Lyme disease, correct?

The larval and nymphal stages of all ticks are small, but an engorged adult tick can be quite large, so a lab would need to identify the tick to be sure your dog has not been bitten by a black-legged tick.

If I find a tick on my dog, should I go to the vet If you are comfortable removing the tick, you do not need to see your vet.

The best way to remove a tick is to use tweezers to grab the tick as close to the skin as possible.

The tick should then be removed by pulling straight out.

Do not twist or crush the tick as you are removing it.

Wash your hands after removing the tick to limit possible exposure to yourself.

How long does the tick need to be attached to transmit infection?

For Lyme disease to be contracted, the tick must be attached to your dog for at least 48 hours.

Therefore, the best means of avoiding Lyme disease is to remove ticks as soon as they are found.

Daily inspections of your dog are recommended, especially if they have been in wooded areas.

In addition to “tick checks,” we also strongly recommend topical parasiticides such as Frontline or Advantix (dogs only).

There are several other tick products available, so please discuss the appropriate choice with your veterinarian.

Be sure to avoid bathing or swimming for 24 hours after application of these topical products.

Follow the application guidelines carefully for best efficacy.

Once a frost occurs, I don’t have to worry about ticks anymore until the following spring, correct?

Adult ticks are active whenever the weather approaches or exceeds freezing.

If there is snow cover, there won’t be much if any tick activity, but if we have several warm winter days in a row, the ticks may be active.

No, Lyme disease is not a zoonotic disease, meaning it cannot be directly transmitted from your dog to you.

However, if a tick crawls off your dog and bites you, you can become infected.

There are several canine vaccines available to prevent Lyme disease.

The need for this vaccine should be determined on a case by case basis following a discussion with your veterinarian.

We recommend that all dogs be tested for Lyme disease before considering a vaccine.

Some opponents of vaccination fear that if your dog is vaccinated and still contracts the disease, the symptoms will be worse.

However this is based on experience with the human vaccine (no longer on the market), and has not been proven in dogs.

For more information on Dr. de Papp or Angell’s Internal Medicine service, please visit www.angell.org/internalmedicine or call 617-522-7282 to schedule an appointment.Dr Jones shows you everything you need to know about Lyme Disease in dogs.

How it is transmitted, Signs that your dog may have it, How to treat it, along with his thoughts on vaccines and prevention.

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Happy Strummin by Audionautix is licensed under a Creative Commons Attribution license (...The disease can be challenging to diagnose because the acute presentation often resembles a flu-like illness and symptoms can be nonspecific.

Lyme disease symptoms can be distinguished from other illnesses, in that symptoms can change, wax and wane in severity or come and go over time. [1] Identifying Lyme disease in children and adolescents can be especially difficult for several reasons.

Young children have a limited medical history and no baseline for clinicians to compare symptoms with.

Their immune system is not yet fully developed, so they’re more prone to contracting common bacterial or viral infections, characterized by flu-like symptoms – making Lyme disease easy to miss.

Changes in cognition and behavior may be blamed on developmental stages.

And lastly, children may struggle with describing or recognizing their symptoms when the infection has disseminated.

One study estimates that 40% of early Lyme disease cases are not diagnosed and go on to develop late Lyme disease. [2] Bulls-eye rash The erythema migrans (EM) rash, or bull’s-eye rash, is the tell-tale sign of Lyme disease.

It is the only objective physical sign that, when present, should confirm the diagnosis of Lyme disease.

The rash usually begins at or near the site of the tick bite.

It usually appears within 7 to 14 days after the bite but can take up to 30 days to appear.

As the infection is disseminating, rashes can appear on different parts of the body and take different forms.

Tick bites on young children frequently occur in the neck and head region.

Rashes may be hidden beneath the hair on the scalp.

Take extra care to check these areas on your child. “Diagnosis of early Lyme disease is based on a physicians ability to recognize erythema migrans.” [3] A study by Johns Hopkins found that “among those with a rash, the diagnosis of erythema migrans was initially missed in 23% of patients.” [4] It is widely reported that 60% to 80% of Lyme disease patients will develop the EM rash.

But that figure is an overestimate and can give parents a false sense of security.

The percentage of patients who present with a rash is disputed and studies vary.

For instance, studies have found that fewer than 50% of patients report an EM rash.

A 2010 study conducted in Maine found that only 43% of the Lyme disease participants recalled the characteristic bull’s-eye rash.

Charles Ray Jones points out that in his clinical experience, only 7% of pediatric patients report seeing the EM rash, while secondary EM rashes appear in 3% to 5% of the cases.

Take away: Don’t rely on seeing a bulls-eye rash to suspect Lyme disease.

Blood tests Serological testing (blood tests) to identify antibodies to the Lyme bacteria can be used to help support a diagnosis.

But current tests have low sensitivity and are unreliable.

Patients must wait 4 to 6 weeks after the tick bite before being tested, since it takes several weeks for a person to develop enough antibodies to be detected in the blood.

The CDC recommends a two-tier process using two types of tests.

The ELISA (enzyme-linked immunosorbent assay) and the Western Blot.

