21st Anniversary Program October 1, *Lyme and Tick Borne Diseases* Prevention, Symptoms, Diagnosis & Treatment

Transcription

1 Harford County Lyme Disease Support Group, Inc. 21st Anniversary Program October 1, 2016 *Lyme and Tick Borne Diseases* Prevention, Symptoms, Diagnosis & Treatment Jean F. Galbreath, President PO Box 13 Street, Maryland We sincerely thank the national Lyme Disease Association, Inc. For providing an educational grant to help make this event possible. LymeDiseaseAssociation.org

2 Introduction Lyme disease, once considered a rare and easily treated ailment, is actually a complex infectious disease that can progress to a chronic state and seriously affect even the most healthy individuals and their pets. The discovery of multiple strains of Borrelia spirochetes (over 300 to date), coupled with the fact that several different forms of spirochetes have been documented (spirochetal, spheroplast, cystic form), is merely the underlying foundation of the comprehensive infectious soup currently referred to as Lyme disease. Biofilms also make treating successfully more difficult. To complicate the picture, there are a growing number of tick borne diseases detected in patients with Lyme disease, such as: Bartonellosis- B. duncani (trench fever), B. henselae (cat scratch fever) Babesiosis- Babesia microti, B. divergens, Babesia-MO1, B. duncani (WA- 1), Babesia variant CA1 and more Ehrlichiosis- Ehrlichia chaffeensis, E. ewingii, E. muris (EML) Anaplasmosis- A. phagocytophilium Rocky Mountain & Other Spotted Fevers- Rickettsia rickettsia, R. parkeri, Rickettsia sp. 364D STARI- Southern Tick-Associated Rash Illness or Master s Disease Tularemia- Rabbit Fever- Francisella tularensis Brucellosis- B. melitensis, B. suis, B. abortus, B. canis Leptospirosis- Leptospira interrogans sensu lato Q- Fever- Coxiella burnetii Mycoplasmas- Mycoplasma fermentans More Information On Lyme and Tick Borne Diseases MarylandLyme.org

3 All too often tick borne infections are overlooked or are misdiagnosed and not treated properly. The CDC warns, Early diagnosis and proper antibiotic treatment of Lyme disease are important strategies to avoid the costs and complications of infection and late-stage illness. Tick borne infections have the ability to damage the brain, the peripheral nervous system and the musculoskeletal system. They may also cause a variety of dermatological, pulmonary, gynecological, endocrinological and urological manifestations and are known to cause life threatening cardiac abnormalities. Without prompt and aggressive treatment they may lead to chronic illness, permanent damage, a significant degree of immune suppression or death. If your child has been diagnosed with Lyme or you even suspect they may have Lyme disease it would be to your advantage to locate a competent practitioner who is extremely familiar with updated testing procedures, clinical diagnoses and treating Lyme and the associated infections. To assist in your search for an experienced practitioner please visit LymeDoc.org Unfortunately, many of the local university, hospital and commercial labs are unable to perform the definitive tests required to detect newly discovered strains or forms of bacteria and the variety of additional infections. As a result many people are not tested, not diagnosed and not treated. The CDC states that Lyme disease is, greatly under reported. In fact, they recently reported there are approximately 300,000 new cases of Lyme disease each year in the United States alone, not the 30,000 that had preciously been reported. Education and prevention are essential to reduce the growing number of cases of tick borne illnesses. Children are at high risk for contracting Lyme and tick borne diseases. We hope this publication will assist you in helping educate yourself and your children so we can reduce your risks and you can receive prompt treatment. More Information On Children With Lyme Disease DrJonesKids.org

