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Ticks.
Summer is in full swing so I'm clearing up some myths and spreading some serious truths about tick bites.
I got a call while I was working at Fire Island last summer about a patient who "definitely has Lyme disease." He was freaking out on the phone because he pulled a tick from his back earlier that morning. After calming him down, I asked him the routine questions. Was the tick engorged? Is it a deer tick? Do you have a rash or a fever? Ultimately, the man was so worried that I had him come down to the clinic.
He brought his tick in a bag. It was a huge tick (aka not a deer tick), still alive, not engorged. His exam was normal. But no amount of reassurance was going to convince this man that it was unlikely that he had or would develop Lyme. After all, this was on Long Island, Lyme Central. But contrary to popular belief, most tick bites do not result in a Lyme infection. In fact only 2-3% of tick bites that come from Ixodes Scapularis (the type of tick that carries Lyme) actually results in an infection.
Although Lyme is the first and most famous name that comes to mind, there are a few other infectious processes, that are spread via tick vector; namely Rocky Mountain Spotted Fever, Ehrlichiosis, Babesiosis. All can cause acute and chronic manifestations and can be potentially life-threatening in some instances.
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We generally regard life-threatening conditions as undesirable, so naturally, it’s best if you never have to experience them in the first place. Some tips for prevention...
✅ Avoid high grasses and shrubs where ticks like to hang out.
✅ Wear lightly colored clothing so you can see the little suckers.
✅ Make sure you cover any exposed skin especially around the ankles.
✅ Wear an FDA-approved DEET-containing repellent.
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Even if you reduce your risk, you may still find yourself fodder for the little fomites. If you find that you have a tick on your clothing, let him go for a swim in your cesspool by promptly flushing him down the toilet. If he is embedded in the skin, take great caution in removing him from the skin.
✅ Wearing gloves, use fine tweezers to grasp the tick as close to the skin as possible.
✅ With a quick but firm motion, remove as much of him as possible without bursting the body as that may spread infectious material.
✅ Thoroughly cleanse the surrounding area with antiseptic.
✅ Contact your doctor if you find any signs of local infection, rash, arthritis or fevers.
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If you happen to be infected with Lyme, there are typically three stages: early, early disseminated, and late. The most common manifestations of early lyme typically occur within 7-30 days and may include fever, rash, fatigue, headache and joint pains. The classic bullseye rash, called erythema migrans, may or may not appear. In weeks to months after the tick removal, muscular and neurologic symptoms may appear. Late Lyme involves symptoms that persist or arise months to years after the initial bite. Patients in this class can experience muscle and joint pains.
Testing for Lyme is a tricky subject because most people believe they need blood tests as soon as they are bitten. But at the early stages, physicians are able to use their clinical judgement to determine whether early treatment is warranted. A patient who comes in with a tick bite and a classic rash gets treated without bloodwork, because there is a certain probability that the patient has Lyme and yet it is highly likely that the test will be negative. In other words, a negative test does not mean that you don't have, or will not develop Lyme.
False-positive tests also cause a tremendous amount of unnecessary treatments. Illnesses such as viruses, inflammatory diseases and cancers may cause false positive results. Testing is also unreliable in patients who have had Lyme in the past, as tests may remain positive despite treatment and resolution of the illness. So clinical interpretation of symptoms is key, along with strategic testing at relevant intervals of time, or if a patient develops symptoms.
If you've been reading this blog, you know how I feel about overtreating common infections with antibiotics. Treatment for Lyme is no different. Many patients are taking antibiotics unnecessarily for fear of the extreme Lyme complications that are unlikely to occur. BUT, if you have a good story, and a physician deems that you may be having symptoms of early Lyme, the treatment is usually 14-21 days of antibiotics. If the symptoms are severe, such as meningitis, you may require intravenous medications. For symptoms of late or recurrent Lyme, the treatment is usually 28 days worth of medicine.
Prophylactic treatment may be offered under the following conditions:
✅ A true adult or nypmhal Ixodes tick was attached for at least 36 hours
✅ The medication is provided within 72 hours of the tick being removed
✅ AND doxycycline is not contraindicated.
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Studies have shown that transmission is unlikely if the tick is embedded for less than 24 hours, but is very likely if the tick is embedded for longer than 72 hours. A single dose of 200mg of doxycycline in this case may prevent Lyme infection.
Perhaps most importantly, don’t freak out if you wake up and see your dog’s new roommate heading towards you for a bloody breakfast. With prompt treatment, most cases can be reliably treated without complications.
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