Last year we posted a review of ticks and Lyme disease, making the point that global warming appears to have led to an explosion of tick populations here in NE Ohio, but that our privileged position of being relatively free of Lyme disease was holding.
Unfortunately, 2018 brings further bad news with regard to Lyme disease. People can now get Lyme disease very easily right here in Cleveland and our surrounding suburbs.
So, here is a brief update on Lyme disease and how we got here.
Why was Cleveland spared, why do we have it now?
Lyme disease is named for where the infection was first discovered in the US, Old Lyme, Connecticut. It is an infection with a bacteria that can only be caught by the bite of a deer tick, typically a baby or nymph tick.
So, you can only get the infection of Lyme disease if there are the right ticks in your area of the world, and if those ticks are loaded with the Lyme disease germ.
As the name of the disease suggests, the germ of Lyme disease, called Borrelia burgdorferi, was all over the regions near Old Lyme, Connecticut including much of New England and the mid to Northern Atlantic seaboard. And when first described, turned out to be all over the Upper Midwest in Wisconsin and Minnesota. That left Cleveland in between and almost free of Lyme. Our ticks simply did not have Borrelia burgdorferi in them. No Borrelia burgdorferi, no Lyme disease.
Over time, the Borrelia burgdorferi bacteria spread eastwards from the Atlantic and westwards from Minnesota and Wisconsin. Cases began appearing in Cleveland and our area, but not many. Now, in 2018, the ticks in our lawns and woods have plenty of the Borrelia burgdorferi bacteria in them, and we are seeing Lyme disease.
I used to practice in the Boston area before moving back home to NE Ohio, and in the Boston area saw many, many cases of Lyme disease. Once I moved here, I only saw a tiny handful of cases, all contracted away from here, mainly in Pennsylvania. At one point I diagnosed a case that led to the third ever case seen at the Cleveland Clinic. Sadly, as Lyme’s germ has reached Cleveland, we are now seeing cases. I just saw a case this month in fact.
So, what is Lyme disease?
(Check out https://www.advancedped.com/getting-ticked-off-ticks-explosion-ne-ohio/ We provide great photos of the ticks that carry Lyme, and the rash of Lyme disease)
As noted above, Lyme disease, when it starts, is an infection like any other. The germ enters the body, grows and causes symptoms, and if cleared the story ends. That is the acute phase of Lyme disease. But if the germ is not found out and it persists, it can spark a chronic reaction from your immune system. Now that is the middle and late stages of Lyme disease, which is no longer a simple infection, but an infection plus an auto-immune disease.
Catching Lyme disease
You can only get Lyme disease if the Borrelia burgdorferi bacteria enters your body.
You can only have the Borrelia burgdorferi bacteria enter your body by the bite of a deer tick, and usually the baby form of it.
You can only get the Borrelia burgdorferi bacteria from the right deer tick if the tick is in your skin for more than 24 hours.
No Borrelia burgdorferi bacteria, OR, usually, no nymph deer tick, OR no nymph deer tick on you for >24 hours, no Lyme disease.
The other good news is that even if the right tick, is on you for the right period of time, and that tick carries the Borrelia burgdorferi bacteria, you will only get infected with the Borrelia burgdorferi bacteria and have Lyme disease 1% of the time.
That means in infected tick on you for over 24 hours will leave you with a 99% chance of not catching Lyme disease.
The problem is the size of the period at the end of this sentence. That’s right the period. The baby, or nymph, deer tick is tiny, it’s the size of the period at the end of these sentences, and so, very very easy to miss.
Early Lyme disease- days after the tick bite [Early Localized Lyme Disease]
About 93% of people who have the Borrelia burgdorferi bacteria enter their body have some sort of symptom. That symptom usually happens a couple of weeks after the bite, but can happen a few days, or, a few months after.
The key symptoms that usually happen are:
- a very special rash called erythema migrans (EM)
The EM rash is seen in most people who get the Borrelia burgdorferi bacteria in them.
Only Lyme disease creates this rash, where a thin red, irregularly circular line appears. The ring gets a bigger without the line getting thicker. Often in the middle is a red, hard area that feels like a low rise lump. About 2/3-3/4 of people with Lyme disease get the rash. So you can have Lyme without the rash and even without any symptoms.
