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Lyme Disease Lyme disease is a bacterial infection caused by a spirochete, Borrelia burgdorferi, the pathogen transmitted to humans by the bite of an infected deer or mouse tick. While most patients who are bitten do not present with infection, those who do must obtain early and effective diagnosis and treatment in order to minimize the development of systemic, long-term complications.

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The Life Cycle of a Tick The deer tick has a two-year life cycle. The first year, they are harmless; the second year, they are potentially infectious. The cycle begins in the spring. Females lay 2,000 to 3,000 eggs that hatch in late summer as uninfected larvae. Once born, the newly hatched ticks begin searching for their first blood meal from small vertebrate animals, usually the white-footed mouse, or birds. If this host has the spirochete, it can be transmitted to the larvae. The host that has the spirochete is not infected, but does act as a

depending on the geographic location.

reservoir and passes the spirochete on to the biting tick. The ticks feed and then lie inactively in the forest leaves during the fall and winter months as they grow into nymphs. In the spring the nymphs, many of whom now carry the spirochete, feed again. If the source of their meal is a human, the spirochete can transfer to the person and infection can result.

yy It takes about 36 to 48 hours for a tick to feed, and infection will not develop unless the tick is attached and feeding. The more quickly a tick is spotted and safely removed, the less the chance of infection. In fact, tick removal within about 24–36 hours results in minimal risk to the host.

In the late summer or early fall, the ticks start to mature to adults and start searching for a host for their meals. The preferred host is the white-tailed deer. The deer do not become infected, but are important in transporting ticks and maintaining tick populations. Most infections occur from bites in the spring and summer, with early clinical manifestations experienced in May through October. Most diagnoses happen in June and July since that is typically when the rash presents and patients see their physician.

yy Due to the life cycle of B. burgdorferi in ticks, a tick must be attached to a person for two to three days to cause infection. Until the tick feeds, only small numbers of bacteria are present. Once feeding begins, the bacteria multiply in the gut of the tick and, after two to three days, migrate to the salivary glands. The tick then injects the bacteria into the host’s bloodstream as the tick completes its feeding. Until this burgeoning occurs, ticks are rarely able to pass on the infection.

The Cycle of Infection

Once the bacteria is transmitted, either:

First, the tick attaches to and feeds on an infected but asymptomatic host, typically a deer or a mouse. The tick then becomes infected, and at its next feeding can infect its new host by transferring bacteria into the host’s bloodstream. For a number of reasons, only about 1% of all tick bites occurring in an endemic area ultimately result in Lyme disease. yy Risk varies depending on the population of infected deer ticks — it ranges from 3–50%,

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yy The spirochetes will be destroyed by the person’s immune system. Patients will be seropositive due to exposure, but will remain asymptomatic; yy The spirochetes will cause a local infection; or yy They will circulate to distant sites, causing disseminated disease.

Diagnosis Early diagnosis and treatment are proven effective in preventing late-stage complications. Patients diagnosed correctly, and effectively treated, can anticipate symptom resolution within four weeks. Only a small percent of patients do not respond to antibiotic treatment, or develop a late relapse. If left untreated, Lyme disease can lead to a number of serious, often irreversible, complications in addition to the challenges and controversies associated with late disease.

tickencounter.org/images/SeasonalPatternOfLymeDisease.jpg

At the site of inoculation, the spirochete often causes a localized rash. It can then spread hematogenously to the skin, heart, nervous system, joints, and other organs, leading to numerous potential symptoms. Timely recognition and effective antibiotic treatment typically allow for rapid symptom improvement, and minimize the likelihood of long-term manifestations. There are three stages of tick development: larvae, nymph and adult. In their nymphal stage, the ticks primarily feed in the late spring and early summer. The majority of Lyme disease cases result from bites by infected nymphs. It is not necessarily that nymphs feed more, but they are small, about the size of a sesame seed, and less likely to be spotted and removed. Adults, which feed predominantly in the fall, are larger and more likely to be noticed in time.

