Overview: Lyme Disease

• Lyme disease is a multisystem infection caused by the spirochetal bacterium Borrelia burgdorferi. B. burgdorferi sensu stricto is the only species known to cause human infection in the United States, whereas pathogenic species in Europe include B. burgdorferi sensu stricto, Borrelia garinii, and Borrelia Afzelii, among others. Seven pathogenic species have been identified in Asia.

• In 1977, Lyme disease was characterized by Steere et al and named for the geographic area (Lyme, Old Lyme, and Haddam, Connecticut) where 39 patients presented with arthritic symptoms of previously unknown cause, although individual cases of Lyme borreliosis were described in Europe in the early twentieth century.

• Lyme disease is the most common vector-transmitted disease in the United States. Approximately 20,000 cases of Lyme disease are reported to the Centers for Disease Control and Prevention (CDC) each year, although the CDC notes that these rates reflect both overdiagnosis of cases and over-all underreporting. Most (95%) reported cases occur in the northeastern and midwestern areas of the United States in 12 states (Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Wisconsin).

Important Points to Consider

• Be careful to assess the diagnostic workup of any new patent who presents with chronic persistent symptoms attributed to Lyme disease. Patents often diagnose themselves by using unreliable symptom checklists found on the Internet.

• EnzymeIinked immunosorbent assay (ELISA) testing is associated with many false-positive results hence the need for confirmation of a positive o ELISA by Western bist. A negative ELSA conversely, does warrant further serologic testing.

• In many conditions, complementary and alternative medicine(CAM) patients and providers are promoting therapies than the mainstream standard of care. Lyme disease is an unusual case in which CAM patients and providers are often seeking more invasive and elaborate interventions than conventionally provided.

Prevention Prescription

• Clear brush and trees, remove leaf litter and woodpiles, and keep grass mowed.

• Wear light-colored clothing that covers the skin to aid in identifying and protecting from tick bites. Tuck pant legs into socks when outdoors in vegetated areas.

• Apply tick and insect repellants containing DEET INN-diethyl-3-methyltoluamide), although excessive doses have been reported to cause neurologic complications in children.

• Permethrin, a synthetic pyrethroid applied to clothing is effective in killing ticks. Toxicities have been reported at high doses

• A plant-based insect repellant containing of lemon rucalyptus has been shown to protect from mosquitoes, but it has not demonstrated efficacy against ticks.

• The most effective methods shown to reduce the risk of Lyme disease in endemic aress are the use of protective clothing and of tick repellants on the skin and clothing.

• Check skin for ticks after being outdoors in the late spring and summer months in endemic areas.

• Bathe within 2 hours after spending time in vegetation.

• Pesticides are effective, but recommendations are tempered by environmental concerns and the risk of harming children and wildlife.

• Reduce the risk of Lyme disease after a tick bite: Remove ticks with fine-tipped tweerers. Using a steady

  motion, grasp the tick as close as possible to the skin. Pull directly away from the skin. Do not use petroleum jelly, nail polish, or heated instruments to remove a tick.

• Monitor for signs and symptoms of Lyme disease after a tick bite.

• Consider antimicrobial prophylaxis (200 mg doxycycline in a single dose for adults or 4 mg/kg up to a maximum dose of 200 mg for children older than 8 years old, and 250 mg of amoxicillin in children younger than years old) if a tick is attached for more than 48 hours in an endemic area, although risk of Borrelia burgdorferi infection is low, 1.2% of untreated children in a large cohort developed Lyme disease after a tick bite in a highly endemic area. Treatment subsequent to symptom onset was associated with a complete recovery.

Integrative therapeutics review

Acute Lyme Disease

• Antibiotics for early Lyme disease

• Doxycycline: 100 mg twice per day for 14 days (range, 10 to 21 days),

• Amoxicillin: 500 mg three times per day for 14 days (range, 14 to 21 days),

• Cefuroxime axetil: 500 mg twice per day for 14 days (range, 14 to 21 days),

• Antibiotics for early Lyme disease with neurologic manifestations

• Doxycycline: 200 mg per day for 14 days

• Ceftriaxone: 2g once per day intravenously for 14 days(range, 10 to 28 days)

• Cefotaxime: 2g intravenously every 8 hours

• Penicilin G: 18 to 24 million units per day divided into doses given every 4 hours

Supplements

• Probiotics: Lactobacillus GG, Lactobacillus sporogenes, or Saccharomyces boulardii, 5 to 40 billion colony-forming units (CFUs)/day throughout the duration of antibiotic treatment

Chronic Persistent Symptoms

Pharmaceuticals

• Antiinflammatory treatments: nonsteroidal antiinflammatory drugs, intra-articular steroid injections, disease-modifying antirheumatic drugs; varied as needed

• Antibiotics (long-term, intravenous): varied, only when borreliosis is confirmed.

• Gabapentin: 300 mg/day, titrating up to a maximum tolerated dose within 4 to 12 weeks (average dose, 700 mg)

Botanicals

• Uncaria tomentosa (cat's claw): 60 mg daily in three divided doses of an extract free of tetracyclic oxindole alkaloids

Nutrition

• Antiinflammatory diet (see Chapter 86, The Antiinflammatory [Omega-3] Diet)

• Aerobic and weight-bearing exercise: 15 to 30 minutes two to three times weekly for at least 4 weeks

Supplements

• Probiotics: Lactobacillus casei strain Shirota, 24 billion CFUs; available in a fermented milk product.

• Omega-3 fatty acids: 2500 mg of omega-3 fatty acids (with 50% or more eicosapentaenoic acid) per day

• Intravenous micronutrients therapy: Myers cocktail, 37 ml. infused weekly

Biomechanical therapies

• Acupuncture: 20-minute individualized session weekly

• Massage therapy: Swedish or other massage approach, 30 to 60 minutes, once or twice weekly,

Mind-body therapy

• Tai chi: group course with an experienced teacher twice weekly for at least 12 weeks

• Mindfulness meditation or mindfulness-based stress reduction: group course with a weekly meeting and daily practice

Key Web Sources

• http://www.cdc.gov/lyme

• http://itunes.apple.com/us/app/lyme-disease-tick-map/id369913510?mt=8

• http://www.tickencounter.org/