Transcription:

Joey Wahler (Host): Lyme disease is a bacterial infection caused when bitten by certain infected ticks. Symptoms range from relatively minor and treatable to far more serious if left untreated. So we're discussing Lyme disease's symptoms and how they're addressed. This is St. Francis Medical Center's word on Wellness, a podcast sponsored by St. Francis Medical Center. Thanks for listening. I am Joey Wahler. Our guest, Dr. Richard Porwancher, a physician with St. Francis Medical Associates and Director of the St. Francis Lyme Disease Center. Also Clinical Associate Professor of Medicine at Rutgers Robert Wood Johnson Medical School. Dr. Porwancher, thanks for joining us.

Richard B. Porwancher, MD (Guest): Thank you very much for inviting me.

Host: Good to have you. So first to get us started when bitten by a tick, what exactly is it that's going on that causes Lyme disease in a nutshell.

Dr. Porwancher: Well, the tick has a bacteria in its intestinal track called Borrelia burgdorferi. And as the tick feeds on an individual's blood, the bacteria goes into the salivary glands, saliva of the tick and is introduced into the person's bloodstream. It takes between 24 to 36 hours before this process can actually inject the bacteria into the person's blood system.

Host: So having said that at the end there, let me ask you, if you do notice a tick on you, there could be time to get it off and not be affected. Right. So what should you do if you have a tick?

Dr. Porwancher: Well, they have tick removal kits that are available in pharmacies and the tick is removed by a tweezers inserted where the mouth parts go into the skin. You don't want to tear the head off with the tweezers. You want to get it where the mouth parts insert themselves and you gently tug on the tick and it lets go after about 15 seconds or so, it's not as strong as you are. But they're available in pharmacies.

If you can get them off before they've been feeding and are obviously engorged with blood. So within the first 24 to 36 hours, the chances of developing Lyme disease are less than a couple percent. The longer they've been feeding, the more likely it'll transmit.

Host: Interesting. It's not all ticks, only certain ones that would carry this. Right? So in what surroundings are we most prone to those kind of afffected tick bites and what's the best way of avoiding them?

Dr. Porwancher: Well, the tick that spreads Lyme disease is called Ixodes scapularis and the more common name for it is the deer tick. And it lives in certain climates, temperate climates on the east coast, for example, between say Virginia and Maine extending westward now into Pennsylvania and parts of Ohio. And then in the Midwest, in Wisconsin and Minnesota, and then in the west coas parts of California. So it's limited in its range and its spread by the deer tick.

Host: And in what kind of an area, would we normally find this kind of tick?

Dr. Porwancher: Well, usually the ticks drop-off the animal on to a brushy or wooded areas. So, the ticks are on the shrubbery or vegetation, and they fall off the vegetation onto a passing animal. So man happens to be an unwitting meal for the tick.

Host: Gotcha. Now symptoms of Lyme disease range from curable to very serious if untreated. Let's start with the first end of the spectrum there. What are the early, less serious symptoms if you will?

Dr. Porwancher: Well, the most common symptom is a rash and it's usually oval and more or less homogeneous or uniform in color. When it's first discovered it's somewhere in the range of around five centimeters or a little bit more, which would be little over two inches between two and three inches.

And it tends to grow over time. Usually between three and 30 days after the bit. And the longer it's on or the longer it's there, the more likely it'll develop a ring-like appearance or bulls-eye appearance. So where there'll be almost multiple rings. And so that's a longer one.

And in some instances, maybe 20%, there'll be multiple lesions, not just at the bite, but in other areas of the skin and that's called disseminated disease. And at that point it can also go to other parts of the body, like the nervous system or joints. But in the early phase, particularly when it's a single rash we can get it early and treat it early and very successfully, probably in the range of 90 to 95% successful.

Host: And then along with that particular kind of rash that as you said, looks basically like a bulls-eye, what in terms of the way you might feel, or some of the other common symptoms early on?

Dr. Porwancher: Well, a person can develop chills and fever, a headache, stiff neck and joint pain. Abdominal discomfort, nausea, vomiting, and diarrhea occur, but they're much less common. Sometimes there can be cardiac symptoms and people can get dizzy. It can cause abnormalities of the conduction system in the heart leading to heart block and fainting. So if a person becomes very dizzy or faint, they need to be checked by their doctor.

