July 2003

Congratulations to Evan Froehlich for solving the balancing scale mind bender. As Evan correctly figured out, 1 pig = ½ crab = 1 ½ mice = 3 armadillos. So 1 pig = 3 armadillos. You will have to wait for next month's Gazette to find out all the answers to last month's mind bender. Hope you all enjoy reading Harry Potter!

Dr. Barenfeld

Lyme Disease------------------------------------------

Over the past ten years Lyme disease has been more misunderstood and has caused more fear in our area than any other disease that I can think of. As always I will present the facts and hope to relieve some of your anxiety. Lyme is actually an old disease. The earliest description of Lyme-type symptoms was reported in 1902. However, the disease wasn't investigated until 1976 when a cluster of children with unexplained arthritis was reported in Old Lyme, Connecticut. Investigation of this epidemic led to the discovery of Lyme disease and its cause. Since that time the reported incidence of the disease and its geographic range have increased dramatically. Lyme disease is caused by a bacterium called Borrelia burgdorferi. It is transmitted by the Ixodid species of tick, the deer tick. The highest rates of infection occur in the Northeast (with a bulls eye on Orange County). High rates of infection are also seen in the upper Midwest (Minnesota and Wisconsin) and to a lesser extent in the far west. In fact Lyme disease has been reported in 49 states and in more than 50 countries.

It is important to understand the life cycle of the deer tick. It consists of three stages - larva, nymph, and adult - that occur during a two year period. Each stage feeds only once. The adult female lays eggs in the spring which hatch into larvae which feed on mice and other small mammals in late summer. If the animals the larvae feed on are infected, the nymphs (which appear the next spring) will be infected and can infect other mammals, including humans. Most cases of Lyme disease are caused by the nymph. This is because it's "pin head" size is difficult to see or feel, and it is most active from May through July when outdoor activities are at their peak. The nymph molts during late summer into an adult. The adults spend the winter on an animal host and can also infect its new host. Because adults are active primarily in the late fall and early spring when fewer people are outdoors, and because they are easier to detect and remove due to their larger size, their danger in transmitting infection to humans is much less than that compared to the nymph. This is true in spite of the fact that adult deer ticks are more likely to carry the bacterium since the tick can acquire the infection with each feed. So the proportion of adult ticks that is infected is higher than that of either nymphs or larvae. To complete their two year life cycle, the adult females lay their eggs in the spring and die. Ticks are active in the winter even with snow on the ground as long as temperatures are above freezing.

B. burgdorferi is transmitted when an infected tick inoculates this bacterium into the blood vessels of the skin of the host. The risk of transmission from infected deer ticks is related to the duration of feeding. Studies have shown that the ticks must feed at least 36 - 48 hours before the risk of transmission of disease becomes substantial. Most people who know they were bitten by a tick will not get Lyme disease. This is true even if the tick was carrying the Lyme germ. Many studies have shown that fewer than 3% of people who know they were bitten by deer ticks will develop Lyme disease. This is because most people who find an embedded tick remove it within 48 hours. Studies also show that most people who develop Lyme disease do not recall a tick bite.

The early symptoms of Lyme disease can be mild and easily overlooked. Flu-like symptoms consisting of chills, fever and fatigue are often experienced, but may not seem serious enough to require medical attention. Fortunately, most people (90%) develop a classic rash called erythema migrans. This rash is usually reddish with a central clear area, hence the commonly known name "bull's eye". It may appear three to thirty days after the bite, is usually at least several inches across in size, and is usually not itchy or painful. The rash may be overlooked if it occurs on the back or on the head. The rash is usually at the site of the tick bite, but may form elsewhere on the body and there may be more than one. Additional later symptoms may include arthritis (painful swollen joints), a mild from of meningitis, and most notably Bells palsy (an inability to move some muscles of the face). Lyme disease has also been known to involve the heart.

