Lyme Disease

What is Lyme disease?

Lyme disease (Lyme borreliosis) is a bacterial infection that is spread by ticks. You may develop Lyme disease if you are bitten by an infected tick. Your risk of developing Lyme disease increases if an infected tick stays attached to your skin for 36 to 48 hours.

Lyme disease is the most common tick-borne disease in the United States.¹ It also frequently occurs in Canada, Europe, and Asia.

Lyme disease is not contagious and cannot be transmitted from person to person.

What causes Lyme disease?

Lyme disease is caused by the bacterium Borrelia burgdorferi. When ticks are infected with this type of bacterium, they can transmit it by biting humans or animals. After you are infected, you may develop Lyme disease within a few days or weeks.

In the United States, the two types of ticks that carry Lyme disease bacteria are:

• Deer ticks , which spread Lyme disease in the northeastern and upper Midwestern U.S.
• Western black-legged ticks , which spread Lyme disease along the Pacific coast—mostly northern California and Oregon.

What are the symptoms?

Early symptoms can include an expanding circular rash called erythema migrans, and flu-like symptoms, such as body aches, fatigue, and mild fever. Most people with Lyme disease have a circular rash at the site of the tick bite. But other people don't have any symptoms in the early stages of Lyme disease and do not remember having had a tick bite.

The incubation period—the time from when you are first infected until you develop symptoms—is usually around 7 to 14 days, but symptoms can start anywhere from 3 days to about a month after you are bitten.

If the early stage of Lyme disease goes unnoticed, later symptoms can include swelling and pain in joints (similar to arthritis); numbness and tingling in the hands, feet, or back; persistent fatigue; poor memory and reduced ability to concentrate; and weakness or paralysis in the muscles of the face.

How is Lyme disease diagnosed?

Lyme disease is diagnosed by evaluating your symptoms and medical history and determining the likelihood that you have been exposed to infected ticks. Having the characteristic expanding circular rash is usually a sure sign of Lyme disease. Blood tests, such as the Lyme disease test, may be used to confirm a diagnosis. Most people who are bitten by a tick will not develop Lyme disease, especially if exposure to the tick occurred outside high-risk areas or if the tick did not stay attached to the skin for 36 hours.²

Misdiagnosis of Lyme disease is common, because the bacteria that cause the illness are difficult to detect with current lab tests and because symptoms of Lyme disease sometimes closely resemble those of other illnesses.

How is it treated?

Treatment with antibiotics usually cures Lyme disease quickly and completely. However, if Lyme disease goes undetected or is not properly treated, problems involving the skin, joints, nervous system, and heart may develop weeks, months, or even years later. These problems usually improve after antibiotic treatment, but in rare cases they may be permanent. Most people with Lyme disease who are diagnosed early and treated appropriately with antibiotics have no long-term disabilities resulting from the disease.³

Frequently Asked Questions

Lyme disease is caused by infection with Borrelia burgdorferi (B. burgdorferi) bacteria.

How the disease is spread

Lyme disease is spread when you are bitten by a tick that is infected with B. burgdorferi bacteria. When an infected tick bites you, bacteria travel to the tick's salivary glands and then into your body through your skin. It takes about 24 hours for a tick to attach itself to the skin and begin to feed. The tick generally must be attached to you for about 36 hours in order for it to transmit the Lyme disease bacteria.

In the United States, the two types of ticks that carry Lyme disease bacteria are:

• Deer ticks , which spread Lyme disease in the northeastern and upper Midwestern U.S.
• Western black-legged ticks , which spread Lyme disease along the Pacific coast—mostly northern California and Oregon.

Dogs, cats, and horses can become infected with Lyme disease bacteria, but they cannot pass the illness to humans. However, infected ticks may fall off the animals and then bite and infect humans. Animals may develop symptoms similar to those seen in people, including fever and swollen joints. A vaccine for dogs is available in some states.

There is no convincing evidence that Lyme disease can be spread to humans by insects such as mosquitoes, flies, or fleas.

Is Lyme disease contagious?

Lyme disease is not contagious and cannot be spread from person to person. But certain precautions should be taken to prevent spread of the illness through ways such as blood transfusions.

• People with active Lyme disease should not donate blood, because the bacteria that cause the illness can be transmitted this way. People who were previously treated for Lyme disease may be able to donate blood, but they should check with the blood bank first.
• A pregnant woman may be able to pass Lyme disease to her unborn child, but proven cases are rare. Lyme disease has not been shown to cause birth defects or fetal death.
• There is no evidence that breast-feeding mothers can pass the illness to their babies through breast milk. However, a nursing mother who is suspected of having Lyme disease may be asked to stop nursing until she has completed a course of antibiotic therapy. The baby is also watched closely for symptoms of Lyme disease.

