LYME IS ENDEMIC IN TEXAS
Texas Department of State Health Services
1) The presence of Lyme disease was established in Texas in 1984. http://www.dshs.state.tx.us/idcu/disease/lyme/description/
2) All 11 of the Texas Public Health districts have reported cases of Lyme/TBD
3) Lyme cases were recorded in Texas as early as 1983 Burgdorfer W, Keirans JE (1983) “Ticks and Lyme disease in the United States,” Ann Intern Med 99: 121.
4) “In 1984, Lyme Disease was identified in Texas. There are typically 50-275 human cases of Lyme disease reported in Texas annually. Texas is endemic for the blacklegged tick, Ixodes scapularis. The diagnosis of Lyme disease may be made solely on clinical symptoms, with or without serologic testing.” (last update 3/22/13) www.dshs.state.tx.us/idcu/disease/lyme/description/ Texas Department of State Health Services Web Site
5) “The Texas Department of Health Laboratory began culturing the Lyme disease spirochete Borrelia burgdorferi in 1985. This organism was subsequently isolated from blood, cerebrospinal fluid, joint fluid, skin, bone, and autopsy tissues from humans. Fluorescentantibody tests with murine monoclonal antibodies confirmed that seven of these isolates were B. burgdorferi and that two others belonged to the genus Borrelia.” 1987 Rawlings J., Fournier P., Teltow G. “Isolation of Borrelia Spirochetes from Patients in Texas,” J. of Clin. Microbiol. 25:1148-1150.
6) “While not being reported in epidemic proportions, Lyme borreliosis is endemic in Texas and physicians need to be familiar with it.” 1991 Goldings AS, Taylor JP, Rawlings J. “Lyme Borreliosis in Texas” Texas Med/The Journal. 87: 62-66.
7) “Between 1990 and 1992, ticks from eight Texas parks were collected and analyzed to determine the prevalence of spirochete infected-ticks. Borrelia spirochetes were detected in 1.03% of 5,141 Amblyomma americanum (L.) adults examined, a species Texas residents often encounter. No spirochetes were observed in the other tick species tested.” 1994 Rawlings J, Teltow G. “Relavence of Borrelia (Spirochataeceae) in Texas Ticks,” J. Med Entomol. 31(2): 297-301.
8) “…also addressed are issues of seronegativity, particularly as they apply to regions of the country where strain variation of borrelia is expected and its influence on standardized testing is unknown.” 1995 Stein Goldings A. “Neuroborreliosis in Texas,” Journal of Spirochetal and Tick Borne Diseases. 2:59-61.
9) “Even though rates of human cases of Lyme Disease as well as rates of Ixodes ticks infected with Borrelia bacteria are both relatively low in Texas, the best data currently available indicate that the assumption of high levels of spatial concordance would not be correct in Texas (Kappa coefficient…” 2014 Atkinson SF et al. “A Determination of the Spatial Concordance between Lyme Disease Incidence and Habitat Probability of Its Primary Vector Ixodes Scapularis (black legged tick),” GeoSpatial Health. 9(1), 203-212.
Texas A&M University Research:
10) “Of the 1235 tick samples collected, 109 were identified as I. scapularis. Infection with B. burgdorferi was detected in 45% of the I. scapularis ticks collected. The model presented here indicates a wide distribution for I. scapularis, with higher probability of occurrence along the Gulf of Mexico coast. Results of the modeling approach applied predict that habitat suitable for the distribution of I. scapularis in the Texas-Mexico transboundary region will remain relatively stable until 2050.” 2014 Ferria-Arroyo et al “Implications of Climate Change on the distribution of the tick vector Ixodes scapularis and risk for Lyme Disease in the Texas-Mexico transboundary region,” Parasites & Vectors 7:199
11) A Texas strain is discussed…“The A in the Texas isolate makes them more similar to strains N40 and 297 than to B31.” 2015 Esteve-Gassent et al “Prevalence of Borrelia burgdorferi-infected ticks from wildlife hosts,” a response to Norris et al Parasites & Vectors 8:129
Centers for Disease Control:
12) “During 1992–2006, a total of 248,074 cases of Lyme disease were reported to the CDC by health departments in 50 states, D.C. and US territories…” CDC. Surveillance for Lyme Disease–United States.1992–2006. MMWR 2008; 57(SS10): 1–9)
13) “Lyme Disease is the most commonly reported vector-borne illness in the United States.” CDC. Surveillance for Lyme Disease–United States. 1992–2006. MMWR 2008; 57(SS10): 1–9
EM RASH IS NOT ALWAYS PRESENT
1) “Along with the ‘flu-like’ symptoms, many victims (about 35%) develop an unusual skin lesion.” http://www.dshs.state.tx.us/idcu/disease/lyme/information/pamphlet/
2) “In approximately 70–80% of cases, patients develop a characteristic rash, erythema migrans (EM), within 30 days of infection with B. burgdorferi.” CDC. Surveillance for Lyme disease–United States. 1992–2006. MMWR 2008; 57(SS10): 1–9)
3) “Seventh nerve palsy due to Lyme disease can develop in patients who have no recollection of an erythema migrans lesion or of a tick bite.” Clin Infect Dis 2006; 43: 1106 (2006 IDSA Guidelines)
EM RASH APPEARANCE VARIES
1) “Classic bulls-eye is NOT the most common presentation of EM as is believed.” Tibbles CD, Edlow JA. Does this Patient Have Erythema Migrans? JAMA 2007; 297:2617–2627.)
