Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click, we are focusing on Lyme Disease. Back issues of the Click are available in the CoramClick archive for easy reference!

	Lyme Disease – Facts About Borrelia burgdorferi Lyme disease is a bacterial infection, and transmitted by a tick bite. It is the most common tick-borne disease and the most rapidly emerging of all vector-borne diseases.
	"Chronic" Lyme Disease: The Controversy Behind Treatment Regimens There is significant controversy among clinicians, patients and organizations regarding the incidence and treatment of the long-term effects of Lyme disease. As a result, antibiotic therapy versus symptomatic therapy only is unclear.
	Common ICD-9 Code A widely used ICD-9 code for diagnosing lyme disease.
	Resource Center for Lyme Disease Helpful resources focused on heart health, heart failure and heart disease.
	Subscribe to the CoramClick Please include your email address, first and last name and company name.

Lyme Disease — Facts About Borrelia burgdorferi

Lyme disease is a bacterial infection, caused by the spirochete Borrelia burgdorferi and transmitted by a tick bite. It is the most common tick-borne disease and the most rapidly emerging of all vector-borne diseases. Lyme disease can invade multiple systems in the human body, giving rise to a wide variation of symptoms and disabilities.

Nature’s reservoir for B. burgdorferi is the white-footed mouse. The deer tick acquires the spirochete by feeding on the mouse. B. burgdorferi is transferred to humans when the infected tick attaches to the person’s skin (transmission of infection typically requires attachment for 24 to 48 hours). The B. burgdorferi spirochete can then cause infection in the person, i.e. Lyme disease.

The numbers of reported cases of Lyme disease have increased dramatically over the decades. For example, in 1992 when the Centers for Disease Control and Prevention (CDC) first started tracking Lyme disease, about 10,000 cases were reported. That number has increased to 27,444 and 26,739 in 2007 and 2008 respectively. As of April 11, 1,619 cases have been reported this year. Significantly, it is estimated that only about 10 percent of the cases of Lyme disease are actually reported to the CDC. Thus, the incidence is likely much higher.

Reported Cases of Lyme Disease – U.S., 2007 One dot placed randomly within county of residence for each reported case. Map Source: Centers for Disease Control

Lyme disease has been reported in virtually every state in the U.S., with the greatest numbers (approximately 95 percent) seen in ten key states — along the East Coast and in Minnesota and Wisconsin.

Since Lyme disease is transmitted via the deer tick, risk factors for infection center on exposure.

Ticks have a two-year life cycle from egg to adult. Nymphs and adults are primarily responsible for transmission of B. burgdorferi to susceptible hosts. In the spring, eggs hatch into a larvae. Larvae feed and molt into a nymph who feed and molt into adults. So, nymphs that feed in the fall and spring become feeding adults throughout the next year. Ticks are typically found in shaded areas within the first three feet above ground. Diagram Source: Centers for Disease Control (CDC)

Risk Factors for Lyme Disease

• Growing populations of deer that support the tick
• Increased residential development of wooded areas where Lyme disease is endemic
  Outdoor work and/or recreational activities in areas where Lyme disease is prevalent
  

Infections are most likely to occur in the spring and summer, between May and August, with the greatest spike in June and July. Fewer cases are reported in the cooler months (October-April) for a number of probable reasons:

• There are a greater number of nymphs feeding, and therefore infecting in the spring
• People tend to be outdoors more in the spring and summer so they have a greater risk of exposure
• While adult ticks are twice as likely to be infected – since they fed as nymphs and again as adults – they are larger than the nymphs and more likely to be spotted and removed before the spirochete invades

Diagnosis
There are no completely reliable diagnostics for Lyme disease. The results of serological testing e.g. indirect immunoflourescence assay [IFA], enzyme-linked immunosorbant assay [ELISA], a Western blot, and/or polymerase chain reaction [PCR], are often unreliable and should be used to support rather than make a diagnosis. Diagnosis is primarily based on clinical symptoms and a history (if known) of a tick bite.

Clinical Signs and Symptoms

Treatment
Treatment decisions depend on stage of illness and presenting symptoms. There is no “cure” for Lyme disease. Fortunately, prompt recognition and antibiotic treatment almost always assures rapid improvement with minimal likelihood of later complications.

The Infectious Disease Society of America (IDSA) has developed guidelines to support treatment decisions, including the following items:

• No antibiotic treatment or single dose doxycycline if:
• An identifiable tick was attached for > 36 hours and treatment was initiated within 72 hours
• Close monitoring for 30 days, treat if symptoms develop
• Oral antibiotic treatment: 10-21 days if early in the disease process
• Tetracyclines (doxycycline) most common
• Amoxacillin or cefuroxime also options
• IV antibiotics: 14-28 days for patients who do not respond to oral antibiotics or have multi-systemic effects
• Ceftriaxone, cefuroxime, penicillin G
• Combination therapy is increasingly used for refractory Lyme disease

Some clinicians recommend that the duration of therapy be guided by clinical, not by a prescribed treatment course. In cases of persistent Lyme disease, several months of antibiotics may be required.

