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Lyme Disease: Epidemiology
€ Global Distribution
• Reflects distribution of Ixodes ricinus complex ticks
• North America, Europe, Asia
€ U.S. Distribution
• Most frequently reported vector-borne disease
• Three principle regions - Northeast, North central
West Coast
€ 1995: 11,603 cases reported to CDC in 43 states and D.C. Overall 4.4
cases/100,000
€ CT, RI, NY, N J, PA, MD, WI, MN account for 92% of cases. Connecticut
accounts for 45.6 cases/100,000; MN - 5.8 cases/100,000. Nantucket
County, MA - 838.8 cases/100,000
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Lyme Disease Epidemiology
€ U.S. Distribution
• 51% males
• 0 -14 years: 24%
• 35 - 49 years: 24%
• Incidence steadily increasing from 1982 -1994
- Increased recognition, increased reporting, true increase
in incidence
• Drop in incidence from 1994 to 1995
- Decreased tick population because of environmental factors
- Decreased reporting of non-Lyme disease from GA and MO
€ Agent
• Borrelia burgdorferi
- Large spirochete, gram-negative, cell structure and motility is
similar to other spirochetes, microaerophilic, can be grown on
media; can be visualized with stining in histopathologic
sections;can be visualized with light microscope,
• Three genomic groups
- Borrelia burgdorferi -- all North American cases, European arthritis
- B. garinii - Bannwarth's syndrome (tick-borne meningopolyneuritis)
- B. afzelii. Acrodermatitis chronica atrophicans
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Lyme Disease Epidemiology
€ Vector
• Ixodes ricinus complex ticks
• 3 Stages - larva, nymph, adult; each feeds once on a different
host; life cycle span of 2 years.
• Humans most often infected from nymphs in the spring, early summer
• Less often infected by adults in the fall, winter, early spring
• Ixodes scapularis - deer tick, black-legged tick, northeast and North
central U.S.
• I. pacificus - western black-legged tick, West Coast
• I. ricinus - western and central Europe
• I. persulcatus - eastern Europe and Asia
€ Reservoirs and Hosts
• In most areas of US, the white-footed mouse (Peromyscus leucopus) is
the most important reservoir of B. burgdorferi
• White-tailed deer are important hosts but not an important reservoir
• In the West, I. pacificus primarily feed on lizards (not an important
reservoir); in these areas, the dusky-footed wood rat is the most
important reservoir
• Birds may serve as a host and carry infected ticks to new locations
• Humans are incidental hosts of B. burgdorferi, and they do not
contribute to its maintenance in nature.
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Lyme Disease Epidemiology
€ Risk Factors
• Living in or visiting areas with high infestation with infected ticks
• Recreational activities
• Outdoor occupations
• Pets
€ Incidence Increasing
• Reforestation and increased deer population
• Migration of people to suburban and rural areas
• Spread of infected ticks to new geographic locations
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Lyme Disease Clinical Manifestations
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Lyme Disease Clinical Manifestations
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Lyme Disease Clinical Manifestations
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Lyme Disease Clinical Manifestations
€ Late Disease
• Months to years after tick bite
• Arthritis (60% of untreated patients)
- 2 weeks to 2 years (median of 6 months)
- Arthritis is recurrent, asymmetrical, oligoarticular, swollen, warm
painful.
- Affects the large joints, most often the knee (90%), lasts several
days to a few weeks.