Lyme disease can usually be diagnosed based on the patient's symptoms, especially if erythema migrans is present. This makes bloodwork unnecessary. Blood tests can be done but may be unreliable with both falsely positive and falsely negative results occurring. Non-specific symptoms such as headache, fatigue and achiness by themselves, without other more specific symptoms associated with Lyme disease, is rarely due to Lyme disease. These symptoms are usually caused by some unexplained virus. Looking for a diagnosis, many people ask for a Lyme titer to be done. Since, as stated above, some Lyme titer results will be falsely positive, this means that some people will be diagnosed with Lyme disease who don't really have it. They will then be treated unnecessarily, won't get better, and will convince themselves they have chronic Lyme disease. This contributes to much of the fear surrounding Lyme disease today.

Treatment for early Lyme disease in children is almost always successful with three weeks of Amoxicillin. For more severe forms of Lyme disease stronger antibiotics and sometimes intravenous antibiotics are used. These are generally successful as well. A Lyme vaccine was approved for use in children and adults fifteen years of age and older in 1998. However, it was shortly taken off the market due to poor results and excessive complications. Therefore, there is no vaccine currently available.

Prevention of Lyme disease can be accomplished with diligence. Avoidance of tick infested areas is nearly impossible. Clearing and cutting of brush and tall grass around houses and at the edges of gardens may help lower the tick population. Ticks like shady, moist ground litter. Chemical insecticides sprayed in your yard are generally not recommended as they may be dangerous to animals and humans.

Clothing should be light-colored to make ticks easier to see. Long sleeves and long pants that are tight at the wrists, ankles, and waist, with pants tucked into socks are preferable but very difficult to enforce during summer heat. Two chemical repellents - DEET and Permethrin are effective and can be used. DEET in concentrations less than 30% can be applied to your child's skin. Serious complications including seizures have resulted from frequent and excessive application of DEET, limiting its use. DEET should be applied sparingly, only to exposed skin, and not to the child's face, hands or skin that is irritated or damaged. After the child returns indoors, treated skin should be washed with soap and water. Permethrin is available in a repellent spray for application to clothing only and is particularly effective because it kills ticks on contact.

The best way to prevent Lyme disease, in my opinion, is through daily bodily inspection. I always say, if your children go to sleep at night without a tick, then they can't get Lyme disease. Remember that the tick must be attached for more than 24 hours for Lyme disease to occur. Therefore careful inspection and prompt removal of the tick will prevent Lyme disease. Carefully inspect your children's entire body. The ticks are hard to see and like to attach in hard to find spots including the scalp, behind or even in the ears, armpits, behind the knee, belly button and groin area.

There seems to be much confusion on the best way to remove ticks. They should be removed using tweezers, grabbing the tick as close to the skin as possible and pulling the tick straight out. Care should be taken not to squeeze the tick's body thereby injecting the bacterium into the skin. Also do not apply mineral oil, petroleum jelly, heat or anything else to remove the tick as this may cause it to inject bacteria as well. After removal apply antibiotic ointment to the bite site. If some of the mouth parts remain embedded in the skin, they should be left alone. There is no evidence that tick remnants have ongoing effects in terms of causing Lyme disease. Removal of these remnants is extremely difficult and will just cause trauma to the skin.

Are you all still with me? Only one more question that I can think of that I have yet to answer. To treat or not to treat tick bites; that is the question. The answer according to most experts and most of the literature I have read is no. Some people suggest that only those ticks that have been attached for more than 48 hours should be treated with antibiotics. Remember that less than 3% of known tick bites will lead to Lyme disease. So by treating all tick bites most people will be given antibiotics unnecessarily. However, with "Lyme Anxiety" prevalent and new studies showing that antibiotics will prevent Lyme disease many people elect to take the antibiotics. The decision to treat should be made after discussing the pros and cons of treatment between you and us.

To quickly summarize, Lyme disease is generally a mild, easily treatable disease that can be prevented with diligent bodily inspection. Hopefully, I have eased some of your fears concerning this disease.