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Recognizing Lyme Disease

Posted Aug 24 2008 1:49pm
DAVID FOLK THOMAS: Welcome to our webcast. I'm David Folk Thomas. Since it was discovered in 1975 after a mysterious outbreak of arthritis in Old Lyme Town, Connecticut, Lyme disease has become a household name. Thousands of new cases are diagnosed every year, and those numbers continue to rise. Now, most folks in the northeast know that it's spread by deer ticks, but what exactly is Lyme disease and how do you know if you have it?

We're going to try to answer all those questions. Joining me to help shed some light, on my left, Dr. Alex McMeeking. He is an assistant professor of medicine at NYU Medical Center. Next to Alex is Dr. Brent Wise. He's a clinical instructor of medicine, also at NYU Medical Center here in New York City. Gentlemen, thanks for joining me.

Alex, let me start right off the bat with you. What is Lyme disease?

ALEX McMEEKING, MD: Lyme disease is a bacterial infection that's spread by a type of bacteria called a spirochete. The particular name of this one is called Borrelia burgdorferi. It's a big, long name. It's spread through the bites of a particular type of tick called the deer tick. It's very common, particularly in this part of the country. In most cases --

DAVID FOLK THOMAS: Could a deer tick be on a dog?

ALEX McMEEKING, MD: Absolutely, absolutely. Though it's called a deer tick, it can be on any animal with fur -- mice, domestic pets commonly bring it into the house if you have a country home, for example, things of that nature, and it can certainly crawl from the dog or the cat, if it's an outdoor cat, and settle on the person. It likes to, unfortunately, drink your blood, and by doing that it can spread this bacteria, which lives in the tick's intestinal tract, into your bloodstream and cause a Lyme infection.

DAVID FOLK THOMAS: Now before we go too much further, I believe we have some pictures of a few ticks, and if you could talk about them right here, Alex. Which one of those is the one you've got to look out for?

ALEX McMEEKING, MD: The tiniest one to the right is called the larval form. The second one is called the nymph form -- this is the second one from the right -- that's the classic one that spreads most of the infections. It's about the size of a sesame seed on a bagel, so it's tiny, tiny, tiny. Most people can't really feel it when it's on your skin. It also has the capability of biting you and releasing a chemical which acts almost as an anesthetic, so most people don't even feel the bite. Probably over 50% of the people who get Lyme disease have no history that they're aware of of having had a tick bite.

DAVID FOLK THOMAS: Now, Brian, when somebody gets bitten by one of these ticks, what should they do? How do they know if they're at risk for Lyme disease?

BRENT WISE, MD: The first thing that's important is if you're going to have exposure to the outside environment is do a tick check when you come in to see if you, in fact, do have ticks on you. If you do have ticks, it's important --

DAVID FOLK THOMAS: Where should you check, by the way?

BRENT WISE, MD: You should check everywhere. You really should look yourself over completely, and you should have someone else help you with that task and look over your back side very carefully to make sure that there are no ticks.

DAVID FOLK THOMAS: I always grew up thinking they get in your hair. Do they like being there, or can they be anywhere?

BRENT WISE, MD: They can be anywhere. Usually, they stay fairly close to where they've landed on your skin, so they're on mostly, I would say, the lower extremities. They can be on the upper extremities, as well. What's important, though, for Lyme disease, the tick has to be in contact with you for 24 hours for the bacteria that Alex mentioned to be transmitted to the human.

DAVID FOLK THOMAS: So then once you find the tick, Alex, what should your next step be?

ALEX McMEEKING, MD: First of all, don't panic. As Brent, mentioned, it has to be on for over a 24-hour period, so if you were just outside and the tick has just recently been found on your skin, the likelihood is it's not been there long enough to transmit infection. However, you should remove the tick, either by trying to pull it off. Again, they're so small it might be hard to do. You can use tweezers. Another trick I've sometimes found works is using something like baby oil, which actually tries to almost smother the tick. That often will get it to release itself from biting through your skin and start to move around, and then you can it much easier if it's already kind of embedded its head into your skin.

DAVID FOLK THOMAS: What are some of the symptoms, Brent, the early manifestations of Lyme disease if you, in fact, have contracted it?

BRENT WISE, MD: The most common symptom is probably no symptoms. But of the symptoms that people do have, a rash is the most typical early manifestation of Lyme disease.

