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Lyme disease is the most common tick-borne disease in the country, with the rate of incidence doubling since 1991. When detected early, antibiotics can usually treat it effectively. Left untreated, it can lead to Lyme meningitis or Lyme arthritis.
Catherine Lachenauer, MD, Children’s Hospital Boston’s director of the Infectious Diseases Outpatient Practice, says there’s a growing controversy, highlighted by current media coverage, over the existence of what a small but vocal number of patients refer to as "chronic Lyme disease." "The majority of practitioners agree that Lyme disease has recognizable manifestations and is usually easily treatable with full resolution with a finite course of antibiotics," she says. "But there’s a minority view that Lyme disease is often a chronic infection that requires long-term antibiotic therapy."
Reported symptoms of chronic lyme disease include fatigue, musculoskeletal pain and memory problems. So far, Dr. Lachenauer says, data does not support the use of long-term antibiotics for treatment of Lyme disease. She suggests that pediatricians discuss the lack of evidence about chronic Lyme disease with their patients, as well as the risks of unnecessary antibiotic therapy.
When pediatric patients present with a tick bite, Dr. Lachenauer recommends that practitioners evaluate what type of tick gave the bite and how long the tick was attached. Although parents might be eager for their
child to be given prophylactic antibiotics, the only recommended preventive strategy is a single dose of doxycycline, given under certain conditions: The patient must have a known deer tick bite, the tick must be attached for at least 36 hours and the doxycycline must be given within 72 hours of the tick’s removal. Doxycycline is generally only recommended to children 8 and older because it stains the teeth of younger children.
If the patient doesn’t meet these criteria, Dr. Lachenauer advises observing for developing symptoms. "If the tick wasn’t attached for 36 hours, there’s a low risk that the patient will have acquired the Lyme bacterium," she says, adding that even if the child does acquire the disease, there’s excellent treatment for early-stage Lyme disease. "They’re highly unlikely to go on to have serious sequelae of Lyme disease," she says.
Dr. Lachenauer advises physicians in Lyme disease-endemic locales to counsel parents on prevention methods, such as wearing long sleeves and socks in wooded or grassy areas and frequent tick checks, particularly during spring, summer and early fall.
In 70 to 80 percent of patients, the first symptom of Lyme disease is the development of early-localized disease, manifesting as a single bull’s-eye rash (erythema migrans) at the site of the tick bite. The rash usually appears within a week or two of the bite, but can appear any time within the first month. Aside from the rash, other early-stage symptoms—fever, headache, malaise, fatigue, arthralgias and myalgias—are easily mistaken for viral illnesses. "Physicians should be aware of the possibility of Lyme disease even in patients who present without the rash," says Dr. Lachenauer.
If the initial Lyme disease isn’t treated, it can develop into early disseminated disease, which commonly manifests in three places: skin, where patients can have multiple bull’s-eye rashes; the central nervous system (commonly cranial nerve palsy and Lyme meningitis); and the heart, where it can cause some degree of rhythm disturbance, usually asymptomatic. Infrequently, patients have significant cardiovascular symptoms.
Untreated patients are at risk of late-stage disease, which usually appears as Lyme arthritis, most often affecting a single joint. "Typically, patients with late-stage Lyme disease seem otherwise healthy but present with a swollen joint, months to even years after the tick bite," she says.
During early-stage Lyme disease, clinicians can diagnose solely on the observation of erythema migrans. For patients without erythema migrans but with other symptoms, a two-tiered antibody test is used. This test is often negative during the first several weeks of infection. Dr. Lachenauer cautions that false positive results can occur. "This is one reason why all children who get a tick bite aren’t routinely tested," she says. After having Lyme disease, patients may test positive indefinitely. "We tell patients that, even when they have been appropriately treated, they can be positive even years later," she says.
For early-stage Lyme disease, the usual recommendation is two to three weeks of oral antibiotic therapy, with doxycycline as the preferred therapy for patients 8 and older. For patients who can’t take doxycycline, amoxicillin or cefuroxime axetil are effective alternatives. Treatment is the same for early disseminated Lyme disease, except for cases of Lyme meningitis and significant heart disease, both of which are usually treated with intravenous antibiotic therapy.
Patients with Lyme arthritis are treated with a four-week course of oral antibiotics. Sometimes, Lyme arthritis doesn’t resolve completely and then Dr. Lachenauer recommends a second course of antibiotics, often intravenously, for four weeks. She adds that a small percentage of patients with Lyme arthritis will develop chronic inflammation, which should be managed by a rheumatologist.
At Children’s Infectious Disease clinic, patients can receive counseling around Lyme disease and access additional therapy as needed. Dr. Lachenauer also welcomes patients who think they are suffering from chronic Lyme disease.
Make an appointment: 617-919-2900
More information: childrenshospital.org/infectiousdiseases
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