Host: Now you hit on it a moment or two ago Doctor, but there are three stages of Lyme disease, right? Early localized, early disseminated and late disseminated, how do they differ in a nutshell?

Dr. Porwancher: Well, the earliest phase is the rash typically associated with the fever and to you know, correct something the most common rash is uniform rather than bullseye is, as it grows and as it's there longer, it becomes a bullseye. But the most common now is just a homogeneous rash, either circular or oval in at least two, three inches across and growing in size as it gets bigger.

And that's the early. And then the second phase is when you can develop a heart block, cardiac meaning cardiac issue, or occasionally you'll develop what looks like Bell's palsy, where one side of the face droops and that's early neurological involvement, sometimes associated with actually a mild meningitis. They usually go together. Although in children, it can be, it can be a meningitis, actually, a mild meningitis, similar to what a viral process might be, and it can get confused between a virus and Lyme disease, which is one of the reasons that they commonly will do a blood testing when you're in a, live in an area and the child comes down with a meningitis, you have to rule out Lyme disease as a potential cause.

And then the more advanced stages involve the joints, typically where people develop frank arthritis with swelling of, of one joint or a couple of joints. And, and that is comes and goes over time. So, it's what they call oligoarticular, which means in Latin just one or very few joints and it can move from joint to joint, the knees, elbows, wrists, shoulders, ankles. Those are the ones that are most common, not as much the spine, but the bigger joints, those, those, sometimes the hip in children in particular. So, and the joint swelling and pain comes and goes over a number of months. It takes between four months and 24 months for the joint problem to begin.

The other manifestation is neurological for late disease, and you can develop a painful nerve condition called radiculopathy, where a nerve root coming from the spinal area will cause pain going down the leg or into the arm sometimes with weakness. And this occurs also many months after an episode of the tick bite or the rash, it can follow the rash.

Although many people have joint problems or the neurological problems don't recall a rash. It happened a long time ago. They may not remember a tick bite, but they developed a joint swelling or they developed a neurological pain, a neuropathy.

Host: So in terms of everything you just mentioned about the broad spectrum of possible impact here, if it's less serious, caught earlier, how's that usually treated and cured? And then if it's far more serious as you described, and it requires more treatment over a longer period of time, how's that addressed? And does that become chronic or is it curable at times?

Dr. Porwancher: Good question. So, the early phase, which is the rash, we typically use oral antibiotics. Doxycycline is the most common one, although for children, ampicillin. There are some other antibiotics that can be used as well for the rash, very successful cure rates above 90%. Very few people go on and develop more serious later stage issues if it's treated during the rash phase. Patients who develop cardiac or the disease or the facial palsy; they typically are treated for between three to four weeks. The rash itself, if you just catch it early with the rash two, three weeks is enough three to four for the, for the more, you know, the, like the early neurological or the cardiac, and then for joint problems that are more deep seated, longer and more serious, that's often treated initially with oral, with doxycycline for around a month. And we see most people get better. I would say about 80%, but about 20% go on and need intravenous. And the intravenous is typically a drug called ceftriaxone, which is a once a day antibiotic that's given via a long catheter that's inserted into the arm.

And that's a once a day medicine and that's given for between three to four weeks. And the same is true for neurological disease that involves the nerve roots coming from the spinal cord. Those, those require longer treatment as well. And typically intravenous, in my view. Some people will use oral antibiotics for longer standing nervous system disease, but I've had variable results with that.

I've had the best results with the intravenous for longstanding neurological. Short term problem, like the facial palsy, meaning Bell's palsy, that that's usually a response that responds typically to the oral antibiotic for three to four weeks.

Host: Now when someone sees you guys about this, one of the first steps is blood work. So two part question, where does the blood go? Is it to a regular lab or a specialty lab? And then how can people be assured that that blood work is accurate? Because you were telling me before we began the interview that sometimes people do ask about that?

Dr. Porwancher: Yes, that's a very good question. So, in the very early phases of the illness, which is the rash, the blood work is typically negative. Meaning doesn't show any evidence of antibodies, the proteins that we make to defend ourselves against the bacteria. The name of the bacteria by the way, is a Borrelia burgdorferi.

