Lyme disease is a systemic inflammatory disorder caused by the spirochete Borrelia burgdorferi, spread by ticks of the genus Ixodes. In the United States, the primary animal reservoir for the spirochete is the white-footed mouse, which also serves as the preferred host for nymphal and larval forms of the tick. Deer are the preferred hosts for the adult ticks in the United States, and sheep in Europe.

The disorder was first identified and named when a cluster of cases occurred in Lyme, Connecticut, in 1975. It has since become the most common tick-borne disease in the United States, with approximately 16,000 new cases reported per year. In addition, Lyme disease may be under reported by as much as a factor of 10.

Humans are bitten by Ixodes ticks in their larval stage, when they are small and difficult to see. Only about 25% of patients with Lyme disease recall a tick bite. The spirochetes enter the skin at the bite, generally after the infected tick has been in place for 36 to 48 hours.

The microorganism may migrate in the lymphatic fluid, producing local adenopathy. It may also spread via the blood to distant sites. Relatively few organisms are seen in involved tissue, suggesting that symptoms are primarily due to host immune responses.

• Environment: Exposure to heavily wooded areas
• Season: Infection is most likely to occur during the summer and fall
• Age: Most common in children and young adults
• Location: Ninety percent of cases occur on the East Coast between Maryland and Massachusetts, as well as Wisconsin, Minnesota, California, and Oregon.

• Red rash appears in at least 75% of patients. Begins as red macule or papule on trunk or extremity 3 to 32 days after tick bite. Expands, often with central clearing, to up to 70 cm in diameter (average 16 cm), known as erythema migrans. Multiple lesions may develop, indicating hematogenous spread of infection.
• Flu-like syndrome: Malaise, fatigue, chills, fever (generally low-grade), headache, stiff neck, myalgia, arthralgia, accompanying or preceding erythema migrans
• Neurologic abnormalities: Develop in about 15% of patients within weeks to months, often last for months, but usually resolve completely. Most common include lymphocytic meningitis, meningoencephalitis, cranial neuritis, especially Bell's palsy, sensory or motor radiculoneuropathies.
• Myocardial abnormalities: Occur in about 8% of patients, within weeks. More common in males. Include atrioventricular blocks of fluctuating degrees, manifesting as palpitations, lightheadedness, and syncope. Chest pain and dyspnea may be signs of Lyme pericarditis, myocarditis, or myopericarditis.
• Arthritis: Seen in 60% of patients within weeks to months. Knee involvement most common. Intermittent episodes may recur for several years.

• Rheumatoid arthritis
• Reiter's syndrome
• Ehrlichiosis (also transmitted by deer tick; approximately 10% to 15% of Lyme disease patients are also infected with another tick-borne illness)
• Rheumatic fever
• Idiopathic Bell's palsy and other CNS syndromes
• Insect or spider bites

Diagnosis may be made based on typical erythema migrans in an endemic area even without laboratory confirmation. Erythema migrans from Lyme disease is rarely found on hands or feet. Ticks are more likely to stop and bite where their forward motion is impeded by obstructions such as skin folds, the hairline, or clothing bands and straps.

Facial nerve palsy is more likely to be bilateral than in most other syndromes. Muscular or joint tenderness or swelling may be noted, especially around the knees.

Laboratory studies are generally unnecessary in early disease with typical presentation. Serologic testing yields many false positives if clinical indicators are weak, and seroconversion may take several weeks in infected patients. If serologic testing is done, a positive ELISA test should be confirmed with the Western blot. The tests can support a diagnosis, but should not be used either to rule in or rule out Lyme disease.

CBC and erythrocyte sedimentation rate are usually normal in early disease. Elevation of at least one LFT occurs in approximately 40% of patients. Recovery of spirochetes from tissue by culture is difficult and time-consuming.

X rays usually reveal only soft tissue swelling. Rarely patients have had some erosion of cartilage and bone.

Many physicians perform a lumbar puncture for detection of meningitis on patients with erythema migrans and any CNS symptoms.

Lyme disease responds well to antibiotics but may not resolve completely until well after treatment course. Symptomatic relief may be offered as well. Early treatment is most successful. Knee joints with effusion may be treated with fluid aspiration and the use of crutches.