2) “Erythema migrans skin lesions can vary in appearance (figure 3). Some lesions are homogeneously erythematous, whereas others have prominent central clearing or a distinctive target-like appearance. [65,91,110] On the lower extremities, the lesion may be partially purpuric. Vesicles or pustules are present at the center of a primary erythema migrans lesion in approximately 5% of cases .” Clin Infect Dis 2006; 43:1101 (2006 IDSA Guidelines)
3) “EM is a red expanding rash, with or without central clearing, which is often accompanied by symptoms of fatigue, fever, headache, mild stiff neck, arthralgia, or myalgia.” CDC. Surveillance for Lyme Disease–United States. 1992–2006. MMWR 2008; 57(SS10): 1–9
EM RASH IS DIAGNOSTIC FOR BORRELIA INFECTION
“Erythema migrans is the only manifestation of Lyme disease in the United States that is sufficiently distinctive to allow clinical diagnosis in the absence of laboratory confirmation.” Clin Infect Dis 2006; 43:1101 (2006 IDSA Guidelines)
LYME DISEASE DIAGNOSIS
1) “Lyme Disease is diagnosed on the basis of physician-observed clinical manifestations and a history of probable exposure to infected ticks. Laboratory results are neither suggested nor required to confirm diagnosis for patients with recent onset (2–3 weeks) of a characteristic EM rash.” CDC. Surveillance for Lyme Disease–United States. 1992–2006. MMWR 2008; 57(SS10): 1–9)
2) “Lyme disease is diagnosed by medical history, physical exam, and sometimes a blood test. It may take four to six weeks for the human immune system to make antibodies against Borrelia burgdorferi and therefore show up in a positive blood test. That is why patients with the Lyme rash usually have a negative blood test and diagnosis is based on the characteristic appearance of the rash.” http://www.idsociety.org/Lyme-Facts/ Infectious Diseases of America Website
PROBLEMS WITH SEROLOGICAL TESTING
1) “Serologic testing is too insensitive in the acute phase (the first 2 weeks of infection) to be helpful diagnostically. [102,103, 116] Patients should be treated on the basis of clinical findings.” Clin Infect Dis 2006; 43: 1101 (2006 IDSA Guidelines)
2) “ELISA’s and immunoblots for detecting anti-Borrelia antibodies have widely divergent sensitivity and specificity, and immunoblots for detecting anti-Borrelia antibodies have only limited agreement. Therefore, the choice of ELISA-immunoblot combination severely influences the number of positive results, making the exchange of test results between laboratories with different methodologies hazardous.” Ang CW, Notermans DW, Hommes M, Simoons-Smit AM, Herremans T. “Large differences between test strategies for the detection of anti-Borrelia antibodies are revealed by comparing eight ELISAs and five immunoblots,” Eur J Clin Microbial Infect Dis. 2011; August 30 (8):1027–1032.
