Beyond the bull&#039;s eye: Recognizing Lyme disease

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Applied Evidence

Beyond the bull's eye: Recognizing Lyme disease

J Fam Pract. 2016 June;65(6):373-379

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From The Journal of Family Practice | 2016;65(6):373-379.

References

1. Centers for Disease Control and Prevention. Lyme disease data. Available at: http://www.cdc.gov/lyme/stats. Accessed April 19, 2016.

2. Lantos PM, Nigrovic LE, Auwaerter PG, et al. Geographic expansion of Lyme disease in the Southeastern United States, 2000-2014. Open Forum Infect Dis. 2015;2:ofv143.

3. Gerstenblith TA, Stern TA. Lyme disease: a review of its epidemiology, evaluation and treatment. Psychosomatics. 2014;55:421-429.

4. Wright WF, Riedel DJ, Talwani R, et al. Diagnosis and management of Lyme disease. Am Fam Physician. 2012;85:1086-1093.

5. Marques AR. Lyme disease: a review. Curr Allergy Asthma Rep. 2010;10:13-20.

6. Borchers AT, Keen CL, Huntley AC, et al. Lyme disease: a rigorous review of diagnostic criteria and treatment. J Autoimmun. 2015;57:82-115.

7. Shapiro ED. Clinical practice. Lyme disease. N Engl J Med. 2014;370:1724-1731.

8. Cook MJ. Lyme borreliosis: a review of the data on transmission time after tick attachment. Int J Gen Med. 2014;8:1-8.

9. Tibbles CD, Edlow JA. Does this patient have erythema migrans? JAMA. 2007;29:2617-2627.

10. 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. Clin Infect Dis. 2006;43:1089-1134.

11. Khalil S, Padala SK, Hui CC, et al. Lyme carditis in the fast lane: from alternating bundle branch block to asystole in 12 hours. Conn Med. 2015;79:517-520.

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18. Berende A, ter Hofstede HJ, Vos FJ, et al. Randomized trial of longer-term therapy for symptoms attributed to Lyme disease. N Eng J Med. 2016;374:1209-1220.

19. Ogden NH, Lindsay LR, Schofield SW. Methods to prevent tick bites and Lyme disease. Clin Lab Med. 2015;35:883-899.

Prevention: Simple measures pay off

Advise patients to avoid ticks by avoiding brushy areas, especially at times when ticks are active. Wearing appropriate outdoor clothing (light-colored garments, long-sleeved shirts, and pants tucked into socks or boot tops) are key preventive steps. The possibility of transmission of B burgdorferi from an infected tick increases with time of attachment. Therefore, individuals spending time outdoors should apply insect repellent (N,N-diethyl-3-methylbenzamide (DEET) or permethrin), check for ticks daily, and remove them promptly if found. Applying pesticides and managing the landscape on one’s property also helps control tick populations.

Antimicrobial prophylaxis with a single 200-mg dose of oral doxycycline is appropriate for a patient who has no contraindications if there is known tick exposure and the patient lives in an area with at least a 20% incidence of Lyme disease, or for any patient who has a tick still attached (and it has been there for 36 hours).^6,10 Prophylaxis can be started within 72 hours of tick removal.

Monitor all patients closely for up to 30 days for signs and symptoms of tick-borne diseases.

A Lyme-disease vaccine in humans was approved by the FDA in 1998, but was removed from the market in 2002 because of poor sales and theoretical concerns about triggering autoimmune arthritis.^{1,4-6,8,10,19}

CASE › Ms. L’s FP opts to forgo doxycycline prophylaxis because she discovered the tick on her arm within 24 hours of the hiking expedition and removed it completely intact. In addition, the FP factored into her decision the fact that Lyme disease is not prevalent in Florida. The FP advised Ms. L about the signs and symptoms to watch for and made sure that a follow-up telephone appointment was scheduled for the next 4 to 6 weeks. Ms. L was also given ample educational pamphlets on the prevention of tick bites and Lyme disease.

CORRESPONDENCE
Sayed K. Ali, MD, FACP, Orlando Veterans Affairs Medical Center, 13800 Veterans Way, Orlando, FL, 32827; sayed.ali@va.gov.