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Diagnosis And Treatment Of Lyme Disease

Updated on February 15, 2016

Microscopic Appearance of Borrelia burgdorferi

Source

Diagnosis of Lyme Disease

Lyme disease has now become a very common vector borne infection. Persons of all ages and both sexes can suffer from the disease.

The increased incidence is due to the spread of tick vectors to new areas, and the encroachment of suburbs on once rural areas, bringing humans and ticks in close proximity.

According to the National Surveillance Case Definition, the criteria to label an illness as Lyme disease include the following :

  1. A person with exposure to a potential tick habitat developing Erythema migrans diagnosed by a physician.
  2. At least one late manifestation of the disease.
  3. Laboratory confirmation.

The serological tests may yield negative results during the first several weeks of infection, and are also unable to differentiate between active and inactive infection. Those with previous Lyme disease - particularly those progressing to late stages - often remain seropositive for years, even after receiving antibiotic treatment. In addition, some individuals show positive results because of asymptomatic infection.

On the other hand, a few people who receive inadequate antibiotic therapy during the initial weeks of infection develop subtle joint or neurological symptoms but are seronegative.

The better part is that , in most cases sero negative Lyme disease is a mild, attenuated illness.

For serological analysis, the CDC (Centers for Disease Control and Prevention) recommends a two step approach.

  • Step - 1 : Samples are first tested by ELISA (Enzyme Linked Immunosorbent Assay).
  • Step - 2 : Equivocal or positive results are tested by the Western Blot method.

Another approach is to use Indirect Immunoflorescence Assay as an initial test.

Western blot assay detects both IgM (early response) and IgG (late response) antibodies to the infection.

IgM antibody appears 2 to 4 weeks after the onset of skin rash, peaks at 6 to 8 weeks, and then declines to low levels after 4-6 months of infection. If the IgM antibody titres remain high more than six months after the initial infection, then it suggests either false positive test results, or constant re infections.

IgG antibodies occur later (appear 6-8 weeks after the onset of disease), peaks at 4-6 months, and may remain elevated at low levels indefinitely despite medication and resolution of symptoms as the infection may persist in a latent form.

Approximately 20-30% people test positive in acute phase samples (within the first one month of infection), whereas, the remaining 70-80% have a positive response during convalescence (2-4 weeks later).

If a person with suspected early Lyme disease has negative results on serological testing, then both acute and convalescent titres should be obtained. A four fold rise in the antibody titre as compared to the baseline is diagnostic of recent infection.

False positive reactions in the ELISA have been reported in cases of syphilis, infectious mononucleosis, and in persons with severe gum disease (due to cross reactivity with oral treponemes). In case of chronic persistent or late Lyme disease the immune system gets involved and autoimmunity and associated conditions begin to show.

False negative results are obtained if tests are performed in very early stages of infection, and when prompt antibiotic therapy is given during early stages, as it aborts seroconversion.

Other less commonly used tests for Lyme disease include the following :

  • Antibody capture ELISA (sensitive for early disease)
  • Detection of immune complexes.


Protect yourself from Lyme disease

What are the common preventive measures against Lyme disease?

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Criteria For Laboratory Evaluation of Individuals With Suspected Lyme disease

Guidelines established by the American College of Physicians for laboratory evaluation of individuals with suspected Lyme disease include the following :

  1. Diagnosis of early Lyme disease is clinical (exposure to endemic areas, physician documented Erythema migrans), and does not require laboratory confirmation.
  2. Late disease requires objective evidence of signs and symptoms, consisting of recurrent and brief attacks of arthritis of large joints (single or a few joints affected at the same time), Lymphocytic meningitis, Bell's palsy, Peripheral neuropathy, Encephalomyelitis, Atrio ventricular conduction defects with or without myocarditis, and laboratory evidence of the disease (Two stage testing).
  3. Individuals with non-specific symptoms and without objective signs should not have serological tests done.

