Source: The Little Red House Blog. http://inthelittleredhouse.blogspot.ca/2010/03/my-story.html

LYME DISEASEAnca Jurjut

January 14, 2015University of Waterloo

Today’s Agenda

1. What is Lyme disease?2. How is it transmitted?3. Is Canada affected?4. What are the symptoms?5. How is it Lyme diagnosed?6. How can Lyme be prevented?7. How is Lyme disease treated?

1. WHAT IS LYME DISEASE?

• Bacterial infection caused by the spirochete Borrelia burgdorferi1

• Present in the blood of wildlife, ticks feed on wildlife and become infected with B. Burgdorferi 1

• Ticks then feed on human blood, releasing bacteria from their midgut to the salivary glands, transmitting bacteria into the human bloodstream1

LYME-CARRYING TICKS

•Blacklegged ticks and Western blacklegged ticks are most responsible for transmission of the bacterium in Canada.1

Larva

Nymph

Adult male

Adult female

2. HOW IS LYME TRANSMITTED?

• From ticks to humans• Bacterial transmission occurs when a tick is

attached to the human body for at least 36-48 hours. 2

• In pregnancy, can be transferred to the placenta

• Lyme disease is not transmitted through ▫ Direct skin-to-skin contact 2

▫ Sharing eating utensils 2

▫ Breast feeding 2

▫ Sexual intercourse 2

3. IS CANADA AFFECTED?• 6 provinces in

Canada are endemic to ticks:

1

▫ British Columbia

▫ Manitoba▫ Ontario▫ Quebec▫ New Brunswick▫ Nova Scotia

Source: Public Health Agency of Canada. http://www.phac-aspc.gc.ca/id-mi/tickinfo-eng.php

ONTARIO

Source: Public Health Agency of Canada. http://www.phac-aspc.gc.ca/id-mi/tickinfo-eng.php

4. WHAT ARE THE SYMPTOMS?STAGE 1: EARLY LOCALIZED DISEASE

o “Erythema migrans”, a bull’s eye rasho Flu-like symptoms

Sore throat Congestion Fever Muscle stiffness Headaches

STAGE 2: EARLY DISSEMINATED DISEASEo Multiple erythema migrans rasheso Bell’s palsyo Meningitiso Carditis

STAGE 3: LATE LYME DISEASEoRecurring arthritiso Heart palpitationso Heart blockoPNS involvement (shooting pain, numbness/tingling in the

extremities)oCNS involvement (Short term memory problems)

WHICH RASHES ARE LIKELY THE RESULT OF LYME INFECTION?

Source: CDC http://www.cdc.gov/lyme/signs_symptoms/rashes.html

A B C

D E

5. HOW IS LYME DISEASE DIAGNOSED?

•Lyme disease diagnosis is based on 3 factors▫Epidemiological exposure▫Clinical symptoms ▫Serology 2

•Serology testing: 2-tier antibody testing method▫ELISA test followed by the Western blot

test2

6. HOW CAN LYME BE PREVENTED?

• Minimize skin exposure ▫ Closed-toe shoes, long sleeves, long

pants, and pull socks over long pants2

▫ Wear a hat 2

• Wear light–coloured clothing to help identify ticks 2

• Take showers to ensure ticks are washed off from areas that are not visible2

• Avoid thick bushes, tall grass, and wooded areas 2

• Apply insect repellant (DEET, icaridin, or permethrin) and focus on ankles, wrist and neck 2

PROPER TICK REMOVAL

1. With a pair of tweezers, gently grasp the tick by the head, as close as possible to the skin

2. Pull the tick out steadily

3. Disinfect the bite site and wash hands with warm water and soap, rubbing alcohol or iodine

4. With tweezers, immerse the tick in alcohol and place it in a sealed bag to send to the local public health unit

  Do not crush the tick with your fingers.

