Understanding Lyme Disease; The Basics
Lyme disease is an infectious illness caused by the bacterium Borrelia burgdorferi and, in rare cases, Borrelia mayonii. It is named after the town of Lyme, Connecticut where it was first described in 1976. These bacteria are spirochetes—spiral-shaped organisms—similar to Treponema pallidum, the bacterium responsible for syphilis. Both diseases can present with early (primary) stages and, if untreated, progress to late (secondary) stages that may remain undetected for extended periods of time. Lyme disease is most prevalent in the Northeastern, Mid-Atlantic, and North-Central regions of the United States.
Seasonality of Lyme Disease
Ticks tend to be ‘snowbirds’; they don’t really like the colder weather and definitely don’t like winter. While tick bites can occur year-round, the majority of Lyme disease cases are reported during the late spring and summer months, particularly from April through September. This period coincides with the nymphal stage of blacklegged ticks, which are smaller and more challenging to detect. However, adult blacklegged ticks can remain active during winter months when temperatures are above freezing, especially on warmer days. They may seek hosts whenever conditions are favorable, so it’s essential to remain vigilant even during colder seasons.
Prevention Strategies: Not on my Watch!
There is no currently available human vaccine for Lyme Disease. Pfizer is reportedly in late stage clinical trials with results expected this year (2025) and a vaccine possibly available in 2026. A previous vaccine approved in 1998 was voluntarily withdrawn for several reasons. So, prevention strategy at this point in time, means avoidance of tick exposure, earliest possible removal for any attached tick, and prophylactic treatment to minimize the risk of Lyme disease:
- Avoid Tick-Prone Areas: When possible, steer clear of wooded, brushy, and grassy regions, especially during peak tick season. But you can’t stay inside forever, so…
- Wear Protective Clothing: Create a barrier between the little hitchhikers and your skin. Wear long-sleeved shirts and long pants tucked into socks to limit skin exposure. Light-colored clothing can aid in spotting ticks more easily. Consider using clothing treated with permethrin, an insect repellent that binds to fabric fibers and provides long-lasting protection against ticks and other insects. Permethrin-treated clothing has been shown to reduce tick bites significantly and is available through various retailers. Alternatively, you can treat your own clothing with permethrin sprays, ensuring they are properly dried before use. It’s important to note that permethrin should not be applied directly to the skin.
- Use Chemical Warfare: Apply insect repellents containing 20–30% DEET on exposed skin and clothing. Treat clothing and gear with products containing 0.5% permethrin.
- Get to Know Your Friends and Family: After outdoor activities, thoroughly inspect your body, clothing, and pets for ticks. Pay close attention to underarms, in and around ears, inside the belly button, behind knees, between legs, around the waist, and in hair. Use a hand-held or full-length mirror to view all parts of your body.
- Shower Promptly: In addition to the social benefits of good hygiene on hot, sweaty summer days, showering within two hours of coming indoors has been shown to reduce your risk of getting Lyme disease and may be effective in reducing the risk of other tick-borne diseases. Showering may help wash off unattached ticks and provides a good opportunity to do a tick check.
“That’s him, he’s the one who slimed me”
Treatment After Tick Bites: A Three-Pronged Approach
Do Ticks really bite? No, they have no teeth and it’s not a momentary thing. Ticks need to attach and stay attached to acquire their blood meal. Unattached ticks pose no threat. How long do they stay attached; generally 3 days minimum and as long as 10+ days if undisturbed. So, if you have an attached tick…
#1 Prophylactic Treatment
First, the tick will need to be removed. There are retail devices that can be purchased but fine-tipped tweezers that can gently grasp the tick as close to the skin’s surface as possible work fine. Pull upward with steady, even pressure,’tenting’ the skin and then be patient. Avoid twisting or jerking the tick or pulling too hard or fast as this can cause parts of the tick (the head) to break off and remain in the skin. After removal, clean the bite area and your hands with rubbing alcohol or soap and water.
A tick gets its blood meal by injecting saliva in order to digest the blood and also keep the blood thin. The Lyme causing bacteria hitch a ride in the saliva. In my experience, the proteins in the saliva, foreign material to our bodies, always cause a small, reddened, inflammed and raised area surrounding the site of attachment. This is not the bullseye rash of primary Lyme but is evidence that the tick has been attached long enough to begin feeding, indicating potential exposure. If a tick has been attached for more than 36 hours and is identified as an adult or nymphal Ixodes in an area where Lyme disease is prevalent, guideline recommendations endorse a single dose of doxycycline (200 mg) may be administered to individuals aged 8 years and older, provided it can be given within 72 hours of tick removal.
If the tick was not attached, the risk of Lyme is 0%. A tick attached for <24 hours carries a less than 1% risk. If attached for > 36 hours and/or engorged, risk varies between 3% to 25% and possibly higher depending on the county, tick density and density of Lyme infected ticks.