Lyme disease may progress in stages from mild symptoms to serious, long-term disabilities if left untreated. There are three stages of Lyme disease: early localized, early disseminated, and late persistent.

Stage 1: Early localized infection (1 to 4 weeks)

Some people with Lyme disease have a rash (called an erythema migrans) at the site of the tick bite. The rash is usually circular and it gets larger over time. Other people don't have any symptoms in the early stages of Lyme disease and do not remember having had a tick bite. About half the people infected with Lyme disease develop a rash within 1 to 4 weeks.⁴

For people who live in areas where Lyme disease most often occurs—in the United States along the Atlantic coast, the Midwest, and parts of Oregon and California—the circular rash is usually a sure sign of Lyme disease, especially when it appears during the summer months.

Some people with Lyme disease will have flu-like symptoms with or without a rash. These symptoms may include:

• Lack of energy, which is the most common symptom.
• Headache and stiff neck.
• Fever and chills.
• Muscle and joint pain.
• Swollen lymph nodes.

In some cases of Lyme disease, the person does not notice any symptoms during this stage.

Stage 2: Early disseminated infection (1 to 4 months)

If Lyme disease is not detected and treated while early symptoms are present, or if you do not have early symptoms that trigger the need for treatment, the infection may affect the skin, joints, nervous system, and heart within weeks to months after the initial infection.

Symptoms at this stage may include:

• Being tired.
• Additional skin rashes in several places on your body that develop as the infection spreads.
• Pain, weakness, or numbness in the arms or legs.
• Inability to control the muscles of the face (paralysis of the facial nerves).
• Recurring headaches or fainting.
• Poor memory and reduced ability to concentrate.
• Conjunctivitis (pinkeye) or sometimes damage to deep tissue in the eyes.
• Occasional rapid heartbeats (palpitations) or, in rare cases, serious heart problems.

Stage 3: Late persistent infections

If Lyme disease is not promptly or effectively treated, damage to the joints, nerves, and brain may develop months or years after you become infected (late Lyme disease). Symptoms at this stage may include:

• Swelling and pain (inflammation) in the joints, especially in the knees.
• Numbness and tingling in the hands, feet, or back.
• Severe fatigue.
• Partial facial nerve paralysis (Bell's palsy), which usually occurs within the first few months after the tick bite.⁵
• Neurologic changes, including problems with memory, mood, or sleep and sometimes problems speaking.
• Chronic Lyme arthritis, which causes recurring episodes of swelling, redness, and fluid buildup in one or more joints that last up to 6 months at a time.

Heart, nervous system, and joint symptoms may be the first signs of Lyme disease in people who did not have a rash or other symptoms of early infection.

If you are bitten by a tick carrying Lyme disease bacteria, a circular skin rash often develops at the site of the tick bite within a month. The rash slowly expands and may become very large. Flu-like symptoms, such as fatigue, headache, sore muscles and joints, fever and chills, and swollen lymph nodes, also may occur. Lyme disease develops in three stages.

Early localized Lyme disease usually occurs 3 days to about a month after being bitten. If Lyme disease is not detected and treated properly during the early localized stage, the infection may progress to the second or third stages of Lyme disease and involve the skin, joints, nervous system, and heart.

Early disseminated Lyme disease is the second stage. It may develop several weeks or months after you become infected and can cause:

• Skin problems, such as an expanding, circular rash at the site of the bite. Additional rashes can then develop on other parts of your body as the infection spreads. More serious skin problems from Lyme disease are rare in the United States but can include swelling in the earlobes and near the nipples, and severe thinning of the skin on the hands and feet.
• Joint problems, which are common and include brief episodes of pain, redness, and swelling in one or more large joints—most often the knee. Joint symptoms usually improve with antibiotic treatment.
• Early nervous system problems, such as pain and weakness in the arms and legs caused by nerve inflammation.
• Heart problems, most commonly a slow or irregular heartbeat (arrhythmia). Heart problems caused by Lyme disease are rare and are even rarer if you did not already have a weakened heart before you got Lyme disease.

