Watch out for Lyme Disease!

Jessica André, MSIII Howard University College of Medicine
EMRA NE Coordinator, 2022-2023

Chris Walsh, MSIII Sidney Kimmel Medical College
EMRA NE2 Representative, 2022-2023

As weather in the Northeast heats up and time spent outdoors increases, children and adults alike are at higher risk of tick-borne illnesses such as Lyme Disease (LD). In fact, May is recognized as Lyme Disease Awareness Month and makes this topic increasingly relevant to shed light upon. Over the last decade, the incidence of LD has amounted to an astonishing 25,000+ cases per year (MyLymeData, 2021). Some factors contributing to the increase in cases include early recognition, the creation of registries such as MyLymeData, and an increased number of ticks, specifically the Ixodes scapularis, carrying the spirochete, Borrelia burgdorferi, that causes LD. Children less than 15 years old comprise a vast majority of patients with LD, with most cases occurring between late spring and late fall in the Northeastern region (CDC, 2021).

As cases continue to skyrocket, the ability of ED physicians to recognize and initiate treatment for LD has become increasingly important, especially in regions such as the Northeast, to reduce long-term sequelae and suffering. The presentation to the ED can range from acute tick attachment to more severe complications, such as lyme carditis or lyme meningitis (Applegren & Kraus 2017). When assessing a patient in the ED with suspected LD, a three-tier classification system is suggested to guide management. Class I categorizes those suspected of LD exposure, such as those with a known bite or a tick attached to their skin. Class II categorizes patients presenting with LD symptoms. These include flu-like symptoms such as fever, headache, nausea, myalgias/arthralgias, and the pathognomonic rash (erythema migrans). Lastly, Class III categorizes patients presenting with delayed sequelae of LD. These can include carditis, chronic arthritis, and neurologic symptoms such as Bell’s Palsy. Each tier differs in presenting symptoms, diagnosis, and treatment regimens, so including LD in the differential when interviewing patients with vague flu-like symptoms and/or cardiac complications is warranted and potentially lifesaving (Applegren & Kraus 2017).

The diagnosis of LD utilizes two-tier testing. The first test ordered is typically an enzyme-linked immunosorbent assay (ELISA) to screen for LD and then a Western blot is ordered to confirm the diagnosis (Applegren & Kraus 2017). Unfortunately, the diagnostic tools available to physicians approved by the FDA are limited in several important ways. First, their sensitivity is relatively low with an estimated 54% cases going undetected. Secondly, these tests indirectly measure infection by detecting antibodies formed against the pathogen. To mount an immune response significant enough for detection, it may take a few weeks for an individual to display a detectable response. Lastly, even if the test is collected later in the course with an appropriate immune response, it can take several days to a couple weeks to result. Prophylaxis may be administered to adults and children but must satisfy a list of requirements to be administered including proper tick identification and tick attachment >36 hours. The drug of choice is doxycycline if not contraindicated. Treatment options for early localized infection, early disseminated, lyme meningitis, and cardiac disease generally involve doxycycline or amoxicillin and have risk for developing a Jarisch-Herxheimer reaction within the first 24 hours with symptoms of fever, chills, tachycardia, and myalgias (Applegren & Kraus 2017).

In addition to early recognition and treatment of LD, it is equally important to educate parents and patients about high-risk exposure opportunities, proper examination of body after prolonged outdoor activities and of outdoor pets, as well as proper removal of ticks and symptoms to be aware of to assess for LD exposure (Fischhoff et al., 2019). Importantly, high-risk exposures are not limited to hiking, trail running, and camping. In fact, most people obtain a tick bite from their own yard or neighborhood, especially in unkempt grass and bushy terrain. Regardless of the activity, preparation is key to preventing LD transmission.

Prior to engaging in a high-risk outdoor activity such as camping, hiking, and gardening, pre-treating clothes with products containing 0.5% permethrin and wearing protective clothing, like long-sleeves, high-socks, and a hat can aid in preventing tick bites (MyLymeData, 2021). Another method of preventing attachment is to place worn clothes into a hot dryer for 10 minutes prior to putting them in the wash to kill any lingering ticks. Once completed with activities, showering, and closely examining intertriginous areas such as the groin, underarms, between digits, buttocks, and back for ticks is vital for prevention. Utilizing mirrors and/or another individual may be particularly helpful (CDC, 2020).

If a tick is found on your person, there are a few steps to follow to reduce the risk of transmission and long-term complications. First, if an intact tick is present, use tweezers and grasp the tick as close to the surface of the skin as possible, pulling upward with steady pressure (Dynamed). Next, disinfect the affected area and, importantly, save the tick for identification. This ensures that appropriate prophylactic measures can be taken if the tick is found to be a pathogen harboring species. If a rash or local irritation is noticed or develops over the next 24-36 hours, it may be helpful to take serial pictures to track development of potential disease such as cellulitis or LD.

In honor of LD Awareness month, we encourage students who are interested in LD, wilderness medicine, and community engagement to organize local events or prepare teaching points upon dispositioning patients in the ED in high-risk regions to educate the general population about LD. A useful resource is LymeDisease.Org where advocates for patient education have put together infographics about LD facts, patient education resources, and tips for organizing a community event.

Whether you are in high-risk regions or not, it is vital to consider LD as a potential diagnosis for patients, young or old, who come to the ED for evaluation and treatment of vague symptoms. We can empower ourselves and our patients to learn about prevention strategies, signs and symptoms to look out for, limitations in diagnosis, treatment, and long-term sequelae of LD. As research of LD develops, we remain hopeful in reducing the financial, emotional, and physical burden of LD on our patients. In the meantime, enjoy the warm weather, take necessary precautions, and be safe.

References:

Applegren, N. D., & Kraus, C. K. (2017). Lyme Disease: Emergency Department Consideration. The Journal of Emergency Medicine, 52(6), 815-824. https://doi.org/10.1016/j.jemermed.2017.01.022

Center for Disease Control. (2020, July 1). Preventing tick bites. Center for Disease Control and Prevention. Retrieved April 2, 2022, from https://www.cdc.gov/ticks/avoid/on_people.html

Fischhoff, I. R., Keesing, F., & Ostfeld, R. S. (2019). Risk Factors for Bites and Diseases Associated With Black-Legged Ticks: A Meta-Analysis. American Journal of Epidemiology, 188(9), 1742–1750. https://doi.org/10.1093/aje/kwz130

Lyme Disease. Dynamed.com. (n.d.). Retrieved April 10, 2022, from https://www.dynamed.com/condition/lyme-disease

MyLymeData. (2021a, May 4). About Lyme Disease. Https://Www.Lymedisease.Org/Lyme-Basics/Lyme-Disease/about-Lyme/. Retrieved April 2, 2022, from https://www.lymedisease.org/lyme-basics/lyme-disease/about-lyme/