• Patients <8 years: amoxicillin 250 mg tid or 30 to 50 mg/kg/day orally in three divided doses (maximum 2 to 3 g/day) for 10 to 21 days.
• Patients >8 years: doxycycline 4 mg/kg/day orally (maximum 200 mg/day) in two divided doses or alternatively amoxicillin. 
• Penicillin allergy: cefuroxime axetil 30 mg/kg/day in two divided doses (maximum 1 to 2 g/day) or erythromycin 250 mg qid or 30 to 50 mg/kg/day in three to four divided doses (maximum 2 g/day) for 10 to 21 days. 
• Neurological involvement: ceftriaxone 75 to 100 mg/kg/day (maximum 2 g/day) IV or penicillin G 300,000 U/kg/day in six divided doses (maximum 20 million U/day) IV for 14 to 21 days. 
• Symptomatic relief: NSAIDs 

Persistent arthritis of the knee may be treated with arthroscopic synovectomy. Heart block may require a temporary pacemaker.

Lyme disease manifests in multiple systems and, therefore, may benefit from a multidisciplinary approach that includes homeopathy, stress management (e.g., biofeedback, support groups), and other adjunctive therapies. Chiropractic manipulative therapy may be instrumental in alleviating pain and improving limited mobility and range of motion (Whitmont 1997; Brier 1990).

An integrative nutritional approach to treating Lyme disease includes anti-inflammatory fatty acids (e.g., borage and fish oils), mitochondrial nutrients (e.g., carnitine and lipoic acid), and nutrients to support adrenocortical function (e.g., vitamin C, vitamin B₆,and pantothenic acid). Mitochondrial nutrients boost the production of energy; cognitive enhancements are used to increase blood flow to the brain. (Imaging studies of patients with chronic Lyme disease show a diminished blood supply to certain areas of the brain.) Calcium/magnesium supplements are suggested for muscle pain and spasm; extra magnesium (30 to 420 mg/day, depending on age and gender) and malic acid should be included when myalgia symptoms predominate (Bock 1999). Malic acid is found in apples, pears, other fruits and is often used as a food addititive.

Although unclear as of yet whether vitamin A supplementation in humans would help treat Lyme disease or its sequelae, vitamin A deficiency has been shown to exacerbate Lyme arthritis in animal models. Insufficient levels of vitamin A may potentiate an acute arthritic inflammatory response mediated by spirochete-initiated IFN-gamma secretion. Conversely, the presence of vitamin A may block IFN-gamma and IL-12 synthesis, thereby lessening acute Lyme arthritis (Cantorna and Hayes 1996).

Other animal models have shown 1,25-dihydroxycholecalciferol to be effective in minimizing or preventing acute arthritic lesions (including foot pad and ankle) in mice infected with B. burgdorferi (Cantorna et al. 1998). Again, no specific conclusions can be drawn from this information regarding humans but it raises an interesting possibility.

Probiotics may be beneficial to re-establish normal intestinal microflora; they may also prevent intestinal dysbiosis and infection that can arise during and after antibiotic therapy for Lyme disease (Bock 1999).

Cognitive deficits secondary to B. burgdorferi infection may respond to L-acetyl-carnitine and antioxidant nutrients (e.g., lipoic acid and CoQ10) (Bock 1999).

Ginkgo (Ginkgo biloba) and valerian (Valeriana officinalis) may be helpful in mitigating cognitive involvement and anxiety, respectively. Both cognitive involvement and anxiety may be associated with Lyme disease (Bock 1999).

Homeopathic treatment can address both the constitutional and acute aspects of disease in general. In homeopathic terminology, the constitutional state reflects a pattern of underlying vulnerability or weakness that is unique to the individual and persists throughout that person's life. Symptoms tend to alternate over time, and treatment consists of selecting the appropriate remedy specific for the patient's constitutional type. By contrast, in acute conditions a remedy can be administered without reference to any particular constitutional state (Ullman 1995).