Doctors typically order the ELISA and if positive, will order the Western Blot to confirm the diagnosis.

For a Lyme disease diagnosis to be made, BOTH tests must be positive.

This method has been hotly contested within the medical community, because it requires that BOTH tests are positive for a diagnosis to be made.

Yet, studies indicate that both tests have low sensitivity.

In fact, the ELISA has been found to miss between 35% and 50% of culture proven Lyme disease cases.Print en españolLa enfermedad de Lyme What Is Lyme Disease?

Lyme disease is the leading tick-borne disease in the United States.

It's caused by a type of bacteria found in animals like mice and deer.

Ixodes ticks (also called black-legged or deer ticks) that feed on these animals can then spread the bacteria to people through tick bites.

Immature ticks, or nymphs, are about the size of a poppy seed; adult ticks are about the size of a sesame seed.

It's important to know and watch for symptoms of Lyme disease because ticks are hard to find and it's easy to miss a tick bite.

In fact, many people who get Lyme disease don't remember being bitten.

The good news is that most tick bites don't lead to Lyme disease.

Lyme disease can affect different body systems, such as the nervous system, joints, skin, and heart.

Symptoms often happen in three stages (but not everyone has all three): A circular rash at the site of the tick bite often is the first sign of infection, usually within 1–2 weeks.

The rash sometimes has a "bull's-eye" appearance, with a central red spot surrounded by clear skin that is ringed by an expanding red rash.

It also can look like an expanding ring of solid redness.

It's usually flat and painless, but sometimes can be warm to the touch, itchy, scaly, burning or prickling.

The rash can look and feel very different from one person to the next, and might look like a bruise on people with darker skin.

It expands over days to weeks, and eventually disappears.

A person also may have flu-like symptoms such as fever, tiredness, headache, and muscle aches.

If not treated, early symptoms may go away on their own.

But in some people, the infection can spread to other parts of the body.

Symptoms of this stage of Lyme disease usually start within several weeks of the tick bite, even in those who didn't have the initial rash.

A person might feel very tired and unwell, or have more areas of rash that aren't at the bite site.

Lyme disease can affect the heart, leading to an irregular heart rhythm, which can cause dizziness or heart palpitations.

It can also spread to the nervous system, causing facial paralysis (Bell's palsy) or meningitis.

The last stage of Lyme disease happens if the early stages were not found or treated.

Symptoms can start anytime from weeks to years after the tick bite.

In kids, this is almost always in the form of arthritis, with swelling and tenderness, particularly in the knee or other large joints.

Having such a wide range of symptoms can make Lyme disease hard for doctors to diagnose, although blood tests can look for signs of the body's reaction to Lyme disease.

Lyme disease is usually treated with a 2- to 4-week course of antibiotics.

Cases that are diagnosed quickly and treated with antibiotics almost always have a good outcome.

A person should be feeling back to normal within several weeks after treatment starts.

Lyme disease is not contagious, so it can't spread from person to person.

If you think your child could be at risk for Lyme disease or has been bitten by a tick, call your doctor.

This is especially important if your child has: a red-ringed rash flu-like symptoms joint pain or a swollen joint facial paralysis Can Lyme Disease Be Prevented?

There's no sure way to avoid getting Lyme disease.

No Lyme disease vaccine is currently on the market in the United States.

To minimize your family's risk in the great outdoors: Be aware of ticks in high-risk areas like shady, moist ground cover or areas with tall grass, brush, shrubs, and low tree branches.

Lawns and gardens may harbor ticks too, especially at the edges of woods and forests and around old stone walls.

Wear closed shoes or boots, long-sleeved shirts, and long pants.

Tuck pant legs into shoes or boots to prevent ticks from crawling up legs.

Use an insect repellent containing 10% to 30% DEET (N,N-diethyl-meta-toluamide).

Wear light-colored clothing to help you see ticks more easily.

Keep long hair pulled back or tucked in a cap for protection.

Check for ticks regularly — both indoors and outdoors.

Wash clothes and hair after leaving tick-infested areas.

If you use an insect repellent containing DEET, always follow the directions on the product label and don't overapply it.

Place DEET on shirt collars and sleeves and pant cuffs, and only use it directly on exposed areas of skin.

You should know how to remove a tick in case one lands on you or your child.

If you find a tick: Use tweezers to grasp the tick firmly at its head or mouth, next to the skin.

Pull firmly and steadily on the tick until it lets go of the skin.

If part of the tick stays in the skin, don't worry.

But call your doctor if you notice any irritation in the area or symptoms of Lyme disease.

Call your doctor, who might want to see the tick.

Note: Don't use "folk remedies" like petroleum jelly or a lit match to kill and remove a tick.

These won't get the tick off skin and might just cause it to burrow deeper.

Tick bites usually don't hurt — and that can make it hard to find a bite early.

So be on the lookout for ticks and rashes, and if you live in high-risk area, do a daily tick check on yourself and your kids.Every year doctors and researchers come across diseases both curable and non-curable.