being the specific type of tick.1 The incidence, however, varies enormously between states. For example, in states such as Alabama or Ohio, the incidence of Lyme disease is 8 years of age, yy The attached tick can be readily identified as an adult tick and is estimated to have been attached for ≥36 hours, yy The prophylaxis can be started within 72 hours of the time that the tick was removed, yy The local rate of infection of these ticks with B. burgdorferi is ≥20%, and yy Doxycycline treatment is not contraindicated. Whether prescribed antibiotic prophylaxis or not, patients should be monitored closely for signs and symptoms of tick borne disease for up to 30 days. Prompt medical treatment should be initiated at the first sign of symptom development. First- and second-line treatment recommendations have been developed by the IDSA, and specific orders should depend on stage and manifestations, including whether oral or intravenous antibiotics are most appropriate. Published treatment guidelines recommend a therapy duration of 14–28 days based on clinical findings and stage of the infection.3,4

Current guidelines support that retreatment may be required for patients with Lyme disease whose specific symptoms of Lyme disease (excluding symptoms of fibromyalgia or chronic fatigue) do not improve. Patients who continue to improve but plateau in their improvement may also need retreatment. Given the cost and convenience, a 30-day course of oral therapy may be indicated before repeating an IV course.

Post-Lyme Disease Up to half of patients with Lyme disease develop a condition termed post-Lyme disease, presenting with symptoms that may persist for years, often compared to fibromyalgia or chronic fatigue syndrome. Unfortunately, there is no well-accepted definition of postLyme disease syndrome. In fact, there remains long-standing controversy as to its existence. Many clinicians believe that patients who complain of persistent symptoms were most likely misdiagnosed to begin with and do not have Lyme disease. A number of experts, however, believe that post-Lyme disease is extremely serious and difficult to treat. The IDSA continues to support that there is a lack of evidence for a chronic Lyme disease diagnosis. In fact, in June 2011, its Lyme Disease Review Panel concurred that all of the recommendations from the 2006 guidelines are medically and scientifically justified in light of the evidence and information provided, including the recommendations that are most contentious: that there is no convincing evidence for the existence of chronic Lyme infection; and that long-term antibiotic treatment of “chronic Lyme disease” is unproven and unwarranted.4 According to the IDSA, there is no convincing biologic evidence for the existence of B. burgdorferi infection after patients complete the recommended treatment regimens

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for Lyme disease, and this antibiotic therapy is not recommended for patients with chronic (≥6 months) subjective symptoms if they were already treated with the recommended antibiotics.4 However, a segment of the medical profession is convinced of the presence and impact of chronic Lyme disease, often prescribing long-term intravenous antibiotics.

Prevention There is no current vaccine against Lyme disease. While avoiding exposure is the best way to prevent infection, it is not always possible or ideal. These common sense precautions, however, can help reduce the risk:5 yy Wear light-colored clothes, longsleeved shirts, and long pants tucked into socks or boots, and even high rubber boots. yy Apply insect repellents containing DEET. Adults can use repellents that contain a DEET concentration of up to 35%; small children should use products with a concentration of 6–10%. A 10% solution lasts about 12 hours, while a 20% sustained-release DEET solution can last 24 hours. Infants under 12 months should use nonDEET repellents; however, these products are not as effective, as their protection lasts only about 20 minutes. yy Spray clothes (not skin) and gear with a solution containing permethrin (Permanone®, Duranon, Permakill) to provide additional protection. Permethrin remains protective through several washings. Pre-treated clothing is also available. yy Self-inspect several times a day. yy When returning from outdoor activities, run clothes through the dryer for 30 minutes at a high-

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heat setting. Simply washing clothes will not kill ticks. yy Upon return from tick-infested areas, conduct a full-body tick check using a hand-held or fulllength mirror to view all parts of your body. Parents should check their children for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in the hair. yy Bathe or shower as soon as possible after coming indoors (preferably within two hours) to wash off and more easily find ticks on your body. yy Examine gear and pets. Ticks can ride into the home on clothing and pets, then attach to a person later. Carefully examine pets, coats, and day packs. Tumble clothes in a dryer on high heat for an hour to kill remaining ticks. If an attached tick is discovered, prompt removal is important. The safest and most effective way to remove an attached tick is to grasp the tick’s mouth area with clean tweezers as close to the skin as possible, pulling upward with a steady, even pressure. It is important to avoid twisting or crushing the tick, or handling it with bare fingers, as this can spread infection. Noxious substances such as a hot match, petroleum jelly, or nail polish prolong exposure time and may cause the tick to eject the spirochete into the body. Once the tick is removed, wash the area with rubbing alcohol, an iodine scrub, soap and water, or antiseptic to destroy any contaminating microorganisms. t