Late persistent Lyme disease is the last and often the most serious stage of the disease. It may develop weeks, months, or rarely, years after the initial infection and can cause:

• Joint problems, such as early arthritis that most often affects the knee. A small number of people eventually develop chronic Lyme arthritis, which usually improves with antibiotic treatment. However, joints that have been badly damaged may take a long time to heal or may not respond to antibiotic treatment. In some cases, surgery to remove the lining of the affected joint (synovectomy) may be necessary.
• Late nervous system problems, such as pain, weakness, or numbness in the arms or legs that can occur when the bacterial infection has spread to the nerves or spinal cord. Severe headaches, fatigue, or problems with vision, hearing, memory, concentration, and thinking can also develop. Serious nervous system problems can cause severe headache and stiff neck due to inflammation of the tissues surrounding the brain and spinal cord (meningitis); paralysis of the nerves that control the muscles in the face (Bell's palsy); and inflammation of the brain (encephalitis). However, these problems sometimes go away on their own; if not, they usually improve after antibiotic treatment.
• Heart problems, which are rare, but can occur months to even years after initially being bitten by an infected tick. The most serious heart problems—such as inflammation of the structures surrounding the heart (pericarditis)—usually resolve without any permanent damage. Unfortunately, heart problems can be the first sign of Lyme disease in a small number of people who did not have early symptoms.

Later symptoms of untreated Lyme disease, such as joint problems, weakness or numbness in the arms or legs, severe fatigue, or difficulties with memory and thinking, may seem like other illnesses such as fibromyalgia or multiple sclerosis.

The main risk factor for Lyme disease is exposure to ticks that are infected with Lyme disease bacteria. In areas where Lyme disease is widespread, several factors may increase your risk, including:

• Spending time outdoors during the warm months of the year when ticks are most active. Most cases of Lyme disease occur in the northeastern United States and Canada when infected ticks are most prevalent—usually between May and November, with peak activity in June and July.
• Working or playing in grassy or wooded areas doing things like gardening or yard work, hiking, camping, hunting, or fishing.
• Having indoor/outdoor pets. They can bring infected ticks into the house. Although dogs and cats can become infected with the Lyme disease bacteria, they cannot pass the illness to humans. However, the infected ticks can drop off the animals and then bite and infect humans. Animals may have symptoms similar to those seen in people, including fever and swollen joints. A vaccine for dogs is available in some areas.
• Having a stone fence or a bird feeder near your house. Stone fences often become homes for mice, and mice may feed on spilled seed from a bird feeder. Where there are mice, there are ticks.

Remove ticks right away, as soon as you notice them. Your risk for getting Lyme disease increases the longer a tick is attached to your body. Ticks generally cannot transmit Lyme disease until they are attached for at least 36 hours.

Call your health professional if:

• A tick is attached to your body and you are unable to remove the entire tick.
• You have a circular red rash that expands over the course of several days, especially if you know you were recently exposed to ticks. The rash may be accompanied by flu-like symptoms, such as fatigue, headache, stiff neck, fever, chills, or body aches.
• You feel very tired or have joint pain (especially with redness and swelling), irregular heartbeats, severe headache, or neck pain.
• You are pregnant or nursing and you think you may have been exposed to ticks.

Watchful Waiting

If you have been in an area where ticks that carry Lyme disease are present, watch for signs of infection such as flu-like symptoms or an expanding red rash.

Who To See

The following health professionals can diagnose and prescribe treatment for Lyme disease or complications of Lyme disease:

• General practitioner
• Internist
• Pediatrician
• Nurse practitioner
• Physician assistant
• Infectious disease specialist
• Rheumatologist
• Dermatologist
• Neurologist
• Cardiologist

To prepare for your appointment, see the topic Making the Most of Your Appointment

Lyme disease may be hard to diagnose because its symptoms are like those of many other illnesses. Your health professional will take a careful medical history and do a physical examination to help diagnose early Lyme disease. You may be asked whether you have recently visited an area where you may have been exposed to ticks. The health professional will ask about your symptoms and look for physical signs that may indicate Lyme disease. The clearest physical sign is an expanding, circular red rash (called erythema migrans).

The early, often vague, flu-like symptoms of Lyme disease can easily be misdiagnosed as another illness (such as chronic fatigue syndrome), especially if you do not have the circular red rash.

Lyme disease tests are blood tests that help confirm a diagnosis of Lyme disease. These tests can detect antibodies to the bacteria (Borrelia burgdorferi) that cause Lyme disease. Although blood tests are fairly reliable, they may not be needed. The decision about when to use blood tests for Lyme disease depends on whether your health professional strongly thinks you have Lyme disease and whether the test results will change the course of your treatment.

Other tests, such as a skin biopsy, may be done to confirm a diagnosis of Lyme disease or to rule out other similar conditions.