3) Published studies detailing POOR Borrelia burgdorferi sensitivity to the Elisa test:
1995 Oksi J. J Clin Microbiol
1996 Le Due T. J Clin Microbiol
1997 Bakkan L. J Clin Microbiol
1999 Trevejo RT. J Infect Dis
1999 Wang G. Clin Microbiol Reviews
1999 Goossens HA. Eur J Clin Microbiol Infect Dis
2001 Van Dam AP. Expert Rev Mol Diagn
2003 Bacon R. J Infect Dis
4) Published studies showing CDC Two Tier Testing is NOT reliable for Borrelia burgdorferi
1993 Dressler J Infect Disease 167:392-400
1993 Schmitz et al Eur J Clin Microb ID 12: 419-424
1995 Engstrom et al J Clin Microbiology 33: 419-427
1996 Ledue et al J Clin Microbiology 34:2343-50
1997 Bakken et al J Clin Microbiology 35(3):537—543
1999 Trevejo et al J Infect Disease 179; 931-8
2001 Nowakowski et al Clinical Infect Dis 33:2023-7
2003 Bacon et al J Infect Dis 187:1187-99
2005 Coulter et al J Clin Micro 43:5080-5084
2008 Wormser et al Clin Vaccine Immunol (10):1519-22
2011 Ang CW Eur J Microbiol Infect Dis 30(8):1027-32
6) Published studies showing C6 Elisa Test has POOR Sensitivity for Borrelia burgdorferi
1999 Liang FT J Clin Microbiol
2003 Bacon RM J Infect Dis
2004 Gottner G Int J Med Microbiol
2007 Gomes-Solecki MJ Clin Vac Immunol
1) “Tickborne Diseases of the US: Anaplasmosis, Babesiosis, Ehrlichiosis, Lyme Disease, Rickettsia parkeri Rickettsiosis, Rocky Mountain Spotted Fever, STARI, Tickborne Relapsing fever, Tularemia, 364D Rickettsiosis.” www.cdc.gov/ticks/diseases
Additionally, recent studies have included Colorado Tick Fever, Powassan encephalitis and Bartonellosis, Heartland Virus and B. myamotoi.
2) “The etiology of residual patient complaints after treatment may include an inflammatory response unrelated to active infection or may be due to alternative disease processes. The possibility that these symptoms may be related to a tick-transmitted coinfection was not evaluated in any of the studies.” Clin Infect Dis 2006; 43: 1103 (2006 IDSA Guidelines)
3) “Humans co-infected with LD and babesiosis appear to have more intense, prolonged symptoms than those with LD alone. Coinfected persons can also manifest diverse, influenza-like symproms, and abnormal laboratory test results are frequently observed…Clinicians should consider the likelihood of coinfection when pursuing laboratory testing or selecting therapy for patients with tick-borne illness.” Swanson SJ, Neitzel D, Reed KD, Belongia EA. “Coinfections Acquired from Ixodes Ticks” Clinical Microbiol Rev. 2006 October; 19(4): 708-727.
4) “In Lyme disease concurrent infections frequently occur…their pathological synergism can exacerbate Lyme disease…clinically relevant co-infections are caused by Bartonella species, Yersinia enterocolitica, Chlamydophila pneumonia, Chlamydia trachomatis and Mycoplasma pneumonia.” In the USA, “human granulocytic anaplasmosis (HGA) and babesiosis” are also important to consider. “The diagnosis is even more complex when co-infections occur in association with Lyme disease.” Berghoff W. “Chronic Lyme Disease and Co-Infections: Differential Diagnosis.” Open Neurol J. 2012. 6: 158-78.
LYME DISEASE CAN BE TRANSMITTED CONGENITALLY
In a May 2014 presentation to the Houston Lyme Disease Support Group, Steven Norris PhD (UT Medical School at Houston) discussed his 20+ year history of Lyme research, publications and patents. He stated during his presentation that he DOES now believe that the “Borrelia burgdorferi bacteria can be passed to the fetus.” In a May 24, 2014 email to the TXLDA Vice-President of Education he provided the following references to be used whenever Texas patients are being told that the Bb infection is unable to be passed to their infant, along with the 1985 CDC MMWR report where Lyme disease and pregnancy is again discussed.
1) “Confirmed trans placental transmission of B.burgdorferi has been documented in several cases” Walsh CA, Mayer EW, Baxi LV, “Lyme Disease in Pregnancy: Case Report and Review of the Literature,” Obstetrical and Gynecological Survey. 2006; 62 (1): 41-50.