Source: CDC. http://www.cdc.gov/lyme/removal/index.html

Drug Efficacy Safety Cost/ Compliance

Doxycycline 100mg PO BIDChild >8y: 2mg/kg BID

-First line: Effective against B. Burgdorferi and Anaplasma phagocytophilium (co-infection) 3

-Absorption is affected by antacids, dairy and iron supplements

-CI: pregnancy, lactation, children ≤8 years old due to tooth discoloration and abnormal bone formation3

-Must avoid sun exposure due to photosensitivity3

-10 day course found to be as effective as 14 day3

-Only tabs-Not covered by ODB -$

Amoxicillin 500mg PO TIDChild: 50mg/kg per day in three divided doses

-First line for children-Effective for tx of early Lyme disease3

-Drug-induced rash -TID x 14 days-Suspension available-Covered by ODB-$

Cefuroxime 500mg PO BID Child: 30mg/kg per day in two divided doses

-Effective for tx of early Lyme disease5

-Drug-induced rash-May cause liver toxicity

-14 day course-Suspension available but is bitter tasting-Covered by ODB-$$

7. HOW IS LYME TREATED?

TREATMENTDrug Efficacy Safety Cost/

Compliance

Macrolide-Clarithromycin 500mg BID-Azithromycin

-Less effective-Reserved for pts with B-lactam allergy , or doxycycline intolerance3

-Clarith> Azith3

-Must be closely monitored to ensure resolution of infection3

-GI problems

-14 day course-Suspension available-Metallic aftertaste-Azith is better tolerated

Ceftriaxone 2g IV QD Child: 50-75mg/kg QD

-Effective-Reserved for late Lyme disease symptoms, including neurological3

-Possible complications with IV therapy-May cause liver toxicity

-IV-Covered by ODB

Penicillin G IV 5 million units Q6HChild: 200, 000 to 400, 000 units/kg per day divided into 6 daily doses

-Effective-Reserved for late Lyme disease symptoms, including neurological3

-Possible complications with IV therapy

-IV-Administration can be painful

TREATMENT: PREGNANCY

• Untreated Lyme disease during pregnancy can lead to stillbirth, as B. burgdorferi has been found to cross the placenta4

• Doxycycline, should be avoided.3 Amoxicillin and cefuroxime remain viable options for Lyme treatment3

• When appropriately treated, no consequences of fetal termination or congenital anomalies were found3

BACK TO THE SCENARIO• 1 month ago: Flu–like symptoms

▫Erythema migrans may have not been within sight (it is not itchy or painful)

• Increasingly more▫Headaches▫Recurrent arthritic pain

• Today: presenting with Bell’s Palsy • Antibiotic therapy (doxycycline) is

required and follow up in 4 weeks 3

▫ If arthritis persists after first antibiotic course, may require IV antibiotics 3

▫ If knee pain continues even after IV treatment, consider using NSAIDs, DMARDs, and corticosteroids3Source: CDC http://www.cdc.gov/lyme/signs_symptoms/

TAKE HOME POINTS1. Lyme disease is caused by a bacteria that is found in

blacklegged ticks and treated with antibiotics

2. Lyme disease is not transmitted through direct skin-to-skin contact, sexual intercourse, or breastfeeding

3. Infected ticks have been found in Canada, and are endemic in Ontario

4. Erythema migrans AND flu-like symptoms are signs of early Lyme

5. Immediate tick removal is key to preventing Lyme disease

6. Take showers daily when camping to wash off ticks

7. A 2-4 week course of antibiotics is curative for most people

REFERENCES1. Phac-aspc.gc.ca. Lyme disease and other tick-borne diseases: Information

for healthcare professionals - Lyme Disease - Public Health Agency of Canada. 2015. Available at: http://www.phac-aspc.gc.ca/id-mi/tickinfo-eng.php. Accessed January 8, 2015.

2. Cdc.gov. CDC - Transmission - Lyme Disease. 2015. Available at: http://www.cdc.gov/lyme/transmission/. Accessed January 8, 2015.

3. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-134.

4.  Walsh CA, Mayer EW, Baxi LV. Lyme disease in pregnancy: case report and review of the literature. Obstet Gynecol Surv. 2007;62(1):41-50.

ANY QUESTIONS?

DOES “CHRONIC LYME DISEASE” EXIST?

• 10% of patients continue to have symptoms more than 6 months after appropriate Lyme disease antibiotic treatment3

▫ Pain

▫ Multiple joint tenderness

▫ Memory and attention deficits

▫ Fatigue

• No objective evidence of joint inflammation, normal scores on neurologic tests3

• It is well established that further antibiotic therapy is not beneficial

-Nadelman RB, Nowakowski J, Forseter G, et al. Failure to isolate Borrelia burgdorferi after antimicrobial therapy in culture-documented Lyme borreliosis associated with erythema migrans: report of a prospective study. Am J Med. 1993;94(6):583-8.-Klempner MS, Hu LT, Evans J, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med. 2001;345(2):85-92.