Lyme Disease

Infectious Agent

Spirochetes belonging to the Borrelia burgdorferi sensu lato complex, including B. afzelii, B. burgdorferi sensu stricto, and B. garinii .

Transmission

Through the bite of Ixodes ticks; infected people are often unaware that they have been bitten.

Epidemiology

In Europe, endemic from southern Scandinavia into the northern Mediterranean countries of Italy, Spain, and Greece and east from the British Isles into central Russia. Incidence is highest in central and Eastern European countries. In Asia, infected ticks occur from western Russia through Mongolia, northeastern China, and in Japan; however, human infection appears to be uncommon in most of these areas. In North America, highly endemic areas are the northeastern and north-central United States. Transmission has not been documented in the tropics. Lyme disease is occasionally reported in travelers returning to other countries from the United States and should be considered in those with consistent symptoms and a history of hiking or camping.

Clinical Presentation

Incubation period is typically 3–30 days. Approximately 80% of people infected with B. burgdorferi develop a characteristic rash, erythema migrans (EM), within 30 days of exposure. EM is a red, expanding rash, with or without central clearing, that is often accompanied by symptoms of fatigue, fever, headache, mild stiff neck, arthralgia, or myalgia. Within days or weeks, infection can spread to other parts of the body, causing more serious neurologic conditions (meningitis, radiculopathy, and facial palsy) or cardiac abnormalities (myocarditis with atrioventricular heart block). Untreated, infection can progress over a period of months to cause monoarticular or oligoarticular arthritis, peripheral neuropathy, or encephalopathy. These long-term sequelae can be typically observed over a number of months, ranging from 1 week to a few years.

Diagnosis

Observation of an EM rash with a history of recent travel to an endemic area (with or without history of tick bite) is sufficient. For patients with evidence of disseminated infection (musculoskeletal, neurologic, or cardiac manifestations), 2-tiered serologic testing, consisting of an ELISA/IFA and confirmatory Western blot, is recommended. Patients suspected of acquiring Lyme disease overseas should be tested by using a C6-based ELISA, as other serologic tests may not detect infection with European species of Borrelia . Lyme disease is nationally notifiable.

Treatment

Most patients can be treated with either oral doxycycline or intravenous ceftriaxone (see http://cid.oxfordjournals.org/content/43/9/1089.full). Diagnosis and management are sometimes controversial and should be managed by those who have experience with this disease.

Prevention

Avoid tick habitats, use insect repellent on exposed skin and clothing, and carefully check every day for attached ticks. Minimize areas of exposed skin by wearing long-sleeved shirts, long pants, and closed shoes; tucking shirts in and tucking pants into socks may also reduce risk (see Chapter 2, Protection against Mosquitoes, Ticks, & Other Arthropods).

CDC website: www.cdc.gov/lyme

Bibliography

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Author

Paul S. Mead