#2 Recognition and Treatment of Primary (Acute) Lyme Disease
This is the Lyme disease about which most people know something. Primary Stage (3 to 30 Days Post-Tick Bite): Did you remove a tick, suspect a tick bite or develop symptoms you think are related to a tick bite? Diagnosing early Lyme disease can be challenging as Serologic testing (blood testing) will likely be negative in the first six weeks of the illness. Guidelines regarding a clinical diagnosis include:
- Erythema Chronicum Migrans (ECM) Rash: A red, expanding rash that may appear at the site of the tick bite. It often develops a central clearing, resembling a “bull’s-eye.” This rash is present in approximately 60+% of infected individuals and typically has no symptoms associated with it; i.e itching, pain, etc… It slowly expands over time; days and weeks! If you suspect a tick bite, continue to monitor the area over a couple of weeks.
- Flu-Like Symptoms: Fever, chills, headache, fatigue, muscle and joint aches, and swollen lymph nodes may accompany the rash or be there independent of a rash. These symptoms are difficult to interpret. They are vague and by themselves associated with many different illnesses. However, in the setting of a confirmed tick bite (i.e. you removed a tick), a flu like illness within 6 weeks is considered confirmation of Lyme disease.
Late primary Stage (Weeks to months Post-Tick Bite): Sometimes called secondary stage, this nomenclature can be confused with Secondary Lyme. If no early ECM rash occurs and no flu-like symptoms are recognized, other signs and/or symptoms may arise within a few weeks to months. These signs and symptoms suggest systemic involvement and at this point, serology blood testing may become positive. Signs and symptoms include:
- Additional ECM Rashes: Multiple bullseye Rashes may appear on other areas of the body.
- Neurological Symptoms: Facial palsy, formerly known as Bells Palsy, is commonly associated with Lyme Disease. Lyme should be a consideration in anyone who develops loss of muscle tone or droop on one or both sides of the face. Other possible symptoms include new severe headaches, neck stiffness, and nerve pain.
- Cardiac Symptoms: New heart palpitations or an irregular heartbeat secondary to the infection are called Lyme carditis and are an important finding and may require more intensive treatment, including hospitalization. IV antibiotics may be preferred.
#3 Secondary Lyme Disease (Late Stage):
Lyme disease infection can go unrecognized if there are minimal or no symptoms. This can happen if the bite is from larva or nymph form or if the attachment is in a hidden area. Similar to syphilis, the infection can smolder over a longer period of time and produce more serious and insidious symptoms. The most common are:
- Lyme Arthritis: Severe joint pain and swelling, particularly in large joints like the knees. This tends to be asymmetric, attacking one or more joints on either side of the body.
- Neuropathy: Numbness, tingling, and shooting pains in the hands or feet. Onset of new neuropathy can be associated with Lyme.
- Cognitive Impairments: Memory problems, difficulty concentrating, and mental fog are a serious sign of central nervous system infection.
Post-Lyme Disease Syndrome (PLDS)
Sometimes referred to as Post treatment Lyme disease syndrome, or chronic Lyme disease, this is a condition where patients continue to experience symptoms either after completing appropriate antibiotic treatment and underscores the need for early and accurate diagnosis of Lyme. Research studies have disproved the concept of a chronic infection, a previous consideration as well as an ongoing controversial topic. However the ongoing symptoms may be severe, debilitating and include fatigue, which can be profound and persistent, muscle and joint aches, brain fog, or memory issues, sleep disturbances, mood changes, including depression and anxiety and headache, or neuropathic pain. Symptoms overlap with other diseases, including chronic fatigue syndrome or fibromyalgia.
Unfortunately, the pathogenesis is not well understood and there is no diagnostic test for PLDS. It is thought to be a post infectious, inflammatory and/or immune mediated response. Diagnosis of the condition is based clinically on a history of documented Lyme disease, completion of antibiotic therapy, persistent, nonspecific symptoms after treatment and no evidence of ongoing infection. It is important to rule out other causes of autoimmune disease, including thyroid issues, infections, and mental health conditions.Prognosis is variable. Research suggests most people improve overtime, although recovery may be slow.
The Take-Home Message
Taking steps to reduce the risk of exposure is the number 1 step. Frequent skin checks is an important ritual to undergo daily if there is the possibility of exposure. Remember that pets can bring ticks into your home and they don’t take the protective steps that you can. If you find an embedded tick, let me (or your MD) know. This is helpful in deciding if treatment is necessary and to record the presence of the ‘tick bite’ for future reference. Antibiotic prophylaxis treatment should be given when deemed appropriate. Lyme prophylaxis is one instance where I am aggressive with antibiotic treatment. Should you develop signs of acute Lyme, notify immediately. Like any medical issue, earlier treatment always results in better outcomes. If you suspect you missed an early diagnosis and are heading into the later stages, contact your MD to diagnose and treat. Avoiding the later stages of Lyme and PLDS are one of the key goals of a treatment regimen.
