Friday, May 25, 2012

Lyme Disease: Q&A with Dr. Mark Pasternack

Mark Pasternack, MD
Mark Pasternack, Chief,
Pediatric Infectious Disease

Q: What’s the best way to protect my child against Lyme disease?

A: Appreciation of tick exposure risk is the best preventative measure. This includes:

  • Minimize exposure to known tick-infested areas. At home, maintaining low cut lawns and removing brush and leaves reduces the local tick population. Tick pesticides can be considered as well.
  • Wear appropriate clothing: ideally, long pants (tucked into socks) to minimize leg exposure, and long sleeve shirts to reduce arm exposure ...not very practical in hot weather
  • Use insect repellent: Insect repellants have proven efficacy in reducing the risk of tick bites. Use products with permethrin on clothing and products with DEET on exposed skin.
  • Check your children (and yourself) for ticks: Most importantly, tick checks each evening for children spending time out of doors. Special emphasis should be placed on the groin, armpits, and scalp. Older children should be taught to examine themselves, since adolescents are not eager to undergo inspection by their parents. Ticks removed on the day of exposure should not pose a risk of Lyme disease transmission (or transmission of other tickborne pathogens).

Q: What are the symptoms of Lyme disease? 

A: The rapidly enlarging bull's eye rash known as erythema migrans is the most common sign of Lyme disease, beginning at the site of a tick bite and appearing 1-2 weeks later. It occurs in roughly 3/4 of patients with Lyme disease.

Symptoms of a flu-like illness frequently accompany the rash, including joint pain, fatigue, headache, fever, or neck pain. The development of these nonspecific symptoms in the summer, in the absence of sore throat, cough, runny nose, etc. may suggest possible early Lyme disease but more commonly are due to other viruses which commonly circulate in the summer.

No specific clinical features are associated with Lyme disease in children.

Q: What should I do if I find a tick on my child?

A: Ticks should be removed with tweezers, and care should be taken to remove the mouthparts entirely. The area should be cleansed thereafter. 

Q: Should I save the tick and bring it to the doctor? 

A: I generally do not recommend laboratory analysis of ticks, since the presence of Lyme disease in the tick does not confirm transmission of infection to the child, and the failure to detect Lyme disease in the analyzed tick does not exclude the possibility of Lyme disease transmission. The cost of tick analysis is sometimes the parents' responsibility, and may be significant.

Q: Do antibiotics cure the disease or will symptoms recur in the future?

A: Antibiotic therapy is believed to be curative. A small fraction of individuals (~10%) have continuing symptoms which are felt by most authorities to reflect a post-infectious syndrome (similar to the fatigue that can follow an episode of acute infectious mononucleosis) and not to reflect evidence of ongoing Lyme disease infection. 

Q: Is it possible to contract Lyme in urban communities?

A: Yes, although the incidence is reduced. Parks, back yards and playgrounds may harbor ticks, and day excursions to higher risk areas may increase the risk of acquiring Lyme disease.

Q: What if we visit a high-risk area? Should my child be treated with antibiotics?

A: Antibiotic courses are not recommended for asymptomatic individuals visiting a high risk area, since the treatment of older children with doxycycline carries the risk of sun sensitivity, and since much of eastern suburban and exurban Massachusetts are now considered high risk areas in their own right.

Doxycycline has been used as post-tick bite prevention (prophylaxis) by giving one double dose (200 mg in adults) following removal of an adherent feeding tick. This reduces the risk of Lyme disease development by 50% or so. No recommendations for post-tick bite prophylaxis using other antibiotics have been developed for younger children (below age 8) in whom doxycycline is generally contraindicated.

Lyme disease therapy is readily available for all individuals with clinical illness.  Doxycycline is typically given to children over age 8; amoxicillin, cefuroxime, or azithromycin are all oral options for the treatment of Lyme disease in children younger than 8 years of age.

Q: With children rolling around on lawns during the summer, is there any non-toxic lawn care which would lessen the chances of ticks inhabiting them? 

A: Lawn treatment reduces the risk of tick exposure. Carbamates, pyrethroids (e.g., pyrmethrin), and pyrethrums (pyrethrin) are considered rather safe due to poor skin absorption and inherent mode of activity.

Q: I often wonder whether my family is better off being exposed to repellants all summer and the toxins that enter our well water from the lawn insect treatments we use or receiving a course of antibiotics in September. I know we want to be careful with overusing antibiotics, but on balance which risk is greater?

A: I do not recommend routine antibiotics at the end of the summer. Antibiotics are safe when used appropriately, although like any medical intervention they are not totally free of risk and complications.

Q: Why is there so much controversy around testing for Lyme? 

A: Patients who believe they have advanced or "chronic Lyme disease" often lack antibodies against Lyme disease, and feel therefore that testing is insensitive. Most authorities feel that Lyme antibody testing is reliable, and that patients with prolonged symptoms and negative antibody tests have other fatiguing illnesses.

Q: What do you think of Bismacine/Chromocine in injectable form or as a treatment for Lyme disease?

A: This product contains the heavy metal bismuth and has been associated with deaths and serious organ toxicities. No injectable form of bismuth is approved by the Food and Drug Administration (FDA).

Q: When will a vaccine be available?

A: A vaccine was available for several years (Lymerix™) but is now off the market. It had modest effectiveness and required 2 injections. It offered roughly 2 years of protection against Lyme disease. The vaccine was generally not covered by insurers and was not widely used. Some theoretical concerns about its safety were raised as well. New experimental vaccines are under development but are not likely to reach clinical practice for several years.

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