Homeopathic reference materials list seven remedies for the acute treatment of Lyme disease: Arsenicum album, Carcinosin, Lac caninum, Ledum, Mercurius, Syphilinum, and Thuja.These, however, are considered only the starting point for determining an appropriate remedy; any homeopathic remedy can be applied to the treatment of Lyme disease if it is the simillimum to the individual case (Whitmont 1997). In homeopathic terminology, the simillimum is the remedy that most closely matches the patient's symptoms (Ullman 1995).

Prescription of nosodes (i.e., serially agitated dilutions of infectious agents) represents a further approach to acute treatment of disease (Jonas 1999). Case studies reveal the effectiveness of a nosode in early Lyme disease, and of combinations of nosode and other homeopathic remedies in chronic disease (Whitmont 1997).

In a trial evaluating the effectiveness of homeopathic remedies and nutritional support in patients with Lyme-related TMJ (temporal-mandibular joint dysfunction), homeopathic remedies were found to be effective in treating acute and chronic infections, aiding the immune system in recognizing pathogens, and alleviating TMJ symptoms (Kacherski 1997). The study involved patients who had systemic chronic Lyme disease with TMJ dysfunction and medical histories of multiple antibiotic protocols. Because bacterial infections may interfere with energy channels, and points on the index finger and the thumb are used to determine the presence or absence of such interference (Van Benschoten 1992), Omura's Bi-Digital O-Ring Test was used to establish the presence of B. burgdorferi infection in the TMJ and surrounding area. (The Bi-Digital O-Ring test is a diagnostic method used by homeopathic doctors, acupuncturists and other specialists to determine grip strength by having the practitioner attempt to separate the patient's thumb and index finger. Lack of strength, in this case, indicates presence of infection). Following confirmation of infection, the Bi-Digital O-Ring Test was also used to determine the appropriate homeopathic remedy and its potency (e.g., 6C, 1M, 10M, etc.) to be used over a treatment period of several months; in other words, the Test was used to assess responsiveness to therapy (Kacherski 1997).

May be helpful in providing pain relief, increasing mobility, and reducing fatigue, common symptoms associated with Lyme disease (Bock 1999).

Chinese herbal formulas, used by many acupuncturists, have been shown to be an effective adjunct in resolving rheumatic and neurological symptoms secondary to B. burgdorferi infection and following multiple courses of antibiotic therapy. Case studies illustrate the effectiveness of Chinese herbal formulas, determined by Omura's Bi-Digital O-Ring Test, applied to patients with established Lyme disease unresponsive to antibiotic therapy (Van Benschoten 1992). Please see section entitled Homeopathy for description of the Omura's Bi-Digital O-Ring Test.

May be beneficial in relieving myalgias associated with Lyme disease and increasing mobility when applied as part of comprehensive physical therapy (Burrascano 2000).

Advanced cases require careful monitoring over months or years, depending on severity of symptoms.

Tick-bite prevention strategies include avoiding heavily wooded areas or wearing protective clothing such as hats, long sleeves, and long pants tucked into socks or boots, and applying tick repellant.

Wearing light-colored clothing makes ticks easier to detect. Remove ticks with tweezers only. Using other methods may cause the tick to regurgitate gut contents, discharging bacteria into the host. Because B. burgdorferi is generally not transmitted until 36 to 48 hours after tick attachment, careful inspection of the body after outdoor activities in wooded or grassy areas is an important preventive step. LYMERix, a vaccine based on recombinant outer-surface protein specific to B. burgdoferi, was approved by the FDA in December 1998. The vaccine is recommended for those who live, travel, or work in Lyme endemic areas and who have exposure to ticks. Efficacy after three doses, given over the course of one year, is roughly 80%.

• Fixed neurological deficits
• Myocardial abnormalities
• Persistent arthritis

Fatalities are rare with Lyme disease. Neurological involvement that is not promptly treated with antibiotics may cause fixed deficits that can be difficult to treat. Likewise, in some patients, arthritis may become persistent and unresponsive to antibiotic therapy. However, the most recent data indicate that the long-term prognosis for most patients treated with antibiotics is excellent, with self-reported health status after 1 to 11 years similar to that of an age-matched control population.

No treatment necessary for seropositive but asymptomatic pregnant women. Amoxicillin may be given to pregnant women if the disease is early and localized. Manifestation of disseminated disease requires penicillin IV.

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