starting any course of treatment or supplementation, particularly if they are currently under medical care, and should never disregard medical advice or delay in seeking it because of something set forth in this publication. References 1. www.cdc.gov/lyme/stats/index.html. Updated November 22, 2011. Accessed March 6, 2012. 2. Johnson BJB. Testing for Lyme disease: follow the steps. http://www.medscape. com/viewarticle/758995?src=nl_topic. Posted March 5, 2012. Accessed March 5, 2012. 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 Disease Society of America. Clinical Infectious Diseases. 2006; 43:1089-1134. 4. Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA). April 22, 2010. Updated June 2011. Accessed March 5, 2012. 5. Adapted from www.cdc.gov/lyme/toolkit. Accessed April 3, 2012.

*Do not use the information in this article to diagnose or treat a health problem or disease without consulting a qualified physician. Patients should consult their physician before

C O R A M ’ S C O N T I N U I N G E D U C AT I O N P R O G R A M

VOLUME 8

Self-Assessment Quiz: Lyme Disease LEARNING GOAL

LEARNING OBJECTIVES

To understand the clinical complexities of Lyme disease.

At the end of this program, the reader will be able to: 1. Define Lyme disease, including its incidence and risk factors for development. 2. Identify typical symptoms of Lyme disease and challenges of diagnosis. 3. Identify common courses of treatment for Lyme disease. 4. List preventive measures for Lyme disease.

SELF-ASSESSMENT QUESTIONS

In the Quiz Answers section on the next page, circle the correct answer for each question. To obtain two (2.0) contact hours toward CE credit, the passing score is 100%. Return your Self-Assesment Quiz to Coram via email, fax or mail. See the next page for details on how to return to your quiz. Please allow approximately seven days to process your test and receive your certificate upon achieving a passing score. 1. Lyme disease is caused by a: a. Virus b. Fungus c. Bacterium 2. A person is very likely to become infected with Lyme disease when bitten by a tick. a. True b. False 3. One of the first signs of Lyme disease is: a. Arthritic symptoms b. Erythema migrans c. Flu-like symptoms 4. A patient who presents with an engorged attached tick is likely to be treated with a single dose of doxycycline if: a. He or she is a teenager. b. The tick is estimated to have been attached for ≥36 hours. c. The antibiotic can be started within 72 hours of the time of tick removal. d. The local rate of infected ticks is ≥20%. e. All of the above. f. A, B and C

5. Current guidelines support that patients with Lyme disease whose symptoms (excluding symptoms of fibromyalgia or chronic fatigue) do not improve may require retreatment. a. True b. False 6. A patient with erythema migrans will progress to stage 2 infection. a. True b. False 7. The most common neurological manifestation of Lyme disease is: a. Radiculoneuritis b. Meningitis c. Bell’s palsy d. Cognitive changes 8. Serologic testing is required to confirm a diagnosis of Lyme disease. a. True b. False 9. Arthritis is a common early manifestation of Lyme disease. a. True b. False 10. Patients at risk for exposure to infected ticks should be vaccinated against the disease. a. True b. False

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C O R A M ’ S C O N T I N U I N G E D U C AT I O N P R O G R A M

Lyme Disease QUIZ ANSWERS Circle the correct answers below to receive 2.0 Continuing Education credits.* 1.

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To obtain Continuing Education credits, please complete this information in full. Please print clearly. Name: _____________________________________________________________ Address: ___________________________________________________________

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City: ________________________________ State:________ Zip:___________ License Number (required to receive CEs): ______________________________ d

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 Certified Case Manager

Employer:__________________________________________________________ c

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*Accreditation Information • Provider approved by the California Board of Registered Nursing, Provider Number 15200 for 1.0 contact hours. • Coram CVS/specialty Infusion Services is approved by the Delaware Board of Nursing, Provider Number DE-14-010517. • Coram CVS/specialty Infusion Services is approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers.

Coram offers other Continuing Education opportunities on home care topics. Contact your local Coram Representative for more information.

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