4 Prevention Anyone spending time outdoors should first plan on enjoying their experience, and they should take sensible precautions to avoid tick exposures. An ounce of prevention is worth a pound of antibiotics! Larval and nymphal deer ticks often hide in shady, moist ground litter, but adult ticks can often be found above the ground clinging to tall grass, brush, trees and shrubs. Ticks also live in lawns and gardens, especially at the edges of woodlands, on fallen trees and around old stonewalls. No natural vegetated area can be considered completely free of infected ticks. Ticks have been known to drop from an overhanging branch or tree limbs making people think they can fly, however, they have no wings. There are many potential hosts for ticks including wild birds and mammals, domestic animals, pets and humans. Once a tick comes in contact with a human it generally climbs upward until it reaches a suitable site, often the back of the knee, groin, navel, armpit, ears, head or neck area. The tick then begins the process of inserting its mouthparts into the skin until it reaches a blood supply. To help prevent exposure to ticks avoid contact with soil, leaf litter and vegetation as much as possible. If children spend time in woods, brush or overgrown fields you should use a combination of precautions faithfully to reduce their chances of getting Lyme and/or other tick borne diseases. Remember ticks can be active when there is an 70% snow covering on the ground. Frequent tick checks during the day should be followed by a detailed tick check each night before going to bed. Consider tucking your pant legs into your socks. Be aware this will give ticks a straight and uninterrupted path to your child s head, especially if their clothes are not treated in advance with a Permanone-based treatment. Don't use fragrances that attract bugs such as perfumed soaps, lotions and creams when going outdoors. Natural insect repellents like citronella, lemon eucalyptus, garlic, rose and geranium oil can be applied to exposed skin (barring sensitivities) for added protection. Keep playground equipment and play areas in sunny locations in your yard.

5 Do not use untreated wood chips in play areas because the chips provide ideal, moist, shaded living quarters for ticks. You may want to keep bird feeders away from the house to discourage mice (a favorite host of ticks) from gathering or nesting near or in your home. Birds carry ticks from one location to another. You should set traps to remove all mice from the home and outbuildings. Ticks can live for over six months without a blood meal. An adult female can produce 2-5 thousand or more offspring. Some homes have been treated for tick infestation after female ticks laid eggs indoors, the eggs hatched and the tiny ticks took up residence. Be sure to remove ticks from your clothing and gear before getting into your vehicle. This will prevent ticks from calling your car their home. To Properly Remove a Tick Follow These Steps Using a pair of tweezers, grasp the tick by the head or mouthparts where it entered the skin. Try not to grasp the tick by the body if possible to help prevent the ticks head or mouthparts from remaining lodged in the skin. Without jerking, pull firmly and steadily- directly outward. Do not twist the tick out or apply soap, petroleum jelly, a hot match, kerosene, alcohol or any other irritant to the tick in an attempt to get it to back out. Doing so can force the ticks fluids into the bite wound increasing the risk of acquiring a tick borne disease. Place the tick in a partially filled bottle of rubbing alcohol to kill it. Mark the bottle clearly with the word "ticks" so it will not be used by anyone for any other purpose. Alcohol bottles have a tight fitting lid and can hold many ticks before having to be disposed of in the trash. Do not crush or burn the tick as that can spread germs in the process. Clean the bite wound with soap, water and a disinfectant to help prevent secondary infections. After the tick is removed, wash your hands and the tweezers with hot soap and water. More Information On Removing An Attached Tick TreatTheBite.com

6 Prevention Tips Check yourself, your children and pets daily for ticks Teach children to check themselves for ticks Wear light-colored clothing to help spot ticks Scan clothing and any exposed skin frequently for ticks while outdoors When possible stay on cleared and well-traveled trails Use insect repellant faithfully- herbal or chemical based products Treat outdoor clothing with a clothing treatment like Permanone Avoid sitting directly on the ground even in the winter Keep long hair tied back or under a hat that has been treated Do a full-body tick-check when ever possible and at the end of the day Prevention Tips For Your Home & Yard Those who enjoy spending time in their yards can reduce tick populations around the home. Keep lawns mowed and edges trimmed Clear away brush, leaf litter and tall grass around houses and at the edges of gardens and walls Stack woodpiles in a dry location and preferably off the ground Clear all excess leaf litter out of the garden in the fall Spray your residential area (areas frequented by humans) with an insecticide in late May (to help control nymphs) and September (to help control adult ticks) You do not need to be fearful or go to extremes to prevent being exposed to ticks, just use some common sense while enjoying the great outdoors. And do enjoy! More Information and Prevention Tips MarylandLyme.org

