Applied Evidence

Beyond the bull's eye: Recognizing Lyme disease

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

Author(s):

A rash occurs in 80% of Lyme disease cases, but only about a third of the rashes develop into a classic bull's-eye lesion. Here’s what to look for and how best to treat.

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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.

12. Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med. 1995;98:25S-28S.

13. Blaut-Jurkowska J, Jurkowski M. [Post-Lyme disease syndrome.] Pol Merkur Lekarski. 2016;40:129-133.

14. Steere AC, McHugh G, Damle N, et al. Prospective study of serologic test for lyme disease. Clin Infect Dis. 2008;47:188-195.

15. Carris NW, Pardo J, Montero J, et al. Minocycline as a substitute for doxycycline in targeted scenarios: a systematic review. Open Forum Infect Dis. 2015;2:ofv178.

16. Marques AR. Lyme Neuroborreliosis. Continuum (Minneap Minn). 2015;21:1729-1744.

17. American Academy of Neurology. Treatment of nervous system Lyme disease. Available at: https://www.aan.com/Guidelines/home//241. Accessed May 13, 2016.

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.

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PRACTICE RECOMMENDATIONS

› Consider the duration of a tick’s attachment and whether it was engorged when assessing an individual’s risk of acquiring Lyme disease. C
› Start treatment for Lyme disease without lab testing if a patient has the painless skin rash—erythema migrans—and a history of tick exposure. C
› Choose doxycycline as first-line treatment for early Lyme disease unless a patient has contraindications. Amoxicillin or cefuroxime axetil are suitable alternatives. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › Alice L, a 39-year-old woman with an unremarkable medical history asks to see her primary care provider right away, concerned she might have contracted Lyme disease. She had been hiking the overgrown trails on her family-owned ranch in Florida, and the next day she noticed a black tick stuck to her forearm. Using tweezers, she pulled the whole tick off intact, put it in a plastic cup, and immediately sought medical attention. How should her family physician (FP) advise her?

Lyme disease is the most common tick-borne illness in the United States, with more than 25,000 cases confirmed in this country in 2014.¹ It is concentrated mostly in the northeast and upper Midwest, and less frequently occurs in the Pacific coastal regions of Oregon and northern California. Cases have also increasingly been reported in the southwest region of the Appalachian Mountains and the mountainous regions of southern Virginia.²

In 2014, the only states reporting no incidence of Lyme disease were Colorado, Hawaii, Louisiana, New Mexico, and Oklahoma.¹ Lyme disease is also endemic in several regions in Northern Europe, Eastern Asia, and Northern Africa.^1,3-7 According to the Centers for Disease Control and Prevention (CDC), boys ages 5 to 9 years are most affected.¹

Disease transmission: Duration of tick attachment is important

The spirochete that causes Lyme disease, Borrelia burgdorferi, is transmitted to humans by the Ixodes tick. The Ixodes scapularis (deer tick) is common in the eastern and northern midwestern states and I pacificus is common in the western United States.

The life cycle. These small, dark-colored ticks have a 2-year life cycle that is comprised of 4 developmental stages: egg, larva, nymph, and adult. Eggs are laid in spring and hatch into larvae during late summer. The larvae feed on small animals (eg, mice, chipmunks, birds) and can acquire B burgdorferi infection at this stage. The larvae then molt into nymphs (<2 mm, and difficult to see), which feed again the following spring to early summer and may transmit the infection to a new host. Nymphs become adult ticks in mid-October to early-November, when the females feed again, mainly on large animals.