- Arthritis becomes chronic in 5% (tend to be HLA-DR4 or HLA-DR2)
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Lyme Disease Clinical Manifestations
€ Late Disease
• Neurologic Manifestations
- Mild subacute encephalopathy - 2 to 3 years after onset;
memory loss, mood changes, somnolence, fatigue, headache
- Polyradiculoneuropathy - spinal pain, radicular pain or
distal paresthesias
• Other Manifestations of Late Disease
- Acrodermatitis chronica atrophicans almost exclusively in Europe
(10% of patients)
- Eye Disease- keratitis, uveitis
- Chronic heart disease is extremely rare
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Lyme Disease Clinical Manifestations
€ Congenital Disease
• Evidence from examination of placentas, fetal tissue, and live newborns
suggests that B. burgdorferi can be transmitted across the placenta
• 3 case reports of "congenital Lyme disease" in newborns born to women
with Lyme disease during pregnancy who were either not treated or
inadequately treated
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Lyme Disease Clinical Manifestations
€ Congenital Disease
• Skepticism
- Causal or coincidental association
- No definite pattern
- No inflammation
• Risk of abnormal outcome with Lyme disease during pregnancy; no
evidence of increased risk especially with appropriate antimicrobial
therapy of maternal infection
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Lyme Disease Diagnosis
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Lyme Disease Diagnosis
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Lyme Disease Diagnosis
€ Serologic Tests
• Only about 1/3 of patients with erythema migrans will have an antibody
response (usually lgM)
• After 4 to 6 weeks, almost all patients will have an IgG antibody
response; IgM response usually disappears by this time but may persist
• Early antimicrobial therapy can abort antibody response
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Lyme Disease Diagnosis
€ Serologic Tests
€ IFA
€ ELISA
• Currently the best available serologic test, results of testing must be
interpreted cautiously
• Not standardized; there is variation among laboratories; inaccuracy of
commercial kits, false-positive and false-negative results, background
level of positively in endemic areas
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Lyme Disease Diagnosis
€ Serologic Tests
• Immunoblotting (Western blotting)
- More specific than ELISA; can distinguish false-positive
from true-positive results
• Two-test approach (Dearborn criteria)
- All specimens positive or equivocal by a sensitive ELISA should
be tested by a standardized Western immunoblot
€ T-cell Lymphoproliferative Assay
• Detects cellular immune response to B. burgdorferi
• Potentially useful in small proportion of patients with seronegative
Lyme disease
• Results have been inconsistent
• Not performed routinely in most labs
€ Polymerase Chain Reaction (PCR)
• Has been used to detect B. burgdorferi DNA in blood, CSF, urine, skin,
and synovial fluid from patients with Lyme disease
• Sensitivity varies from 59% to 100%
• Major concern is false-positive results from contamination
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Lyme Disease Diagnosis
€ Synovial Fluid
• WBC usually around 30,000 but may be as high as 110,000
• Mostly neutrophils
€ Neurologic Disease
• Meningitis
- CSF - 30 to 200 WBC (lymphocytes)
- Normal to slightly elevated protein
- Normal glucose
- CSF index of >1 suggests intrathecal production of antibodies to B.
burgdorferi
- Positive PCR
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Lyme Disease Diagnosis
€ Encephalopathy
• CSF index of >1
• Elevated protein
• Positive PCR
• Abnormal MRI
• Abnormal neuropsychological testing
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Lyme Disease Treatment
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Lyme Disease Treatment
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Lyme Disease Treatment
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Lyme Disease Treatment
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Personal Protection from Tick Bites
€ CDC Recommendations
• Avoid tick-infested areas especially in May-July
• Wear light-colored clothing; tuck pants into socks and shirt into pants;
tape area where pants and socks meet; wear long-sleeve shirts; wear
a hat
• Walk in center of trail
• Inspect body carefully after being outdoors, and remove attached ticks
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Personal Protection from Tick Bites
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Tick Control
€ Deer
• Important blood source and host for adult tick, not a reservoir
for B. burgdorferi
• Have to totally eradicate- not practical
• Other large animals would fill void
€ Mice
• Host for ticks and reservoir for B. burgdorferi
• Removal not practical
• Other small mammals would fill void
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Tick Control
€ Habitat Modification
• Mow vegetation, burn brush, remove leaf litter, closely cut lawn,
move wood piles away from house, free rock walls of vegetation
€ Biological Control
• Hunterellus hookeri
- Small wasp, one of few well-studied natural enemies of deer ticks;
Female wasp oviposits in deer tick larvae, blood-fed nymph killed
by emerging wasp; Scarce in most areas where deer ticks are
found
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Tick Control
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Management of Tick Bites
€ Tick Removal
• Use thin-tipped tweezers
• Grasp tick close to skin
• Pull straight upward, slowly and steadily
• Avoid squeezing tick
• Clean wound with antiseptic
€ Prophylactic Antimicrobial Therapy
• The risk of developing Lyme disease after a deer tick bite is very low.
• Given the low risk of developing Lyme disease after a recognized deer
tick bite and uncertain effectiveness of prophylactic antimicrobials,
routine antimicrobial prophylaxis for persons with a recognized deer tick
bite is not indicated.
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Lyme Disease Vaccine
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Lyme Disease Prognosis
€ Symptoms such as fatigue, arthralgia, and myalgia may persist for several
weeks after completion of a course of antimicrobial therapy. Symptoms
generally resolve spontaneously without additional antimicrobial therapy.
€ No evidence that children with any manifestation of Lyme disease benefit
from either prolonged (>4 weeks) or repeated courses of antimicrobial
therapy.
€ B. burgdorferi infections can trigger a post-infectious syndrome (eg, chronic
fatigue, fibromyalgia) that does not respond to antimicrobial therapy.
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Lyme Disease Prognosis
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Rahn DW, Malawista SE. Lyme disease: recommendations for diagnosis and
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Gerber MA, Shapiro ED, Burke GS, et al. Lyme disease in children in southeastern
Connecticut. N Engl J Med 135: 1270-1274, 1996.
Shapiro ED, Gerber MA, Holabird NB, et al. A controlled trial of antimicrobial
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