Regular common cold and cough disease can get cured while there are few diseases like Aids and final stages of cancer whose cures are simply far from the reach of the medical science.

So, What is Lyme disease?  Lyme disease is a disease caused by the Borelia type bacteria which starts to appear after two weeks of its occurrence the disease can get treated by using antidotes within a week or two only after it gets processed within 48 hours.

So, today for the knowledgeable purpose we bring in the signs and effects of the disease in children and dog.

After the tick bite of the insect, it takes about a week to show the signs of Lyme disease.

The bite invites a rash on a children body which is neither itchy nor painful.

The first signs that a person usually faces are fever, headache, and dizziness.

If the insect sting is not treated further, it invites additional symptoms like stiff neck with a severe headache and heart palpitations.

After a month people start to develop swelling and joint pains.

When children get stung by the infected bacteria, they get a rash with a pink color in the center and red color on the surrounding skin.

While they suffer from a headache, stiff neck, muscles and joint pains, fever and chills, poor appetite, swollen glands and sore throat.

On the other hand, dogs face the loss of appetite, reduction in energy, generalized stiffness and lameness.

Effects of Lyme disease; Lyme disease has got mostly identified on the Northern side of America, and the European countries and the researcher Lyme pediatric expert Charles Ray Jones identified the effects of the bacterial infection on the children when they get attacked by the small stingy creatures.

According to Charles, insomnia, nausea, abdominal pain, low memory concentration, difficulty in giving attention and expressing thoughts are the few effects that the young patients come across after being the secret victim of the insect.

While dogs develop a severe kidney disease, swollen lymph nodes and a fever between 103 degrees to 105 degrees.

They also develop a heart disease, nervous system disease and if the condition fails to get treated within a particular time, the dog may even die.

The disease when gets infected to the children or dog can get treated with the help of antibiotics like doxycycline, amoxicillin, or cefuroxime axel.

But if they fail to get treated for the particular period, then the children will suffer forever with a mental disorder while dogs will land up in the grave.

However, people can cure the disease on hand by preventing it altogether.

The parents must take care of the children properly by making them wear a light colored dress so that they can be spotted and removed.

Similarly, the parents are advised to make their children tuck in their trousers inside the socks so that no insect gets inside the trousers.

Use of insect repellent is another way of preventing the bugs from approaching the human skin.

In dogs, two types of blood test can be conducted to diagnose the Lyme disease.

One is antibody test, and the other one is polymerase chain reaction (PCR) test.

The antibody acts as the antidote inside the dog body and reacts to the bacterium while PCR confirms about the availability of the bacterium inside the body.

To overcome the disease a week, extensive treatment is to be carried out to root out the disease altogether.  Moreover, the pet owners can follow preventive measure before getting their pets attacked from the sting of the insect, i.e., keeping your dogs away from the untidy garden area and by taking the dogs for regular medical check-ups.

So, with the rapid advancement of the disease in the American and European territory, the disease has become quite a concern for the residence.

The residents, as well as the government, are equally responsible for alleviating the disease from the state so awareness campaign regarding the prevention of Lyme and free medical checkup, health insurance, and vaccination approach must get provided for the secure health children.

While the public places like parks, garden, picnic spot should get at least brushed with medical sprays where the children and their pet can safely spend their time.Overview Lyme disease is an underreported, under-researched, and often debilitating disease transmitted by spirochete bacteria.

The spiral-shaped bacteria, Borrelia burgdorferi, are transmitted by blacklegged deer ticks.

Lyme’s wide range of symptoms mimic those of many other ailments, making it difficult to diagnose (1, 2).

The blacklegged ticks can also transmit other disease-causing bacteria, viruses, and parasites.

These ticks that transmit Lyme are increasing their geographical spread.

As of 2016, they were found in about half the counties in 43 of 50 states in the United States (3).

Lyme is the fifth most reported of notifiable diseases in the United States, with an estimated 329,000 new cases found annually (4).

But in some states, estimates suggest that Lyme disease is profoundly underreported (4).

Some studies estimate that there are as many as 1 million cases of Lyme in the United States every year (5).

Most people with Lyme who are treated right away with three weeks of antibiotics have a good prognosis.

But if you’re not treated for weeks, months, or even years after infection, Lyme becomes more difficult to treat.

Within days of the bite, the bacteria can move to your central nervous system, muscles and joints, eyes, and heart (6, 7).

Lyme is sometimes divided into three categories: acute, early disseminated, and late disseminated.

But the progression of the disease can vary by individual, and not all people go through each stage (8).

Every individual reacts to the Lyme bacteria differently.

Here is a list of 13 common signs and symptoms of Lyme disease.

Rashes The signature rash of a Lyme tick bite looks like a solid red oval or a bull’s-eye.

The bull’s-eye has a central red spot, surrounded by a clear circle with a wide red circle on the outside.

The rash is a sign that the infection is spreading within your skin tissues.

The rash expands and then resolves over time, even if you’re not treated.

Thirty percent or more of people with Lyme disease don’t remember having the rash (9).

The ticks in the nymph stage are the size of poppy seeds, and their bites are easy to miss.