2) “Trans placental transmission occurs as is evidenced by the presence of B. burgdorferi organisms isolated from postmortem and placental tissue.” Qasba N, Shamshirsaz AA, Feder HM, Campbell WA, Egan JF, Shamshirsaz AA. “A Case Report of Human Granulocytic Anaplasmosis (Ehrlichiosis) in Pregnancy and a Literature Review of Tick-Borne Diseases in the United States during Pregnancy,” Obstetrical and Gynecological Survey. 2011; 66 (12): 788-795.
3) Schlesinger PA, Duray PH, Burke BA, et al. “Maternal-fetal transmission of the lyme disease spirochete, Borrelia burgdorferi.” Ann Intern Med. 1985; 103: 67-68.
4) MacDonald A, Benach J, Burgdorfer W. “Stillbirth following maternal Lyme disease.” NY State J Med. 1987; 87: 615-616.
5) Weber K, Bratzke HJ, Neubert U, et al. “Borrelia burgdorferi in a newborn despite oral penicillin for Lyme borreliosis during pregnancy.” Pediatr Infect Dis J. 1988; 7: 286-289.
6) Lavoie PR, Lattner BP, Duray PH, et al. “Culture positive, seronegative transplacental Lyme borreliosis infant mortality.” Arthritis Rheum. 1987; 3(suppl):S50.
7) “Prevention and early diagnosis are important during pregnancy. Rarely, Lyme disease acquired during pregnancy may lead to infection of the placenta and may possibly lead to stillbirth. Studies of women infected during pregnancy have found there are no negative effects on the fetus when the mother receives appropriate antibiotic treatment for her Lyme disease.” CDC Brochure #CS226008-A, “Lyme Disease: What You Need to Know” What To Do If You Suspect Lyme Disease During Pregnancy
2006 IDSA GUIDELINES
1) “It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.” Clin Infect Dis 2007; 44: 1138 (15 April)
2) “More than half of the recommendations in practice guidelines issued here are based on opinions from experts rather than higher-level evidence from clinical trials.” Lee DH, Vielemeyer O. “Analysis of Overall Level of Evidence behind Infectious Disease Society of America practice guidelines,” Arch Intern Med. 2011; 171(1): 18–22.)
TEXAS LEGISLATION AFFECTS DOCTORS
1) SENATE BILL 1360/HB 2975
Sec.156.059 “Continuing Education in Tick-Borne Diseases.”
Enacted in 2011 encourages Texas physicians to pursue continuing medical education in the diagnosis and treatment of tick-borne diseases, including Lyme disease.
2) Physicians are required by law to report a case of Lyme Disease, a reportable disease.Texas Health and Safety Code SUBTITLE D. PREVENTION, CONTROL, AND REPORTS OF DISEASES Communicable Disease Prevention and Control Act 1989 Sec. 81.049. FAILURE TO REPORT; CRIMINAL PENALTY. (a) A person commits an offense if the person knowingly fails to report a reportable disease or health condition under this subchapter. (b) An offense under this section is a Class B misdemeanor.
INFECTIONS ARE THE MOST OFTEN MISDIAGNOSED
“The most common misdiagnosed diseases were (in order) infection, neoplasm, myocardial infarction, pulmonary emboli and cardiovascular disease.”
C. McDonald, MB Hernandez, Y. Gofman, S. Suchecki, W. Schreier, “The Five Most Common Misdiagnoses: a meta-analysis of autopsy and malpractise data,” The Internet Journal of Family Practise 2009; Volume 7,Number 2. DOI: 10.5580/9ce
2014 ILADS GUIDELINES
- Available on the National Guidelines Clearinghouse website.
- The only guidelines available that are written in accordance with the Institute of Medicine (IOM) standards for the development of trustworthy guidelines.
- Only guidelines available that are based on the GRADE process.
- Only guidelines use a patient centered approach.
- Only guidelines which are current, replacing the old 2006 IDSA guidelines.
Cameron, Johnson, Maloney. “Evidence Assessments and Guideline Recommendations in Lyme Disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease.” Exp Rev of Anti Inf Therapy.; 2014 (1-33)Texas Lyme Disease Association Board of Director’s/VP Education Debra McGregor RN, BSN December 1, 2015 NOTE: Two links to websites in this fact sheet were no longer available or spelled incorrectly. We have linked to similar pages on the source website cited in the article so that you would get accurate information from the true source. (CDC.gov, not .com; and http://www.dshs.state.tx.us/idcu/disease/lyme/description/ instead of /pamphlet)