7 Additional Prevention Information Insect repellents containing DEET should not be used on children under 2 years of age. Oil of lemon eucalyptus products should not be used on children under 3 years of age. Oil of lemon eucalyptus, oil of citronella and IR3535 are repellents made from natural materials such as plants, bacteria and certain minerals. When applying insect repellents to children avoid their hands, eyes and any cut or irritated skin. Do not allow children to handle insect repellents. When using repellents on children, apply it to your own hands and then put it on the child. After returning indoors bathe the child and check for ticks. One of the most effective prevention methods is to spray clothing in advance (allowing it to dry) with Permanone Clothing Treatment. This treatment will kill ticks crawling across the surface of the material. The treatment is effective for two to four weeks when applied properly (check label). Upon returning home, clothes can be placed in a hot dryer for one hour to kill ticks. Simply washing clothes will not kill all ticks. Pets should be checked daily for ticks. Consider treating your pets with one of several products designed to kill fleas and ticks. Contact your veterinarian for more specific advise on the proper flea and tick control for your pet. Remember no tick control product is 100% effective and a daily tick check is still required. Special note to families hunting wild game- Check yourselves, your clothing and your dogs before going home. If you bag a deer or other wildlife wrap the animal in a sheet that has been pre-treated with Permanone as soon as possible. Or once at home hang the deer over an old sheet that has been liberally treated with Permanone. As the deer cools, ticks will drop off and land on the treated material and will be killed. This will help prevent unnecessary exposure for your family, pets and others living in the neighborhood. More Information on Prevention MarylandLyme.org

8 Tick Borne Diseases Signs, Symptoms, Diagnosis and Treatment Anaplasmosis- A. phagocytophilium Anaplasmosis SYMPTOMS- HGA symptoms usually appear within a few days to two weeks after being bitten by an infected tick. Symptoms include severe headaches, fever, chills and shaking, loss of appetite, joint aches and muscle pain. The patient may experience vomiting, diarrhea, cough or a loss of appetite. A rash may appear in a small percentage of patients. Symptoms of HGA may be very mild to quite severe. DIAGNOSIS- Blood tests for Anaplasma infections may be negative, especially in the early phase. Routine blood tests may indicate a low blood platelet count, low white blood cell count or increased liver enzymes. TREATMENT- Adult patients who show signs or symptoms of HGA should immediately be treated with an antibiotic (doxycycline is drug of choice) to reduce the risk of severity and long-term complications. Rifampin is an option for pregnant women, young children, or patients who are allergic to doxycycline. Babesiosis Babesiosis- Babesia microti, B. divergens, Babesia-MO1, B. duncani (WA- 1), Babesia variant CA1 and more SYMPTOMS- The parasite that causes Babesiosis invades and destroys red blood cells and can cause a malaria-like (relapsing) illness that can become chronic and/or can be fatal (10%- 28% fatality rate). Symptoms may appear as a sudden onset or may take months to years to fully develop. There can be "flares" of symptoms every four to six days. Symptoms can include dizziness, depression, suicidal tendencies, low to high intermittent fevers, fatigue that worsens with exercise, anxiety, chills, waves of sweats at night that can also occur during the day, mood swings, soreness or pain on the top of the head, numb spots on head, drenching night

9 sweats, feelings of being off-balance, muscle pains, memory and cognitive disorders, temperature intolerance, racing heart and/or irregular heart beat (often worse at night), breathing difficulties (air hunger- need to sigh and take a deep breath), appetite swings, sensitivity to light, disturbances in autonomic nervous system, enhanced senses, headaches (often pressure headaches- behind the eyes- can feel like head is in a vise), headaches that feel like moving sensations and malaise. Patients with Babesiosis may also experience orthostatic hypotension, episodes of vomiting, panic disorder, hypercoaguable states (thick blood), severe insomnia, obsessive compulsive disorder (OCD), wrist and hand pain, dehydration or swelling, pain in feet/ankles, bleeding tendencies, acute respiratory distress syndrome, unexplained weight gain or loss, dark colored urine (blood in urine), anemia, swollen spleen (can rupture in some cases), enlarged liver, attention deficit disorder (ADD), vivid dreams, nightmares, congestive heart failure, respiratory failure, renal failure, bruising, jaundice, pulmonary edema, myocardial infarction, anorexia, evidence of shock and encephalopathy. Symptoms can range from mild to severe. DIAGNOSIS- Babesia tests are unable to detect the infection in all patients. Therefore, doctors should treat the patient, not the test! It is recommended doctors run multiple tests to improve the chance of detecting the infection. Antibody tests from Quest Lab (includes two strains) and PCR tests from IGeneX Lab for Babesiosis are useful if positive, but a negative result does not rule out the disease. The Babesia organism is rarely detected in blood smears. TREATMENT- A combination of Atovaquone/Mepron, 2-4 T per day (1-2 T, 2x per day) and Zithromax or Biaxin, is a common treatment for Babesiosis. This combination is reported to have less serious side effects than quinine and clindamyacin. Eating fatty foods (bacon, ice cream, etc) while taking Mepron has been reported to increase absorption of the drug. In some patients recovery was not seen until five years into treatment and relapses are fairly common. Heparin inhibits the growth of Babesia and has been shown to eliminate the infection by covering/coating the outer area of red blood cells, preventing the parasites from entering individual cells. When adrenal function is low, response to treatment can be negatively affected.