The initial red rash usually appears at the site of the bite within 3 to 30 days (11).

Similar but smaller rashes can appear three to five weeks later, as the bacteria spread through tissues (12).

The rash can also take other forms, including a raised rash or blisters (14).

If you do have a rash, it’s important to photograph it and see your doctor to get treated promptly.

Summary: If you see a flat rash shaped like an oval or bull’s-eye anywhere on your body, it could be Lyme.

Fatigue Whether or not you see the tick bite or the classic Lyme rash, your early symptoms are likely to be flu-like.

Symptoms are often cyclical, waxing and waning every few weeks (12).

Tiredness, exhaustion, and lack of energy are the most frequent symptoms.

The Lyme fatigue can seem different from regular tiredness, where you can point to activity as a cause.

This fatigue seems to take over your body and can be severe.

You may find yourself needing a nap during the day, or needing to sleep one or more hours longer than usual.

In one study, about 84 percent of children with Lyme reported fatigue (8).

In a 2013 study of adults with Lyme, 76 percent reported fatigue (15).

Sometimes Lyme-related fatigue is misdiagnosed as chronic fatigue syndrome, fibromyalgia, or depression (8).

In some Lyme cases, fatigue can be disabling (16).

Summary: Extreme fatigue is a frequent symptom of Lyme.

Achy, stiff, or swollen joints Joint pain and stiffness, often intermittent, are early Lyme symptoms.

Your joints may be inflamed, warm to the touch, painful, and swollen.

You may have stiffness and limited range of motion in some joints (1).

Sometimes your knees may hurt, whereas other times it’s your neck or your heels.

Bursae are the thin cushions between bone and surrounding tissue.

The pain may be severe, and it may be transitory.

People often attribute joint problems to age, genetics, or sports.

Lyme should be added to that list, as these statistics indicate: One study estimates that 80 percent of people with untreated Lyme have muscle and joint symptoms (17).

Fifty percent of people with untreated Lyme have intermittent episodes of arthritis (17).

Two-thirds of people have their first episode of joint pain within six months of the infection (18).

Use of anti-inflammatory drugs may mask the actual number of people with joint swelling (19).

Summary: Joint pain that comes and goes, or moves from joint to joint, could be a sign of Lyme.

Headaches, dizziness, fever Other common flu-like symptoms are headaches, dizziness, fever, muscle pain, and malaise.

About 50 percent of people with Lyme disease have flu-like symptoms within a week of their infection (18).

Your symptoms may be low-level, and you may not think of Lyme as a cause.

For example, when fever occurs, it’s usually low-grade (18).

In fact, it can be difficult to distinguish Lyme flu symptoms from a common flu or viral infection.

But, unlike a viral flu, for some people the Lyme flu-like symptoms come and go.

Here are a few statistics from different studies of Lyme patients: Seventy-eight percent of children in one study reported headaches (8).

Forty-eight percent of adults with Lyme in one study reported headaches (20).

Fifty-one percent of children with Lyme reported dizziness (8).

In a 2013 study of adults with Lyme, 30 percent experienced dizziness (15).

Thirty-nine percent of children with Lyme reported fevers or sweats (8).

Among adults with Lyme, 60 percent reported fever in a 2013 study (15).

Forty-three percent of children with Lyme reported neck pain (8).

A smaller number of children with Lyme reported sore throats (8).

Summary: Low-level flu symptoms that periodically return could be a sign of Lyme.

Night sweats and sleep disturbances Sleep disturbances in Lyme are common.

Your body temperature may fluctuate, and night sweats or chills can wake you.

Here are some of the statistics from studies: In a 2013 study, 60 percent of adults with early Lyme reported sweats and chills (15).

The same study reported that 41 percent experienced sleep disturbances (15).

Twenty-five percent of children with Lyme reported disturbed sleep (8).

Summary: Sleep disturbances are common with Lyme, including night sweats and chills.

Cognitive decline There are many kinds and degrees of cognitive disturbances, and they can be scary.

You may notice that you have difficulty concentrating in school or at work.

Your memory may have lapses that weren’t there before.

You may have to reach to remember a familiar name.

You may feel as though you’re processing information more slowly.

Sometimes when driving or taking public transportation to a familiar place, you may forget how to get there.

Or you may be confused about where you are or why you’re there.

You might get to a store to shop, but entirely forget what it was that you were supposed to look for.

You might at first attribute this to stress or age, but the decline in capabilities may worry you.

Here are some statistics: Seventy-four percent of children with untreated Lyme reported cognitive problems (8).

Twenty-four percent of adults with early Lyme reported difficulty concentrating (15).

In later Lyme, 81 percent of adults reported memory loss (21).

Summary: Lyme bacteria can affect your brain and mental processes.

Sensitivity to light and vision changes Bright indoor light may feel uncomfortable or even blinding.

Light sensitivity is bad enough for some people to need sunglasses indoors, in addition to wearing sunglasses outdoors in normal light.

Light sensitivity was found in 16 percent of adults with early Lyme (15).

In the same study, 13 percent reported blurry vision.