Other Tests To Detect Lyme disease

Other diagnostic tests for specific organ systems affected include the following :

  • Culture - Borrelia burgdorferi may be cultured from skin lesions.
  • PCR - Detection of Borrelia DNA by PCR (Polymerase Chain Reaction) is useful in case of Lyme arthritis. Whether a positive PCR indicates persistence of the microbe, or is a marker of residual DNA (and not active infection) still remains investigational.

Non-specific laboratory abnormalities include the following :

  • Elevated ESR (>20mm/hour)
  • Mildly abnormal liver function tests.
  • Mild anemia
  • Raised white blood cell count (11,000-18,000/micro liter)
  • Microscopically detected blood in urine.

The most common conditions that resemble late Lyme disease are chronic fatigue syndrome and fibromyalgia. Some people develop these chronic conditions in association with, or after Lyme disease. Compared with Lyme disease, these conditions lead to more disabling symptoms that include marked fatigue, severe headache, diffuse muscle and bone pains, multiple symmetric tender points in characteristic locations, pain and stiffness in many joints, and difficulty in concentration. They lack joint swelling and inflammation; and have normal results on neurological testing.

Treatment of Lyme disease

Manifestation
Drug and Dosage
 
Erythema migrans
Doxycycline, 100 mg twice daily for 3-4 weeks; or amoxicillin, 500mg three times daily for 3-4 weeks; or cefuroxime axetil, 500 mg twice daily for 3-4 weeks
 
Neurological disease (Bell's palsy)
Doxycycline, or amoxicillin as above for 3-4 weeks
 
Other central nervous system disease
Ceftriaxone, 2 g IV once daily for 2-4 weeks; or penicillin G, 20 million units daily IV in 6 divided doses for 2-4 weeks; or cefotaxime, 2 g IV every 8 hours for 2-4 weeks
 
Cardiac disease (First-degree block)
Doxycycline oe amoxicillin as above for 3-4 weeks
 
High degree atrioventricular blocks
Ceftriaxone or penicillin G as above for 2-4 weeks
 
Arthritis oral dosage
Doxycycline, or amoxicillin as above for 4 weeks
 
Arthritis intravenous dosage
Ceftriaxone or penicillin G as above for 2-4 weeks
 
Acrodermatitis chronica atrophicans
Doxycycline or amoxicillin as above for 4 weeks
 

The best preventive measure is to avoid being bitten by the Borrelia vector

Source

Prevention of Lyme disease

Simple preventive measures to check the spread of Lyme infection include the following :

  • Avoid tick-infested areas.
  • Cover exposed skin with long-sleeved shirts and wear long trousers tucked into socks.
  • Use tick repellents (such as DEET)
  • Inspect for ticks after exposure
  • Take a shower after returning from the woods.

These measures are especially essential for pregnant women and children below the age of 8 years, in whom the drug of choice Doxycycline use should be avoided, as can cause serious side effects.

Prophylactic antibiotic therapy may be given in situations where follow-up is uncertain; the person is a pregnant woman (antibiotic amoxicillin preferred), or the tick was engorged when removed.

Lyme disease - a vector borne multi organ disease

  • This illness is commonly caused by the spirochete Borrelia burgdorferi, and is characterized by erythema migrans skin rash, progressing into arthritis of large joints, meningitis, Bell's palsy, heart blocks, and peripheral neuropathy.
  • Common laboratory tests to diagnose the disease include ELISA, Western blot, Indirect Immunoflorescence test, PCR, bacterial culture, and detection of immune complexes.
  • Preventive measures to avoid being bitten by the Borrelia vector include use of repellents, protective clothing, and inspecting for ticks after exposure.
  • At present there is no immunization available, but a vaccine against bacterial Osp (Outer surface protein) is undergoing clinical trials.