10 Patients may experience a worsening of the symptoms while treating Babesiosis (reported in some to be during the first two weeks or later). Once this worsening occurs a few times, the patient should enter into a more stable recovery phase, although with each dose increase you may notice more symptoms. Of special note- this worsening is often accompanied by what patients have dubbed the "Mepron Blues", which can be a severe depression, emotional instability, insomnia, rages, aches, pains and an increase in anxiety levels. Bartonellosis Bartonellosis- Bartonella henselae- cat scratch fever, Bartonella quintanatrench or shin bone fever SYMPTOMS- Typically a gradual onset of symptoms. Fatigue, dizziness, stiff legs, pain in feet (especially bottoms of feet- worse in the morning), sweats, restlessness, myalgias, migrating pain in and around joints, heart attacks, heart valve problems, endocarditis (mortality 25%), cardiomegaly, strokes, skin tags, burning and crawling sensations. Aseptic meningitis, encephalopathy, fever, panic attacks, liver or spleen abnormalities, low-grade fever, abscesses, hot flashes, muscle cramps, confusion, abdominal pain, hepatitis, seizures (mild to severe), numbness in hands, rage, depression, difficulty walking, facial numbness, wandering (usually unilateral) joint pain, urinary disorders or arthritis can be present. Tender sub-cutaneous nodules may appear along the outer thigh, triceps shins and other areas of the extremities. Some patients experience acute and relapsing symptom patterns, painful headaches, lymphadenopathy, GI symptoms (gastritis and abdominal pain), cognitive dysfunction and joint swelling. CNS lesions, red splotches or slightly raised red spots on skin, lymph swelling, skin manifestations (acne, stretch marks, subcutaneous nodules), spider veins, bone pain- especially in shins (Bartonella quintana, aka shin bone fever), along the rib cage and chest wall pain can occur. Ice-pick pain sensations in head, mild sore throat, softening of bone, bone infections, radiculitis, difficulty swallowing, transverse myelitis, polyneuropathy, bipolar disorder, slurred speech, elevated liver enzymes, gall bladder dysfunction, crusty scalp, respiratory complications, personality

11 disorders, irregular pulse, and an array of eye related problems such as raccoon eyes (dark circles around eyes), very dry eyes, conjunctivitis, neuroretinitis and a loss of vision. Bartonella symptoms may wax and wane or appear to be in remission. Symptoms may return quickly if treatment is discontinued too soon. Bartonella has been misdiagnosed or mistaken for vasculitis, breast cancer, hepatitis, Kaposi s sarcoma, splenic lymphoma and a variety of neurological and psychiatric illnesses. DIAGNOSIS- Treat the patient, not the test! Quest Diagnostics: Bartonella Species Antibody (IGG, IGM) with Reflex to Titers, Code 34251x. TREATMENT- There is no one-size-fits-all treatment protocol for Bartonella infections. Doxycycline, rifampin, ciprofloxacin, erythromycin, tetracycline, clarithromycin, azithromycin or combinations of antibiotics have been used with varying degrees of success. Continuing treatment is often necessary in long standing cases. Relapses are common. Brucellosis Brucellosis- B. melitensis, B. suis, B. abortus, B. canis Brucellosis is most often spread to humans by eating or drinking unsterilized milk, raw cheese (especially goat cheese), and meat products from infected animals, or having close contact with an animals waste products. Ticks have been known to pass the infection and transmission from human to human (mother to infant, sexual transmission) is possible. SYMPTOMS- may include day and night sweats with odors, headaches, fluctuating fevers, nervousness, weakness, anorexia, arthritis, chills, depression, malaise, joint/muscle pain, insomnia, constipation, and impotence. Later symptoms may include brain infection (encephalitis), hepatitis, endocarditis (heart), uveitis, spondylitis, prostatitis, anaemia, leukopenia, thrombocytopenia, meningitis, optic neuritis and neurological disorders. Mothers breast-feeding may pass along the infection. Sexual transmission has been reported.