Summary: Light sensitivity, including to indoor light, is a symptom of Lyme.

Other neurological problems Neurological symptoms can be subtle and sometimes specific.

In general, you may feel unsure of your balance or less coordinated in your movements.

Walking down a slight incline on your driveway might take an effort that it never did before.

You might trip and fall more than once, although this never happened to you before.

For example, the Lyme bacteria may affect one or more of your cranial nerves.

These are the 12 pairs of nerves that come from your brain to your head and neck area.

If the bacteria invade the facial nerve (the seventh cranial nerve), you can develop muscle weakness or paralysis on one or both sides of your face.

This palsy is sometimes mistakenly called Bell’s palsy.

Lyme disease is one of the few illnesses that cause palsies on both sides of the face.

Or you may have numbness and tingling on your face.

Other affected cranial nerves can cause loss of taste and smell.

A Centers for Disease Control and Prevention (CDC) study of 248,074 reported Lyme disease cases nationwide from 1992 to 2006 found that 12 percent of Lyme patients had cranial nerve symptoms (9).

As the Lyme bacteria spread through the nervous system, they can inflame the tissues where the brain and spinal cord meet (the meninges).

Some of the common symptoms of Lyme meningitis are neck pain or stiffness, headache, and light sensitivity.

Encephalopathy, which alters your mental state, is less common.

These neurological symptoms occur in about 10 percent of adult individuals with untreated Lyme disease (18).

Summary: Neurological problems, ranging from balance issues, to stiff neck, to facial palsy, could be symptoms of Lyme.

Skin outbreaks Skin symptoms appear early in Lyme (21).

You may have unexplained skin rashes or large bruises without usual cause.

They could also be more serious, such as B cell lymphoma (21).

Other skin ailments associated with Lyme are: morphea, or discolored patches of skin (21) lichen sclerosus, or white patches of thin skin (21) parapsoriasis, a precursor to skin lymphoma In Europe, some of the skin diseases that result from Lyme transmitted by a different Borrelia species are: borrelial lymphocytoma, which is common in Europe as an early Lyme marker (22) acrodermatitis chronica atrophicans (21) Summary: In addition to the classic Lyme rash, other unexplained rashes can be Lyme symptoms.

Heart problems Lyme bacteria can invade your heart tissue, a condition called Lyme carditis.

The bacterial interference in your heart can cause chest pains, light-headedness, shortness of breath, or heart palpitations (23).

The inflammation caused by the infection blocks the transmission of electrical signals from one chamber of the heart to the other, so the heart beats irregularly.

Here are some statistics: The CDC reports that only 1 percent of reported Lyme cases involve carditis (23).

Other studies report that 4 to 10 percent of Lyme patients (or more) have carditis (24, 25).

However, these figures may include a broader definition of carditis.

With treatment, most people will recover from an episode of Lyme carditis.

The CDC reported three sudden Lyme carditis deaths from 2012–2013 (26).

Summary: Lyme bacteria can affect your heart, producing a range of symptoms.

You may be more irritable, anxious, or depressed.

Twenty-one percent of early Lyme patients reported irritability as a symptom.

Ten percent of Lyme patients in the same study reported anxiety (15).

Unexplained pain and other sensations Some people with Lyme may have sharp rib and chest pains that send them to the emergency room, suspecting a heart problem (27).

When no problem is found, after the usual testing, the ER diagnosis is noted as an unidentified “musculoskeletal” cause.

You can also have strange sensations like skin tingling or crawling, or numbness or itchiness (27).

Tinnitus can be a nuisance, especially at bedtime when it seems to get louder as you’re trying to fall asleep.

About 10 percent of people with Lyme experience this (15).

One study reported that 15 percent of Lyme patients experienced loss of hearing (28).

Jaw pain or toothaches that are not related to actual tooth decay or infection.

Summary: Lyme can be the cause of unexplained sensations or pain.

Regression and other symptoms in children Children are the largest population of Lyme patients.

The CDC study of reported Lyme cases from 1992–2006 found that the incidence of new cases was highest among 5- to 14-year-olds (9).

About one quarter of reported Lyme cases in the United States involve children under 14 years old (29).

Children can have all the signs and symptoms of Lyme that adults have, but they may have trouble telling you exactly what they feel or where it hurts.

You may notice a decline in school performance, or your child’s mood swings may become problematic.

Your child’s social and speech skills or motor coordination may regress.

Children are more likely than adults to have arthritis as an initial symptom (25).

In a 2012 Nova Scotian study of children with Lyme, 65 percent developed Lyme arthritis (30).

Summary: Children have the same Lyme symptoms as adults, but are more likely to have arthritis.

What to do if you suspect Lyme disease If you have some of the signs and symptoms of Lyme, see a doctor — preferably one familiar with treating Lyme disease!

The International Lyme and Associated Diseases Society (ILADS) can provide a list of Lyme-aware doctors in your area (31).

Summary: Find a doctor familiar with treating Lyme disease.

The commonly used ELISA test is not a reliable indicator for many Lyme patients (32).