But in any case, they measure antibodies against that bacteria and they're only positive, I would say, even with the very best tests, 50, 60% of the time, which means that there are enough times when the blood work is negative, that it really isn't that useful early, early in the disease. It's much better for the doctor to be knowledgeable about the rash and then treat the rash when they see it. If they're not sure it's, they're better off referring the patient to a dermatologist or infectious disease person who's more familiar with the illness. I think relying on the blood work early on is fraught with problems because it's just too soon for a person to make the antibodies.

Now, when a person has meningitis or the facial palsy, meaning Bell's palsy or any of the later stages, the blood work is positive about 80 to 95% of the time. Blood work is very helpful in the middle to later phases, it's very helpful then. The early phase, not so much. The middle to later phase is a much more helpful.

So most patients after about say four weeks or six weeks of illness are going to show a positive blood test. And if they don't, you need to think about other potential causes of the, of the problems that they present with. So the blood work is really quite reliable after the person's been ill for four to six weeks.

And I would say 98, 99% of the time, we're going to see some positive blood tests in people who have. So it's a very good thing, you know, in terms of ordering the blood, blood antibody levels and they can go to a standard reference laboratory. It doesn't need a specialty lab. The only time I use a specialty laboratory is in trying to dose in trying to diagnose a European Lyme disease.

The strains in Europe are different than those in the US. That requires a specialty laboratory. That's the only exception. All the other times we can use a standard reference laboratory and there are many to diagnose Lyme disease. You don't need anything special.

Host: Gotcha. And so in summation here, any quick, final thought, any message or misconception that you want to talk about and clear up for people listening?

Dr. Porwancher: Sure. Two things. One is that the disease is curable in the early stages, meaning the rash, 95% or more, the middle stages to the later stages, 80 to 85% or more. Usually with oral antibiotics then the vast majority of the remainder will respond to intravenous. Even if the oral doesn't work, I don't have that many people that fail. Now in some instances, and I'm not going to say it's common, but it does happen, people can develop some aches and pains afterwards, typically some joint pain, and this tends to occur in people where the diagnosis has been delayed or misdiagnosed for a long time, sometimes years. So, those instances where the diagnosis has been delayed, some people will have some chronic symptoms.

So I can't guarantee that there won't be some symptoms where the diagnosis has been missed or delayed, but in the vast majority of people get better and fully recover. The other item I think to mention is prevention. I think it's important that people cover themselves when they're out in woods or brushy areas hiking and things like that, you want to wear a long sleeve shirt maybe some, a long sleeve pants, sweat pants with or jeans with the socks over the ankles.

Very lightly. You can use some spray insect spray over the counter insect spray on the clothing. That's usually effective and a little bit on the hands to put it on the nape of your neck, around your wrists and ankles. Doesn't have to be much just very lightly. Then when you come in from going outdoors, you strip, inspect, and shower or.

Because the ticks usually crawl for an hour or so before they bite, they like warm moist areas like back of the knee, groin, trunk, armpit. That's where they like kids head and neck around the nape of the neck and ears. So if you bathe, after you come in, inspect, you can often get them off either before they've bitten or shortly after they.

That window period of around 24 to 36 hours where you can get them off and before they've had a chance to transmit. Now, if you're unlucky and the tick looks like it's been on there for a while. And particularly if it's engorged with blood, a single dose of antibiotic, that's a doxycycline, two capsules for adults, less liquid for children given within three days of the often is curable, will cure or prevent Lyme disease from developing. So this is not for the rash it's if the person's been bitten and it's been there for a while and is bought and engorged, that's when the antibiotic can prevent Lyme disease from the.

Well, a lot of good detailed information there. Folks we trust you're now familiar with Lyme disease and how it's addressed. Dr. Richard Porwancher. Thanks so much.

Thank you very much for inviting.

Host: For more information, or to make an appointment at the St. Francis Lyme Disease Center, please call 609-581-6060. That's 609-581-6060. If you found this podcast helpful, please share it on your social media. And thanks again for listening to St. Francis Medical Center's Word on Wellness, a podcast sponsored by St. Francis Medical Center. Hoping your health is good health. I'm Joey Wahler.