12 DIAGNOSIS- CDC utilizes a test called the Brucella microagglutination test (BMAT) that can detect antibodies to Brucella species - abortus, melitensis or suis. There is no serological test available to detect antibodies to B. canis. Initially, IgM levels rise, followed by IgG titers. Persistently elevated IgG titers or second rises in IgG usually indicate chronic or relapsed infection. TREATMENT- It can be difficult and is not always curative. Antibiotics, or combinations of antibiotics are used to try to eliminate the infection. Ehrlichiosis Ehrlichiosis- Ehrlichia chaffeensis, E. ewingii, E. muris (EML) Ehrlichia HME or HGE (rickettsial diseases related to RMSF) may be fatal, however, milder and chronic forms do exist. Usually Ehrlichiosis symptoms appear within the first two weeks after exposure. Blood transfusions from infected individuals to uninfected individuals are a serious problem that has been responsible for a number of deaths. SYMPTOMS- Usually rapid onset- Headaches (sometimes sharp- shooting pain), fevers, chills, myalgias (mild to severe muscle pain), fatigue, nausea, vomiting and cough are some of the more prominent symptoms. It can be mistaken for the flu in milder cases. Low white blood count and elevated liver enzymes are seen in many cases. Seldom people have a rash, but it can occur. Tests can vary from lab to lab and may not detect the infection. DIAGNOSIS- Indirect fluorescent antibody (IFA) test is not used as commonly as a PCR test. IFA measures the amount of antibody you have in your blood to the bacteria that causes Ehrlichiosis. TREATMENT- Treat suspected Ehrlichia immediately. Doxycycline is the treatment of choice for both adults and children. Doses may need to be increased or extended due to the severity or duration of the illness and additional co-infections involved. More Information On Tick Borne Diseases MarylandLyme.org

13 Leptospirosis Leptospirosis- Leptospira interrogans sensu lato, aka Weil Disease Many wild and domestic animals, including cattle, pigs, rodents and dogs can carry Leptospira bacteria. Some infected animals become sick, yet others show no signs of illness. Some animals become long-term carriers. Humans usually become infected when coming in contact with water or soil contaminated with urine of infected animals. Symptoms typically begin 3-21 days after exposure. SYMPTOMS- can include high fever and chills, severe headaches, nausea and vomiting, muscle aches and pains, liver and kidney damage, jaundice (yellow skin or eyes), red eyes, low blood pressure, meningitis, rash, abdominal pain, difficulty breathing, diarrhea and severe bleeding. Jarisch- Herxheimer reactions can occur while treating. DIAGNOSIS- A variety of serological methods, including the enzymelinked immunosorbent assay (ELISA) (Annexes 10 and 11) have been developed, many of which are relatively simple screening tests for leptospirosis. The most sensitive and specific test accurate at the acute phase of the disease is polymerase chain reaction (PCR). It is not available in most highly endemic areas and the serological reference method by micro agglutination testing (MAT) is restricted to reference laboratories. TREATMENT- Leptospirosis can be treated with antibiotics, however, the protocol may not be curative. Mild leptospirosis is treated with doxycycline, ampicillin or amoxicillin. For severe leptospirosis, intravenous penicillin G has been the drug of choice, although the third-generation cephalosporins, cefotaxime and ceftriaxone, have become widely used. Additional Tick Borne Diseases Mycoplasmas- Mycoplasma fermentans Q- Fever- Coxiella burnetii STARI- Southern Tick Associated Rash Illness (aka Master s Disease) Tularemia- Rabbit Fever- Francisella tularensis

14 Lyme Disease Lyme Disease- Borrelia burgdorferi, B. miyamotoi, B. afzelii, B. garinii and 300 additional known strains, plus new discoveries with some still unnamed. Lyme disease, an infectious disease caused by one or more strains of Borrelia bacteria, is most often transmitted to animals and humans by the bite of an infected tick. Studies have recently confirmed it was possible to sexually transmit Lyme disease. Congenital Lyme (mother to baby) has also been documented and breast-feeding has been implicated in the transmission of Lyme disease. DIAGNOSIS- Testing for Lyme disease, which has always been unreliable, has been proven to miss up to 75% of people who are infected. Some experts believe the number missed is closer to 90%. Additionally, standard blood tests are only capable of detecting the body's response to one (1) strain of Borrelia (burgdorferi). Over 300 strains have been reported to date. Health care professionals treating large numbers of Lyme patients often use labs that specialize in tick borne disease testing in an effort to obtain more accurate results. For a list of preferred labs please go to MarylandLyme.org SYMPTOMS- Patients with early Lyme disease may experience fatigue, chills, fever, headache, muscle aches, joint pain, popping or cracking noises in joints (especially neck) and swollen lymph nodes. They may have no obvious symptoms as the disease disseminates or while the spirochetes bury and hide in protected niches in the body (bladder, brain, joints, muscles, tendons, ligaments, eyes, etc.). Symptoms may peak every 4 weeks. Symptoms of Lyme disease may not be noticeable or pronounced or may come and go, however, the infection can linger and produce symptoms years after a person was originally infected, especially during times of stress, after child birth, after an auto accident, the death of a loved one or when someone is experiencing other illnesses. There can be a slow response to treatment. When tests are negative and symptoms vary inexperienced doctors sometimes falsely considers the patient has no illness at all. They may assume the patient developed an "all in the head" syndrome and label them as such. When this occurs the disease