The Western blot test tends to be more sensitive, but it still misses 20 percent or more of Lyme cases (32).

If you don’t have the initial Lyme rash, diagnosis is usually based on your symptoms and your potential exposure to blacklegged ticks.

The doctor will rule out other possible diseases that may cause the same symptoms.

Summary: Lyme diagnosis is usually based on your symptoms.

What to do if you have a blacklegged tick bite Remove the tick by pulling it directly out with fine-tipped tweezers.

Don’t crush it or put soap or other substances on it.

See if you can identify what kind of a tick it is.

Immediately after removing the tick, wash your skin well with soap and water or with rubbing alcohol.

The Lyme bacteria is transmitted only by blacklegged ticks in their nymph or adult stage.

The doctor will want to determine if it’s a blacklegged tick and if there’s evidence of feeding.

Your risk of getting Lyme from an infected tick increases with the length of time that the tick fed on your blood.

Summary: Pull the tick out with tweezers and save it in a resealable container for identification.

Antibiotics work If you have the classic Lyme rash or other symptoms of early Lyme, you’ll need at least three weeks of oral antibiotics.

Shorter courses of treatment have resulted in a 40 percent relapse rate (33).

Even with three weeks of antibiotics, you may need one or more courses of antibiotics if your symptoms return.

Lyme is tricky and affects different people in different ways.

The longer you’ve had symptoms, the more difficult it is to treat.

Summary: At least three weeks of oral antibiotics are recommended when you have symptoms of early Lyme.

The bottom line Lyme is a serious tick-borne disease with a wide range of symptoms.

If you get treated as soon as possible with an adequate course of antibiotics, you’ll have a better outcome.Skip to Content In this section Practice Point Lyme disease in Canada: Focus on children Posted: Sep 2 2014 | Reaffirmed: Jan 30 2017 The Canadian Paediatric Society gives permission to print single copies of this document from our website.

For permission to reprint or reproduce multiple copies, please see our copyright policy.

Principal author(s) Heather Onyett; Canadian Paediatric Society, Infectious Diseases and Immunization Committee Paediatr Child Health 2014;19(7):379-83 Abstract Lyme disease, the most common tick-borne infection in Canada and much of the United States, is caused by the bacteria Borrelia burgdorferi.

Peak incidence for Lyme disease is among children five to nine years of age and older adults (55 to 59 years of age).

The bacteria are transmitted through the bite of infected black-legged ticks of the Ixodes species.

The primary hosts of black-legged ticks are mice and other rodents, small mammals, birds (which are reservoirs for B burgdorferi) and white-tailed deer.

Geographical distribution of Ixodes ticks is expanding in Canada and an increasing number of cases of Lyme disease are being reported.

The present practice point reviews the epidemiology, clinical presentation, diagnosis, management and prevention of Lyme disease, with a focus on children.

Key Words: Black-legged tick; Borrelia burgdorferi; Erythema migrans; Post-treatment Lyme disease syndrome   Lyme disease (LD), a serious disease, is the most common tick-borne infection in Canada and the Northeastern to Midwestern United States, with cases also occurring (with less frequency) on the west coast.

LD is caused by the bacteria spirochete, Borrelia burgdorferi, transmitted to humans through the bite of infected black-legged ticks: Ixodes scapularis in Eastern and Central Canada and Ixodes pacificus in British Columbia.[1] The primary hosts (carriers) of black-legged ticks are mice and other small rodents, small mammals, birds (which are a reservoir for B burgdorferi) and white-tailed deer (Figure 1).

Although dogs can contract LD and carry ticks into homes and yards, there is no evidence that they spread the infection directly to people.[2] Peak incidence for LD is among children five to nine years of age and older adults (55 to 59 years of age), and many cases likely go unreported.[1] No relationship between treated maternal LD and abnormal pregnancies or disease in infants has been documented.[3] Although there is a theoretical risk, no case of infection has been linked to blood transfusion.[4] Ticks cannot jump or fly.

Instead, they climb and wait on tall grasses or shrubs for a potential host to brush against them.

They then transfer to the host and seek an attachment site.[5] Immature ticks (nymphs) are responsible for most human LD infections because their very small size hinders detection.[1] If a tick is found attached to or feeding on a child, remove it as soon as possible.

Ticks can attach and feed for five days or longer (Figure 2).

Removing a tick within 24 h to 36 h of its starting to feed is likely to prevent LD.[6] Figure 1) The life cycle of black-legged ticks and Lyme disease.

Reproduced with permission from the United States Centers for Disease Control and Prevention (Atlanta, USA): www.cdc.gov/ticks/life_cycle_and_hosts.html Figure 2) Female black-legged ticks in various stages of feeding.

Reproduced from reference 1 © All rights reserved.

With permission from the Minister of Health, 2014 How prevalent is LD in Canada?

Black-legged tick populations are well established in parts of British Columbia, Manitoba, Ontario, Quebec, New Brunswick and Nova Scotia, and may be expanding.

Migratory birds can bring infected ticks into nonendemic areas, and people may also become infected while travelling to other endemic areas in North America and Europe.[6] In 2009, LD became a nationally reportable disease.