Prospects of a Lyme disease Vaccine

In 1998 the FDA approved a vaccine for Lyme disease prevention, called LYMErix which was later withdrawn from the markets in year 2002. Protection provided by this vaccine diminished over time. So a person who has been vaccinated against this disease before 2002, is no longer protected against the disease

According to the Lancet Infectious Disease, a new vaccine is undergoing phase-1&2 clinical trials at the Stony Brook University School of Medicine and National Laboratory, that has been aimed at the outer surface protein of the bacteria. By using the scaffold of this protein Osp A, the experts have developed a set of specific proteins that do not normally exist in nature. These new proteins, better known as Chimeras contain components from different species of Borrelia. Thus it is being expected, that after completing the Phase - 3 clinical trials, this vaccine should have a protective effect against all the possible species of Borrelia that are causing the disease in the entire Northern hemisphere.

Mixed infections are a cause of treatment failure

Most areas endemic for Lyme disease are also endemic for babesiosis and ehrlichiosis. Coinfection with the microbes causing these infections may be associated with more severe symptoms than with either agent alone and is another possible explanation for failure to respond to therapy directed at Lyme disease

Reference Sources :

www.webmd.com/rheumatoid-arthritis/arthritis-lyme-disease

lymedisease.org/resources/handouts2.html

www.medicalnewstoday.com/articles/260471.php

Disclaimer: This Hub has information meant for educational purposes. It in no way intends to replace or substitute the advice of your doctor or health care provider.

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    • RockyMountainMom profile image

      RockyMountainMom 3 years ago from Montana

      Thank you for clarifying in your introduction that the definition of Lyme given here is for surveillance purposes. The difference between surveillance criteria and diagnostic criteria can be confusing for doctors and patients, who often don't realize that Lyme disease is a clinical diagnosis, which does not rely on laboratory confirmation, which is extremely unreliable.

      My past comments on this hub, as well as several other people's comments from around the same time, seem to have gotten lost here---your text still states that 20-30% of patients test positive during acute infection and that the remaining 70-80% test positive later. This would be 100% of cases detected through two tiered testing, which is not the case. Multiple studies, multiple labs, and multiply testing methods have evaluated the current two tiered testing criteria and have found that this strategy only correctly identifies 35-65% of positive cases.

      It is very dangerous for patients to think that a negative laboratory test means they don't have lyme disease. I remained misdiagnosed for three years because of false negative laboratory tests. People can die while waiting for treatment.

      More than half of patients with Lyme Disease will test negative using the testing criteria you describe here (if tested at all).

      More than 270,000 of the 300,000 new cases per year will go un-diagnosed or misdiagnosed in the U.S. alone.

      The explanations for false negatives you provided account for a small proportion of false negative results, meaning that hundreds of thousands of patients each year will have false negative results but do not fall within those parameters.

      Delayed care will make their recovery complex and long. In few to no cases will 3-4 weeks of antibiotics be adequate after the average 2-3 year delay in diagnosis due to false negative test results and improper application of surveillance criteria for diagnosis.

      Additionally, there are now peer reviewed studies confirming that multiple species of ticks that transmit lyme to humans, both hard bodied and soft bodied species. Evidence is growing that multiple types of biting insects transmit Lyme to humans.

      Chronic fatigue syndrome and fibromyalgia commonly mimic late state lyme disease, seldom the reverse.

    • Emilia Riera profile image

      Emilia Riera 3 years ago from Philadelphia, Pennsylvania

      I know a child who underwent a regression similar to autism, but at a much older age. It was later attributed to Lyme's Disease. I had no idea that there was once a vaccine. I hope that it is perfected, so that no one else suffers this terrible condition.

    • RockyMountainMom profile image

      RockyMountainMom 3 years ago from Montana

      Following up on earlier concerns....

      READERS PLEASE NOTE

      PLEASE DON'T TAKE THE STATEMENTS IN THIS HUB AS FACT!

      If you suspect Lyme disease, please look for more information. This hub is inaccurate about testing, diagnosis, and treatment.

      I am disappointed to see it promoted so much within Hub Pages lists because THIS INFORMATION IS TERRIBLY DANGEROUS.