15 is left to progress unchecked and can result in severe chronic illness, disability and even death. Jarisch-Herxheimer reactions can occur while treating. Lyme disease can mimic, show similar symptoms to or be confused with chronic fatigue syndrome, multiple sclerosis, Alzheimer's, Parkinson's disease, Lupus, Lou Gehrig s (ALS) disease, Guillian-Barre syndrome, polymyositis, hepatitis, cardiac disorders, fibromyalgia, ringworm, Tullio phenomenon, encephalitis, ADD, ADHD, lupus, meningitis, depression, panic disorders, Bell s Palsy, candidiasis, chronic mononucleosis, hypoglycemia, scleroderma, Epstein Barr virus, autoimmune diseases, Bannwarth s syndrome, cancers, kidney disease, Reynaud s syndrome, stress-related illness, sleep disorders, thyroid problems, vasculitis, TMJ, anorexia, agoraphobia, cerebrovascular disorders, arthritis, anorexia, connective tissue diseases, hearing disorders, Crohn s disease, purpura, pseudotumor, Sjogrens syndrome, stroke and respiratory insufficiency. Lyme disease can have a wide range of symptoms, which can go dormant (sometimes for years), can migrate, return, disappear, or change day by day. Symptoms can be aggravated by stress, medications, weather and other outside influences. SOME of the symptoms associated with Lyme disease include: Flu-like symptoms, headaches (mild to severe), recurring low grade fevers or fevers up to degrees. Usually in the first few weeks of Lyme disease fevers tend to be higher. (Patients with Lyme disease tend to have a "normal temperature" after infected- below 98.6 degrees- therefore, a slight rise in temperature may be all that is noted.) Often patients exhibit unrelenting fatigue (mild to extreme), joint pain (with or often without swelling), muscle pain, connective tissue pain, a recurring and severe sore throat (sometimes only on one side of the throat), swollen glands (come and go), varying shades of red on ear lobes and pinna, malar rash, extremely cold hands and feet in a warm environment, weakness, lightheadedness, eczema and psoriasis, painful or itching skin, flushing, night or day sweats, inordinate amounts of sweating, anhydrosis (inability to sweat) or dermatitis (acrodermatitis chronica). There may be a rash, but it isn't noticed or it may not appear in all

16 cases. The rash may be basically circular with outward spreading, however, other presentation are seen. The rash may be singular or multiple, at the site of a bug bite, or in another location, warm to touch, or slightly raised with distinct borders. In dark-skinned people the rash may appear as a bruise. Numbness, sleep disturbances, vertigo, hearing loss, feelings of being offbalance, unexplained weight gain or loss, and feeling "infected" are also problems associated with Lyme disease. Symptoms may develop that include: panic attacks, anxiety, depression, mild to severe cognitive difficulties, mood swings, coma, seizures, dementia, mania, bipolar disorders, vivid nightmares, stammering speech, confusion, memory loss (short or long term), "brain fog", vibrating feeling in head, topographical disorientation or environmental agnosia (inability to recognize familiar surroundings). Some patients have problems with numbers and sequencing, disorganization of thoughts, rambling on in great detail while talking, frequent errors in word selection or pronunciation, changes in personality, short attention span, Tourette manifestations, OCD (obsessive compulsive disorder), raging emotions and cranial nerve palsies. Some patients explain symptoms as feeling apart from everything, feeling unattached, robot-like, not doing their own thinking, looking through a veil, feeling withdrawn or feeling like they are swaying side to side. Patients have reported bladder dysfunction such as neurogenic bladder with either hesitancy, frequency, loss of bladder awareness, urinary retention, incontinence or symptoms of UTI and chronic pyelonephritis (kidney). Interstitial cystitis, irregular or severe menstrual cycles with decreased or increased bleeding, early menopause, a new onset of P.M.S. symptoms, and disturbed estrogen and progesterone levels are documented in many cases. Other problems include altered pregnancy outcomes, severe symptoms during pregnancy, abdominal bloating, irritable bowel syndrome, abdominal pain and cramping (may appear to be ulcers), loss of sex drive, testicular or pelvic pain, prostate problems, breast pain and fibrocystic breast disease. Diarrhea (which can come and go or last for months with no explanation), constipation (which can be severe enough to cause blockage), irritable bowel

