About Lyme Disease

History
In November of 1975, the Connecticut State Health Department was contacted by two women, Polly Murray and Judith Mensch, who lived in a small town of Lyme, Connecticut. Both Murray and Mensch reported that their childred had been diagnosed with juvenile rheumatoid arthritis, and each knew of others in the area with similar symptoms. They reported the occurrence of arthritis in 12 children in Old Lyme; of these, 4 lived on the same street. The mothers also reported arthritis in several members of their families and in families living in the neighboring towns of Lyme and East Haddam.

The Health Department contacted Allen Steere, who was studying rheumatology at Yale University. Steere had also gained some epidemiological experience during a stint at the Epidemic Intelligence Service, a semi-military unit of infectious disease scientists set up in the 1950s to develop offensive biowarfare capabilities. Mrs. Murray handed Steere a list of dozens of ailing children. He began by calling each family and eventually compiled a list of 39 children. Steere and colleagues identified an additional twelve adults suffering from juvenile rheumatoid arthritis. A quarter of the people Steere interviewed remembered getting a strange, spreading skin rash (erythema migrans) before experiencing any other symptoms. A European doctor happened to be visiting Yale at the time, and he pointed out that the rash was similar to one frequently encountered in northern Europe and known to be associated with tick bites. Most of the rashes were found somewhere on the torso, suggesting a crawling insect rather than a flying one or a spider, but most patients did not remember being bitten.

Steere then learned about the work of the Swedish dermatologist Arvid Afzelius, who in 1909 had described an expanding, ring-like lesion and speculated that it was caused by the bite of an Ixodes tick. The rash described by Afzelius was later named erythema migrans. Research in Europe had found that erythema migrans and acrodermatitis chronica atrophicans, another rash caused by tics in Europe, responded to penicillin, suggesting that the cause was bacterial, not viral. Yet no microorganisms could be found in fluid from the joints of Lyme disease patients.

Symptoms
According to CDC (Centers for Diseases Control and Prevention) web site, the Lyme disease bacterium can infect several parts of the body, producing different symptoms at different times. Not all patients with Lyme disease will have all symptoms, and many of the symptoms can occur with other diseases as well. If you believe you may have Lyme disease, it is important that you consult your health care provider for proper diagnosis.

The first sign of infection is usually a circular rash called erythema migrans or EM. This rash occurs in approximately 70-80% of infected persons and begins at the site of a tick bite after a delay of 3-30 days. A distinctive feature of the rash is that it gradually expands over a period of several days, reaching up to 12 inches (30 cm) across. The center of the rash may clear as it enlarges, resulting in a bull's-eye appearance. It may be warm but is not usually painful. Some patients develop additional EM lesions in other areas of the body after several days. Patients also experience symptoms of fatigue, chills, fever, headache, and muscle and joint aches, and swollen lymph nodes. In some cases, these may be the only symptoms of infection.

Untreated, the infection may spread to other parts of the body within a few days to weeks, producing an array of discrete symptoms. These include loss of muscle tone on one or both sides of the face (called facial or "Bell's palsy), severe headaches and neck stiffness due to meningitis, shooting pains that may interfere with sleep, heart palpitations and dizziness due to changes in heartbeat, and pain that moves from joint to joint. Many of these symptoms will resolve, even without treatment.

After several months, approximately 60% of patients with untreated infection will begin to have intermittent bouts of arthritis, with severe joint pain and swelling. Large joints are most often affected, particularly the knees. In addition, up to 5% of untreated patients may develop chronic neurological complaints months to years after infection. These include shooting pains, numbness or tingling in the hands or feet, and problems with concentration and short term memory.

Diagnosis
According to CDC web site, Lyme disease is diagnosed based on symptoms, objective physical findings (such as erythema migrans, facial palsy, or arthritis), and a history of possible exposure to infected ticks. Validated laboratory tests can be very helpful but are not generally recommended when a patient has erythema migrans. When making a diagnosis of Lyme disease, health care providers should consider other diseases that may cause similar illness. Not all patients with Lyme disease will develop the characteristic bulls-eye rash, and many may not recall a tick bite. However, CDC also recommends a two-step process when testing blood for evidence of Lyme disease. The first step uses an ELISA or IFA test. The second step uses a Western blot test.

Treatment
To read treatment guidelines developed by the Infectious Disease Society of America, IDSA Guidelines for Treatment of Lyme Disease. To read treatment guidelines developed by the International Lyme and Associated Diseases Society, ILADS Guidelines for Treatment of Lyme Disease.

Pregnancy
CDC stated "Studies of women infected during pregnancy have found that there are no negative effects on the fetus if the mother receives appropriate antibiotic treatment for her Lyme disease. In general, treatment for pregnant women is similar to that for non-pregnant persons, although certain antibiotics are not used because they may affect the fetus. If in doubt, discuss treatment options with your health care provider."; however, "....there has been concern about the effect of maternal Lyme disease on pregnancy outcome. We reviewed cases of Lyme disease in pregnant women who were identified before knowledge of the pregnancy outcomes. Nineteen cases were identified with onset between 1976 and 1984. Eight of the women were affected during the first trimester, seven during the second trimester, and two during the third trimester; in two, the trimester of onset was unknown. Thirteen received appropriate antibiotic therapy for Lyme disease. Of the 19 pregnancies, five had adverse outcomes, including syndactyly, cortical blindness, intrauterine fetal death, prematurity, and rash in the newborn. Adverse outcomes occurred in cases with infection during each of the trimesters. Although B burgdorferi could not be implicated directly in any of the adverse outcomes, the frequency of such outcomes warrants further surveillance and studies of pregnant women with Lyme disease."