Middle Stage Lyme disease- days to weeks after the acute infection [Early Disseminated Lyme Disease]
If not treated the Borrelia burgdorferi bacteria can spread from the skin where the tick bit. Once it spreads, it can go all over the body and cause all sorts of troubles, including:
- Sensitivity to light, stiff neck
- Facial muscle drooping
- Shooting pains in limbs
- Memory loss
- Loss of sleep
- Heart arrhythmias
Late Stage Lyme disease- months after the acute infection [Late Disseminated Lyme Disease]
Again, this stage occurs if the bacteria of Lyme disease continues to be present even after many months. The symptoms for this stage of the disease can be even more serious than in the middle stages and may include:
- In about 1 in 20 people with late stage disease there can be shooting pains, decreased powers of thinking, changes in gait. mood alterations
- Migraine headaches
- Lyme arthritis- mainly causing inflammation in the knees
Some studies have found that despite this very broad array of terrible things that can happen as a result of untreated Lyme disease, the probability of someone infected with Lyme developing depression or fibromyalgia is no more likely than in those without Lyme disease.
What to do in the summer?
The big question when it come to Lyme disease is when to treat.
The issue is simple only if symptoms of Lyme disease infection actually appear. The #1 most common symptom in early disease is the red ring rash called erythema migrans. So if you ever see a thin red, irregular circular rash appear around the spot of a bug bite, make sure a doctor takes a look ASAP, and if it is erythema migrans, expect to have your child receive an antibiotic course. Antibiotics are of course used if any symptoms of Lyme disease, early or late, appear.
The issue becomes more complicated if your child has no symptoms. Why even worry if there are no symptoms? The problem as noted above is that the bug that delivers the infection most commonly is pretty tiny, again the size of this period. That leads to two conundrums:
- Your child has been playing outside, we now know Lyme disease carrying baby deer ticks are around here, you don’t see any ticks or tick bit marks, but can you be sure there were no tick bites?
- Your child comes inside, you look for ticks and you find some and remove them.
Let’s talk about the first challenge, simply playing outside. There is a very deep consensus that if there is no evidence of a tick bite, even playing in a region that has Lyme disease carrying ticks running about, does not justify treatment with an antibiotic. The reason is that the evidence is strong that treating this way does not protect well. Further, if we treated every child in this category, we would need to put every child who plays outside, on an antibiotic every day. So we do not do this.
Now, how about if you remove a tick from around here. The guidelines are very clear. Keep the tick, we can tell how long it’s been on your child by its size. Further, we can tell if it’s a baby deer tick or not, only the baby deer ticks that have been gorging for over 24 hours pose any risk. So the rule here is that we treat with antibiotic only if the tick is a nymph deer tick and on for over 24 hours. Other situations do not go on to develop Lyme, so no need to treat.
A Note on Tick Removal
The key points here are very straight forward:
- Don’t waste your time in any remedy beyond complete removal or freezing. All other solutions fail regularly.
- To remove, use a pair of tweezers that can grab the tick as close to the skin as possible to grip the head,and slowly pull.
- To freeze, use an approved method that actually kills the tick by the freezing technique.
- Save the tick and bring it to the doctor for identification of species and time on skin by size.
- Lyme disease is an infection. It can only be caused by a certain type of germ, around here that is Borrelia burgdorferi.
- Lyme disease is here in NE Ohio.
- This dreadful and frightening infection is luckily only transmitted by a certain type of tick, in a certain stage of its life, and only after being on the skin for more than 24 hours. That tick is the nymph deer tick.
- Kids playing outside where ticks live (which is all over the place), do not need to be treated for Lyme disease if they have not found a tick on them.
- Kids playing outside who have been found to have tick(s) on them do not need to be treated unless the tick found is a nymph deer tick that has been measured to have been on the skin over 24 hours (a measure we can do on the tick in the office).
- Kids who develop symptoms of Lyme disease all need antibiotic treatment to cure the infection and prevent further symptoms developing over time. The best sign to see for this purpose is a thin, red, irregular circular rash called erythema migrans. It is often the first symptom of Lyme disease. If we see it we treat.
Lyme disease is an awful infection, but if treated early further symptoms can definitely be prevented. Although now here in NE Ohio, there is still no need to put people with low or no risk for developing the infection on treatment.
We hope everyone has a wonderful and safe summer, I still plan to fully enjoy the great outdoors.
To your health,
Dr. Arthur Lavin