DAVID FOLK THOMAS: I think we have a video of that.


DAVID FOLK THOMAS: So when we see this pop up, if you could explain what this rash looks like, right there.

BRENT WISE, MD: This is a classic erythema migrans rash with a bull's-eye lesion. You can see in the center where it's dark red, and then it is a clearing area where the skin has returned more to its normal color, and then it gets red again. That's why we call that a bull's-eye rash.

DAVID FOLK THOMAS: How long after you been bitten, so to speak, will you get that rash?

BRENT WISE, MD: That would probably be about 48 hours, would you say, Alex?

ALEX McMEEKING, MD: Anything from 48 hours up to, sometimes, as much as two to three weeks.

DAVID FOLK THOMAS: Is the tick in the center of that bull's-eye, or can that appear anywhere?

ALEX McMEEKING, MD: Usually it does occur around the bite, but the rash has been known to occur other places, as well. Also, what's important is that the rash does not have to be that typical bull's-eye rash to be Lyme disease. It can be almost any type of rash.

DAVID FOLK THOMAS: Okay, you can have another rash also, because we knew you were going to say that. Not really. Anyway, what about this rash we're going to look at right there? What's that one about? That's not a bull's-eye.

BRENT WISE, MD: No. That is an eschar. That is most likely from around where the tick actually bit, and that blackened area is probably surrounding the tick bite with an erythema, or redness, around that black area.

DAVID FOLK THOMAS: And then, Alex, what happens then? Then what happens after you get the rash? What other symptoms?

ALEX McMEEKING, MD: You may get spread of the bacteria through your body. It can end up, for example, in your joints, causing chronic or recurrent arthritis. You can get involvement of the heart, with involvement of the conduction system of the heart, causing what they call heart blocks, or you can get involvement of the central nervous system with various manifestations from a type of what they call encephalitis to chronic, recurrent neurologic symptoms that can be very hard to diagnose as Lyme disease.

DAVID FOLK THOMAS: What is the connection I mentioned earlier, back in '75 in Old Lyme Town, Connecticut, with arthritis outbreaks? What is the connection between Lyme disease and arthritis?

ALEX McMEEKING, MD: They think that either the bacteria or your immune response to the bacteria causes an inflammation in the joints. Why this particular bacteria ends up in joints I don't think anyone is certain, but it tends to be in larger joints, such as the knees, the ankles, the elbows, things of that nature, and particularly in children it was first misdiagnosed as what they call juvenile arthritis. It can also be misdiagnosed in older people as degenerative osteoarthritis, lupus, rheumatoid arthritis, a number of different conditions. Certainly, physicians have to be aware and do blood testing for Lyme antibodies so they don't miss the diagnose and mistreat somebody for another type of arthritis when all the time the person has Lyme disease.

DAVID FOLK THOMAS: Now, Brent, you mentioned earlier that a lot of times there are no symptoms, so I guess you can't do it. If you don't know you've been bitten and you don't have symptoms, can they eventually -- or do they go away? What's going on?

BRENT WISE, MD: They can eventually manifest themselves. I was saying that the most common -- no symptoms -- is right at the very beginning of the bite. Many people don't notice the rash or don't have one, and it's not until they're diagnosed when they develop the manifestations that Alex was mentioning of either conduction problems in the heart or arthritis or chronic neurologic symptoms that then, on checking their serum antibody for Lyme disease, it's found out that they were positive.

DAVID FOLK THOMAS: When is tick season? It's in the Northeast, I mentioned, Old Lyme Town, Connecticut, where it got its name, but can you get it other places?

ALEX McMEEKING, MD: Actually, it's been reported, I believe, in 47 states in the United States. It's mostly concentrated in the Northeast and the upper Midwest, like Wisconsin, Minnesota, and, again, in the Pacific Northwest. But you can get it less commonly in other states.

The season usually begins in the spring -- March, April -- with the nymph form, then over the course of the spring into summer, the number of cases gradually drops off, but you can get cases as late as the fall from the adult tick. It can occasionally cause bites which spread Lyme disease, also.

DAVID FOLK THOMAS: All right. That's all the time we have on our webcast for Lyme disease. Remember, if you're outdoors, you've got to check yourself for ticks because Lyme disease is something to be treated seriously. My name's David Folk Thomas. We'll see you next time.

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