The number of reported cases has increased from 128 in 2009 to an estimated ≥500 in 2013.[1][7] What are the clinical manifestations of LD?

Clinical manifestations are divided into early localized, early disseminated and late disease.

Early localized disease: Erythema migrans (EM) – a rash at the site of a recent tick bite – is the most common presentation in children and adults (Figures 3 and 4).[4][8] EM typically develops seven to 14 days (range three to 30 days) after a tick bite.

EM begins as an erythematous macule or papule that rapidly expands centrifugally, sometimes with central clearing.[4] The lesions may be round or oval, flat or slightly raised, and are typically ≥5 cm in diameter.

However, fever, malaise, headache, mild neck stiffness, myalgia and arthralgia often accompany EM.[1][4] Early LD can occur without rash, and rash may not be detected by all patients in which it occurs.

Without treatment, EM resolves spontaneously over a four-week period, on average.

Early disseminated disease: Approximately 20% of children with LD first present to a health care provider with multiple, rather than single, EM lesions.

This rash usually occurs several weeks after the tick bite and consists of secondary annular, erythematous lesions similar to but typically smaller than the primary lesion.

These lesions reflect spirochetemia with cutaneous dissemination.[4] Other manifestations of early disseminated disease (with or without rash) include acute neurological signs, such as facial nerve palsy, papilledema and lymphocytic meningitis.[4][9] Children with facial palsy should be assessed for meningitis, especially if neck stiffness or severe headache occurs.[9][10][11] Lyme carditis, resulting in heart block, is rare in children.[4] Late disease: Children treated with antimicrobial agents in the early stage of LD very rarely develop late disease.[4] The most common late-stage symptoms are pauciarticular arthritis affecting large joints, especially the knees, which may manifest weeks to months (mean four months) after the tick bite.

Arthritis can occur without a history of earlier stages of illness.

Peripheral neuropathy and central nervous system manifestations can also occur, although rarely during late disease in children.[4] Figure 3) Clinical manifestations of confirmed Lyme disease cases (United States, 2001 to 2010).

The most common presentation is the erythema migrans rash.

Reproduced from reference 8 with permission from the United States Centers for Disease Control and Prevention (Atlanta, USA) Figure 4) Erythema migrans rash showing the classic ‘bull’s eye’ form.

Reproduced from reference 1 © All rights reserved.

With permission from the Minister of Health, 2014 How is the diagnosis of LD made?

Early localized disease: In general, the diagnosis of LD is principally clinical, supported by a history of potential tick exposure in an area where it is known or suspected that black-legged ticks have been established.

However, because tick populations are expanding, it is possible that LD can be acquired outside of currently identified areas.

Such a possibility should be considered when assessing patients.

Patients with clear symptoms of early LD should be diagnosed and treated without laboratory confirmation,[1][4][10][11] because antibodies against B burgdorferi are often not detectable by serodiagnostic testing within the first four weeks after infection.[4][12][13] All clinical manifestations of possible LD, except EM, require laboratory confirmation.[13] Early disseminated and late disease: Two-tiered serological testing, including an ELISA screening test followed by a confirmatory Western blot test is used to supplement clinical suspicion of disseminated or late LD (Figure 5).

Two-tiered testing is necessary because the ELISA may yield false-positive results from antibodies directed against other spirochetes, viral infections or autoimmune diseases.[1] Table 1 provides information related to the performance characteristics of serological assays in different clinical presentations of LD.[6][14] Supplemental tests can detect Borrelia species that cause LD outside of North America.

Therefore, travel history should be documented.[1] Some individuals treated with antimicrobials for early LD never develop antibodies against B burgdorferi.

They are cured.[4][13] Most individuals with early disseminated disease and almost all individuals with late disease have antibodies against B burgdorferi.

Once such antibodies develop, they persist for years.

A decline in antibody levels is not useful to assess treatment response.[1][3] Serological test results for LD should be interpreted along with careful consideration of the clinical setting and quality of the testing laboratory.[1][15] Tests of joint fluid for antibody to B burgdorferi and urinary antigen detection have no role in diagnosis.[3] In suspected Lyme meningitis, testing for intrathecal immunoglobulin M or immunoglobulin G antibodies may be helpful.[1][5][14] Figure 5) Two-tiered serological testing for Lyme disease.

Source: Dr L Robbin Lindsay, Research Scientist, Field Studies (for the Public Health Agency of Canada’s Lyme Disease Surveillance Group).

EM Erythema migrans; Ig Immunoglobulin How is LD treated?

Treatment of LD should follow the clinical practice guidelines by the Infectious Diseases Society of America[1][10][11][16] and the American Academy of Pediatrics (Tables 2 and 3).[4] Arthritis frequency has decreased in the United States, probably because of improved recognition and earlier treatment of patients with early LD.

Up to one-third of LD patients with arthritis experience residual synovitis and joint swelling, which almost always resolve without repeating the antibiotic course.