17 syndrome, spastic colon, nausea, stomach acid reflux, gastritis, abdominal myositis, and indigestion are some of the gastro-intestinal disorders reported. In addition, patients demonstrate a higher occurrence of various types of tumors and cysts (liver, breast, bone, ovary, skin, pineal gland and kidney). Some Lyme patients are diagnosed by their eye care professionals and have been documented as suffering from one or more of the following disorders: conjunctivitis, ocular myalgias, keratitis, episcleritis, optic neuritis, pars planitis, uveitis, iritis, transient or permanent blindness, iritis, photophobia, temporal arteritis, vitritis, Horner's syndrome, ocular myasthenia gravis, and Argyll-Robertson pupil. Often these eye problems require a changing of prescription glasses more often than normal. Heart-related problems can include: mitral valve prolapse, irregular heart beat, myocarditis, pericarditis, enlarged heart, inflammation of heart muscle or membrane, shortness of breath, strokes and chest pain. Twitching of facial muscles, Bell's palsy, tingling of nose, cheek or face are reported. In addition, there may be chest pain or soreness, enlarged spleen, liver function disorders, tremors, extreme sensitivity to being touched or bumped, burning sensations, stiff neck, meningitis and encephalitis. Patients may experience continual or recurring infections (sinus, kidney and urinary tract are most common). They can suffer from a weakened immune system, the development of new allergies, recurring upper respiratory tract infections (causing or worsening of pre-existing sinusitis, asthma, bronchitis, otitis, mastoiditis), and allergic or chemical hypersensitivity's. Other noted problems include: T.M.J., difficulty swallowing or chewing, tooth grinding, arthritis (in small joints of fingers and larger, weight bearing joints), Osgood-Schlatter's syndrome (water on the knee), bone pain, goutlike pain in toe, muscle spasms to the point of dislocating joints and tearing muscle tissue, leg and hip pain, "drawing up" of arms, "growing pains" in children, tendonitis, heel pain, carpal tunnel syndrome and paravertebral lumbosacral muscle strain/spasm. Some patients tend to suffer from an intense monthly "flare-up" of symptoms as spirochetes reproduce and/or die off during treatment. This is referred to as a herx, herxheimer or Jarisch-Herxheimer reaction.

18 *** Important: Having one or more of the above symptoms does NOT necessarily confirm a Lyme disease diagnosis. This is simply a list of symptoms documented by various scientists, researchers and physicians in areas where Lyme disease is prevalent.*** TREATMENT- Everyone agrees the sooner treatment begins after a bite by an infected tick the better! Ticks live in the dirt and consume blood from a number of wild and domesticated animals that can carry and transmit multiple disease causing organisms. Ticks are known to be infected with pathogens that can spread throughout the body quickly and cause a variety of mild to life-threatening symptoms. Waiting to see if the infections spread through your body, or if you get a rash, or if you get sick before starting treatment does not make sense. Forget the old "wait and see" approach! Current treatment guidelines agree- Get it Right, Treat The Bite! More information at TreatTheBite.com Protocols standardizing the duration of treatment and types of antibiotics that will best kill the bacteria were never developed. One dose of an antibiotic, or 10 days, two weeks, three weeks and a month of antibiotics are cited in some literature as preferred or recommended treatment, however, in many cases these protocols have failed miserably. The choice of an antibiotic originally was in part determined by cost rather than what is best for the patients, and the unsupported recommendations are still promoted by those with personal or financial interests in the outcomes. Determining what treatment to use and for how long is nothing more than a guessing game- the toss of a coin. Experienced health care professionals contend treatment protocols must be tailored to fit individuals, each with their own unique histories, clinical signs and symptoms because if one thing is for sure, we know for certain one size does not fit all. Recommendations for the best early treatment protocols, ones having successful results for many patients in many cases, are offered for your consideration. Sources for these recommendations are included. More Treatment Recommendations