      I read and believed similar things and remained misdiagnosed for 3 years, allowing Lyme to spread through every part of my body and destroy my life.

      People can die of Lyme disease, so I find the high visibility of this hub incredibly disturbing.

      I've been fretting about this quite a bit and am even writing a series to address this, since it overlaps with misinformation outside of Hub Pages. But that doesn't change anything for all of the people that may read this hub but not others.

      There are many helpful hubs on this topic, many based on first hand experience. Please read those, too.

      PLEASE DON'T TAKE THE STATEMENTS IN THIS HUB AS FACT!

      (One of the sources list, Lymedisease.org, contains much better information-----the intro of this hub makes many improvements from previous hubs by this author, but from diagnosis forward, this is blatantly contradictory to info you will find from that source.)

    • Social Minds profile image

      Donna S 3 years ago from Southern California

      Yes! I have been tempted to purchase the sequel off the site! Great, I'll be checking out your Hub!

      And looking for you in the film as well ; ) or at least the pole! Lol!

    • RockyMountainMom profile image

      RockyMountainMom 3 years ago from Montana

      P.S. I forgot I had the trailer in Part 2 of my Diagnosis and Treatment Series until I published it just now!

    • RockyMountainMom profile image

      RockyMountainMom 3 years ago from Montana

      It is an amazing film....a sequel has come out, too! It's only available through the documentary website so far, but there's a trailer on youtube (called Emergence). I'm "almost' in the trailer in the scenes from the San Francisco rally---my kids and I laugh about it because I was too tired to stand up for part of the time, so I'm resting on a pole behind the people in the shot---the pole is in the movie, though. I have some of my photos from that day in one of my hubs (including the thumbnail image---it's on why patients are waiting years for treatment).

      I can't wait to see the sequel! (Photos of the director and Jordan Fisher Smith are in that hub, too)

    • Social Minds profile image

      Donna S 3 years ago from Southern California

      I agree with you as well RockyMountainMom regarding cross-referencing this post. I know someone who is struggling currently with the disease. He and his sister got it in utero. That's when I started doing my own research on Lyme Disease. A really good documentary that highlights what it is like to live in the late stages of the disease, it's called Under Our Skin.

    • RockyMountainMom profile image

      RockyMountainMom 3 years ago from Montana

      I think you are spot on regarding that study, Social Minds, in regards to modes of transmission and numbers of patients.

      Readers should also be aware that a number of important aspects of Lyme disease are disputed. The perspectives in this hub are very divergent from those of the Lyme community (Lyme doctors, patients, researchers) and the overall stance of this hub on diagnosis and treatment should be compared with other sources, starting with numerous hubs written by patients that identify the areas where important controversies exist.

      This hub's overall stance on diagnosis and treatment could be very dangerous, so please cross reference this information before drawing conclusions, since the areas of controversy are not disclosed in this hub.

      There is scientific evidence that directly refutes a number of these perspectives (as covered in recent patient-written hubs).

      Some critical examples readers should gain further information on (these and others are covered extensively in other hubs, as well as why it matters--donotfear has written about this, and I have also):

      1. Surveillance criteria should not be used diagnostically

      2. False negatives in the first rung of two tiered testing range from 65-85%, NOT zero as is dangerously stated here

      3. There is a lot more to the issue of anitbiotics and new vaccines than what is stated here

    • Social Minds profile image

      Donna S 3 years ago from Southern California

      I have reason to believe that this disease is also sexually transmitted. There was a fairly recent study that showed the survival of spirochete Borrelia burgdorferi, in semen and vaginal secretions. There are just so many people that have Lyme Disease, I find it hard to believe everyone has been biten by a tick. Any thoughts on this?

    • hypnodoctor profile image

      hypnodoctor 3 years ago

      It's important to know that ticks can hide in your clothes long after you've came back from the hike and inspected yourself. I always wash my clothes after I come from hiking in tick-infested areas. But if you get a tick, don't panic. If you take it out within 24 hours, you should be OK. Great Hub! Voted up.

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