For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, some experts recommend retreatment with another four-week course of oral antibiotics or with a course of parenteral ceftriaxone.[10] For cases with ongoing arthritis, consultation with an expert is recommended.[4] Consider hospitalization and constant monitoring for a child with heart block and syncope that may rapidly worsen enough to require a pacemaker.[10] The Jarisch-Herxheimer reaction (fever, headache, myalgia and an aggravated clinical picture lasting <24 h) can occur when therapy is initiated.

Nonsteroidal anti-inflammatory agents should be started and the antimicrobial agent continued.[4] Approximately 10% to 20% of cases experience lingering symptoms of fatigue and joint and muscle aching that last longer than six months.

The clinical term for this condition is ‘post-treatment Lyme disease syndrome’ (PTLDS).[17] The exact cause of PTLDS is not yet known.

Most medical experts believe that lingering symptoms are the result of residual damage to tissues and the immune system.[17][18] Recent evidence suggests that persistent infection with B burgdorferi occurs only rarely after appropriate treatment.[19] Long-course antibiotic treatments do not provide long-term improvement in PTLDS cases.[10][13][17] Figure 6) How to remove a tick.

Reproduced with permission from the United States Centers for Disease Control and Prevention (Atlanta, USA) How to remove a tick Use fine-tipped tweezers to grasp the tick close to the skin surface (Figure 6A).

Pull upward with steady, even pressure (Figure 6B).

Try not to twist or jerk, which can cause the mouthpart of the tick to break off and remain in the skin.

If this happens and you are unable to remove the mouthpart easily with clean tweezers, leave it alone and let the skin heal.

Clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water.[21] The Public Health Agency of Canada advises people to: Keep any ticks they remove themselves in a resealable plastic bag or pill vial and note the location and date of the bite.

Watch for symptoms and see a health care professional immediately should symptoms appear.

Take the tick with them to their medical appointment, to verify species and test as needed.[1] How can LD be prevented?

Physicians should be aware of the epidemiology of tick-borne LD in their area,[1][2][7] and recommend some basic precautions for families living, hiking or camping in rural or wooded areas where they may be exposed to ticks.[1][2][3] Where play spaces adjoin wooded areas, landscaping can reduce contact with ticks.[3] A pictogram from the Centers for Disease Control and Prevention is available at: www.cdc.gov/lyme/prev/in_the_yard.html.

Repellents can be applied to clothing as well as to exposed skin.

Always read and follow label directions.[1][20] Do a ‘full body’ check every day for ticks.

Promptly remove ticks found on yourself, children and pets.

Shower or bathe within two hours of being outdoors to wash off unattached ticks.[1] For more information on how to prevent tick bites, refer to a recent practice point from the Canadian Paediatric Society at: www.cps.ca/en/documents/position/preventing-mosquito-and-tick-bites.

Postexposure antibiotic therapy Consensus on postexposure prophylaxis for LD is lacking at this time.

Some experts recommend giving doxycycline as a single dose of 200 mg for children and youth ≥8 years of age after a tick bite (for individuals weighing <45 kg, 4 mg/kg to a maximum of 200 mg).

Prophylaxis can be started within 72 h of removing a tick, even if it has been attached for ≥36 h.[1][4][7][10] Data are insufficient to recommend amoxicillin prophylaxis in younger children.[1][4][10][11] In Canada, such prophylaxis should be considered in ‘known endemic areas’ (see Table 1 and Figure 1 in reference 1).

Physicians should bear in mind that the true prevalence of B burgdorferi is often unknown and that the geographical range of infected ticks is expanding in some areas.[1] The Public Health Agency of Canada continues to monitor the distribution and prevalence of infected ticks as well as cases of LD.[1][7] A vaccine to prevent LD in humans is not available at the present time.[1][4] Selected resource: Government of Canada.

Acknowledgements This position statement was reviewed by the Acute Care and Community Paediatrics Committees of the CPS.

Special thanks are due to Drs Nicholas Ogden and Michel Deilgat, with the Centre for Food-borne, Environmental and Zoonotic Infections Diseases, and Dr L Robbin Lindsay, Research Scientist, Field Studies, for the Public Health Agency of Canada’s Lyme Disease Surveillance Group.     CPS INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE Members:  Natalie A Bridger MD; Jane C Finlay MD (past member); Susanna Martin MD (Board Representative); Jane C McDonald MD; Heather Onyett MD; Joan L Robinson MD (Chair); Marina I Salvadori MD (past member); Otto G Vanderkooi MD Liaisons: Upton D Allen MBBS, Canadian Paediatric AIDS Research Group; Michael Brady MD, Committee on Infectious Diseases, American Academy of Pediatrics; Charles PS Hui MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive (IMPACT); Dorothy L Moore MD, National Advisory Committee on Immunization (NACI); Nancy Scott-Thomas MD, College of Family Physicians of Canada; John S Spika MD, Public Health Agency of Canada Consultant: Noni E MacDonald MD Principal author: Heather Onyett MD   References Public Health Agency of Canada.

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed.

Variations, taking into account individual circumstances, may be appropriate.

Internet addresses are current at time of publication.