19 MarylandLyme.org TICK BITES Embedded Tick With No Signs or Symptoms of Lyme Disease (As little as four hours of tick attachment can transmit pathogens) 1) Adults: Oral therapy for 28 days. 2) Pregnancy: Amoxicillin 1000 mg q6h for 6 weeks. Test for Babesia, Bartonella and Ehrlichia. Alternative: Cefuroxime axetil 1000 mg q12h for 6 weeks. 3) Young Children: Oral therapy for 28 days. EARLY LYME DISEASE Single Lyme Rash [erythema migrans] With No Other Symptoms 1) Adults: oral therapy- must continue until symptom and sign free for at least one month, with a 6 week minimum. 2) Pregnancy: 1st and 2nd trimesters: I.V. X 30 days then oral X 6 weeks 3rd trimester: Oral therapy X 6+ weeks as above. Any trimester- test for Babesia and Ehrlichia. 3) Children: oral therapy for 6+ weeks. Consider Doxycycline first due to concern for tick borne co-infections. Doxycycline- Adults: 200 mg bid w/ food; doses of up to 600 mg daily are often needed, as doxycycline is only effective at high blood levels. Not for children or in pregnancy. If levels are too low at tolerated doses, give parenterally or change to another drug. Amoxicillin- Adults: 1g q8h plus probenecid 500mg q8h; doses up to 6 grams daily are often needed. Pregnancy: 1g q6h and adjust. Children: 50 mg/kg/day divided into q8h doses. Recommendations from Advanced Topics in Lyme Disease - Dr. Joseph Burrascano A document with the above information can be printed and taken to your doctor s office by going to- TreatTheBite.com For someone with a more advanced case of Lyme disease, especially with the potential for one or more co-infections, a Lyme disease specialist should be consulted- LymeDoc.org

20 Rocky Mountain & Other Spotted Fevers, Rickettsia sp. Rocky Mountain Spotted Fever, Rickettsia rickettsii, (RMSF) is the most common rickettsial diseases in the United States. It is a potentially fatal disease with a mortality rate as high as 30%. Early treatment with appropriate antibiotics is required to prevent the disease progression and should be started as soon as the disease is suspected. Untreated cases may result in death within 20 days after exposure. The hospitalization rate is over 70% even in treated patients. The incidence is highest amongst persons aged 5-9 years and in those years old. Tick attachment time can be as little as 10 minutes before Rocky Mountain Spotted Fever is contracted. Various additional spotted fevers can be missed when using tests designed to detect Rocky Mountain Spotted Fever. SYMPTOMS- High fever (>102 F), headaches, and myalgias (most common symptoms). 25% of patients are reported to develop signs of encephalitis. Confusion, lethargy, vertigo, ataxia, seizures, cranial nerve palsy, photophobia, dysarthria, paralysis and a loss of hearing may be noted. Gastrointestinal symptoms may include abdominal pain, diarrhea, loss of appetite, nausea and vomiting. Splenomegaly and hepatomegaly may occur. Some patients develop a maculopapular rash (mild to severe). The rash often begins on the extremities (palms of hands and soles of feet) and spreads toward the trunk. (Do NOT wait for a rash before treating RMSF.) Pulmonary edema, pneumonitis, shortness of breath may be present. Petechial conjunctivitis, optic disc edema, anterior uveitis and retinal vascular dysfunction may occur. The infection can become chronic. DIAGNOSIS- Lab tests to detect RMSF may not indicate a person was exposed if performed during the first several weeks of infection. Never wait for tests results or rely on a negative test result if RMSF is suspected. TREATMENT- Treat immediately! RMSF should be treated ASAP with antibiotics. A course of oral doxycycline is usually recommended. Severe disease may require long treatment courses. Inadequately treated RMSF can cause multiple organ damage, chronic illness, disability or death. TREAT IMMEDIATELY if a spotted fever is even suspected. After The Bite- Lucy Barnes

21 Dog ticks are sometimes called wood ticks. Widely distributed east of the Rocky Mountains. Multiple diseases. American dog tick (Dermacentor variabilis) Often called deer ticks or bear ticks. Widely distributed. Range expanding. Multiple diseases. Blacklegged tick (Ixodes scapularis) Found worldwide. Red-brown color is distinctive. Multiple diseases. Brown dog tick (Rhipicephalus sanguineus) Aggressive tick. Adult female has a white star on her back. Range expanding across USA. Multiple diseases. Lone star tick (Amblyomma americanum)