Recurrent disease can develop, most likely due to a failure to eradicate the organisms. Early and aggressive antibiotic treatment is indicated for recurrence.

Prevention

"Chronic" Lyme Disease:
The Controversy Behind Treatment Regimens

There is significant controversy among clinicians, patients and organizations regarding the incidence and treatment of long-term effects of Lyme disease. Unfortunately, there is no consensus on the definition of chronic Lyme disease, making scientific conclusions regarding incidence, prevalence and pathogenesis difficult. As a result, the impact of long-term antibiotic therapy versus symptomatic therapy only is unclear.

Often termed post-Lyme disease syndrome (PLDS), post-treatment chronic Lyme disease or chronic Lyme disease, there are a significant number of patients whose symptoms do not abate, even months to years after antibiotic treatment. The course is typically variable with indolent onset. The challenge is in determining if the symptoms are in fact secondary to a previous Lyme disease infection or are simply complaints typical of, and no less frequently reported, than the general population.

It is expected that, with appropriate treatment of Lyme disease, there will be no long-term negative sequelae. When patients continue to present with late and/or persistent symptoms, several contributing factors have been proposed, including:

• Non-compliance with prescribed antibiotic treatment
• Delayed diagnosis and/or treatment of initial B. burgdorferi infection
• Residual damage
• Slow resolution of the inflammatory process
• Tick-borne co-infections
  

There is no doubt that patients reporting PLDS have life-altering symptoms, affecting both their physical and psychosocial quality of life. Common lingering symptoms are typically subjective and may include those listed below.

Multiple studies have shown that long-term antibiotic use does not improve symptoms. Given the lack of evidence to support symptom improvement.

Organizations such as the IDSA and the National Institute of Allergy and Infectious Diseases (NIAID) do not consider long-term antibiotic therapy to be effective and therefore do not recommend it.

Conversely, a notable group of patients and clinicians consider Lyme disease in some patients to remain an active infection and become persistent, recurrent and/or refractory, even after initial antibiotic therapy. Many experts believe that persistent disease may require treatment with repeated and prolonged antibiotics and, in fact, the duration of antibiotics should be lengthened to prevent or delay recurrent or refractory Lyme disease. They report notable symptom improvement when long-term antibiotics are administered. The controversy will likely not be settled until a clear definition of “chronic” Lyme disease is made and specific controlled studies support evidence-based treatment decisions.

Common ICD-9 Code: Lyme disease 088.81

The above ICD-9 code is associated with diagnosing lyme disease. Please note, this information is not all-inclusive and ICD-9 codes are updated on a regular basis. Always check that you are using the current and correct code.

Resource Center

The Centers for Disease Control and Prevention (CDC)

National Institute of Allergy and Infectious Disease (NIAID) at the National Institutes
of Health (NIH)

The Infectious Disease Society of America (IDSA)

The Lyme Disease Foundation

The International Lyme and Associated Disease Society (ILADS)

Bibliography

• Wormser, GP, Dattwyler, RJ, Shapiro, ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical practice guidelines by the Infectious Disease Society of America. Clinical Infectious Diseases, 2006; 43:1089-1134.
• http://www.guideline.gov/summary/summary.aspx?doc_id=4836&nbr-3481&string=Lyme. Retrieved 4/21/2009.
  
• http://www.canlyme.com/treatment.html. Retrieved 4/21/09.
  
• http://www3.niaid.nih.gov/topics/lymeDisease/understanding/chronic.htm. Retrieved 4/21/09
  
• www.cdc.gov

The CoramClick, brought to you by Coram, Inc., is a quarterly publication that is provided free of charge to the community. Opinions expressed by contributing authors and sources are not necessarily those of the publisher. Information contained in this newsletter is for educational purposes only and is not intended as a substitute for medical advice. Do not use this information to diagnose or treat a health problem or disease without consulting a qualified physician. Please consult your physician before starting any course of supplementation or treatment, particularly if you are currently under medical care. Never disregard medical advice or delay in seeking it because of something you have read in this newsletter. © 2009 Coram, Inc. All rights reserved. No part of this publication may be distributed, reprinted or photocopied without prior written permission of copyright owner. All service marks, trademarks and trade names presented or referred to in this newsletter are the property of their respective owners.