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Lyme disease: Then and now

Posted Sunday, June 25, 2006

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While leafing through a patient's medical record recently, preparing it for electronic scanning, I came across a barely legible note by a former colleague dated July 13, 1975. The patient, then a 45-year-old high school gym teacher and scoutmaster, came to see the doctor after three days of fever, chills, and night sweats. He had a 101-degree temperature and a 6-inch-wide rash on his back described in the chart as a "target" with alternating red circles emanating outward from a dark red spot--a then-uncommon type of rash called erythema migrans. Aspirin and bed rest were prescribed. Follow-up notes two weeks later read, "patient better, afebrile (no fever); rash has faded."

This was about the same time that a group of determined mothers in the small Connecticut town of Old Lyme began demanding a medical explanation for the rashes, fevers, and inflamed joints that were afflicting their children. They managed to attract the attention of medical researchers, who slowly began to unravel the tangled thread that linked those rashes and joint complaints to a previously unknown microscopic organism spread by the ubiquitous deer ticks that inhabited the woods.

Thus was Lyme disease "born." It has now been reported in virtually every state and is endemic in a dozen states in the Northeast and upper Midwest.

For almost as long as the disease has been around, it has been a source of controversy and confusion. Early diagnosis has been difficult, especially for the 20 to 30 percent of patients who don't develop the rash. A vaccine was developed, then removed from the market amid uncertainties about its safety and effectiveness. Doctors and patients have argued about the appropriate type and duration of antibiotic treatment. But in the past few years researchers have learned much more about optimal treatment.

When and how to treat

Early treatment of Lyme disease is critical; the longer the time between infection and treatment, the more likely it is that the patient will develop so-called "late manifestations" of the disease, such as painful, swollen joints, heartbeat conduction problems, facial nerve palsies, or chronic meningitis.

For that reason, anyone living in an endemic Lyme area who develops the rash should receive immediate antibiotic treatment--no blood test needed. A 2003 study reported in the Annals of Internal Medicine found that 10 days of doxycycline works just as well as the standard 20-day course.

An even faster treatment is possible for those "lucky" enough to find an engorged deer tick on their body. A single large dose of doxycycline within 72 hours of tick removal will prevent the development of Lyme disease nearly 90 percent of the time. Again, this tactic should only be used in areas with a high incidence of Lyme.

If neither a tick nor a rash is discovered, diagnosis can be made only when a later manifestation appears. Treatment at that time doesn't always have a happy outcome. Symptoms usually, but not always, clear up with three or four weeks of intravenous antibiotics. Nonspecific symptoms, such as cognitive defects, memory loss, or fatigue, are the least likely to respond to antibiotic treatment. Many self-help groups and Lyme disease clinics advocate treating those symptoms with repeated courses of intravenous antibiotics. Unfortunately, clinical studies have shown such treatments don't help and may actually cause harm from antibiotic side effects.

Prevention preferred

Since treatment with antibiotics has no guarantee of success in all cases, prevention is the preferred way to avoid this disease.

  • Wear protective clothing, such as long pants and sleeves, and tuck pants into socks, especially when walking in low grass or past low-growing brush.

  • After a walk or a hike, check yourself for ticks. If you find one, grasp it with tweezers close to the skin and slowly but firmly pull it off.

  • Use a deet-based insect repellent on your exposed skin or permethrin on your clothes. Picaridin, a mosquito repellent introduced in 2005, has not yet been thoroughly tested against ticks.

  • To deny ticks a comfortable habitat in your yard, keep your grass cut short and place a strip of wood chips or gravel between your lawn and surrounding shrubs and wooded areas.

And our gym teacher? Despite never having received antibiotics, he did not develop late complications and has remained in good health. A Lyme disease test five years ago was negative, which makes me wonder: Did he actually have Lyme disease at all--or did he just have the luck to escape it?


This information is for educational use only, and is not a substitute for prompt professional medical advice.

The sooner you spot and remove a tick, the less likely you are to get Lyme disease. But if you do get infected, early treatment works best. and your doctor can guide you through treatments for Lyme disease that work well.

Subscribe to today and find out which medications are best for treating Lyme disease and more than 100 other medical conditions.

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