Early Detection

It is important to get treatment for Lyme disease as soon as possible. Talk to your doctor if you have had a tick attached to your skin, especially if you live in an area where people have reported getting Lyme disease. Also watch for early symptoms of Lyme disease, such as a slowly expanding rash or flu-like symptoms.

If possible, put the tick that was attached to you in a jar or on a damp paper towel in a zip lock baggie and take it to the doctor with you. Sometimes tests can be done on the tick to see if it is a carrier of Lyme disease.

Lyme disease is treated with antibiotics such as doxycycline or amoxicillin. Antibiotic treatment for early Lyme disease is effective, and symptoms usually go away within 3 weeks of treatment.⁶

The earlier antibiotic treatment is started after infection, the faster and more completely you will recover.⁷ Research indicates that if you are given a single dose of the antibiotic doxycycline within 72 hours after being bitten by an infected tick, your chances of getting Lyme disease may be reduced by up to 87%.⁸ This treatment may be especially effective for those who live in high-risk areas.

If Lyme disease is not diagnosed and treated until later problems arise, it may take you a long time to get better or you may need additional treatment.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, are usually helpful for symptoms of arthritis that can occur with late Lyme disease. These symptoms may include pain, swelling, redness, warmth, and limitation of movement.

Some people with untreated Lyme disease get achy joints. Occasionally, repeated episodes of swelling, redness, and fluid buildup in one or more joints can last up to 6 months at a time. This is a condition called chronic Lyme arthritis. Treatment for this problem usually requires antibiotics, such as amoxicillin or doxycycline. However, joints that have been badly damaged by Lyme arthritis may take a long time to get better, or antibiotics may not improve symptoms. If chronic Lyme arthritis continues despite antibiotic treatment, surgery to remove the lining of the affected joint (synovectomy) may be considered.

Long-term antibiotics are also commonly used to treat nervous system problems (such as tingling and numbness or conditions such as meningitis). But a number of examinations and tests may be done to rule out other causes of symptoms before more aggressive or long-term antibiotic treatment is started.

People with partial facial paralysis (Bell's palsy) as a result of Lyme disease may improve on their own without additional treatment.

Antibiotics and other treatments are used to help people who develop serious heart problems, such as severe irregular heartbeat or pericarditis, from Lyme disease that was left untreated or was not treated effectively. But these problems are extremely rare, especially in people who did not have heart problems before getting Lyme disease. Heart problems may start getting better on their own, even before antibiotic treatment has started.

In the past, a Lyme disease vaccination was available for people who lived in high-risk areas, but the vaccine is no longer made. It was removed from the market due to uncertainty over its effectiveness and lack of demand.

What To Think About

Most people who have had a tick bite do not get Lyme disease. But it is still important to talk to your doctor if you have had a tick attached to you.

Previously, health professionals recommended using the antibiotic doxycycline for about 20 days to cure early Lyme disease. However, a study suggests that 10 days of doxycycline is as effective as 20 days to cure early, uncomplicated Lyme disease.⁹ The type of antibiotic your doctor gives you and the number of days you take it depends on your symptoms and the stage of the disease. Talk to your doctor if you have any questions about your antibiotic treatment.

Misdiagnosis of Lyme disease is common, especially if you do not have the characteristic circular red rash. In addition, anxiety and awareness of Lyme disease has resulted in frequent use of antibiotic treatment for people who really do not need it. In general, antibiotics are not usually needed unless it is clear you have Lyme disease.

In some rare cases, severe joint and nervous system damage cannot be reversed.

Lyme disease can be prevented. If you visit or live in an area where it frequently occurs, you can greatly lower your risk of getting Lyme disease by taking steps to avoid tick bites and checking for and promptly removing ticks from your body and clothing. Quickly removing attached ticks is especially important if you are pregnant or nursing because the effects of Lyme disease on a fetus are not fully understood. However, pregnant woman can be assured that with proper treatment of Lyme disease, there is very little risk of harm to the baby.

If you or someone in your family has been exposed to ticks, watch carefully for symptoms of Lyme disease (such as flu-like symptoms or a circular red rash), and contact your doctor right away if symptoms appear. If you find a tick attached to your body and think the tick has been there longer than 24 hours, ask your doctor whether a single dose of antibiotics could help prevent Lyme disease from developing.

How to avoid tick bites

• Learn where ticks and deer that carry ticks are most commonly found in your community, and avoid those areas if possible.
• Cover as much of your body as possible when working or playing in grassy or wooded areas. Wear a hat, a long-sleeved shirt, and long pants with the legs tucked into your socks. Keep in mind that it is easier to spot ticks on light-colored clothes.
• Use insect repellents, such as products containing DEET, that are effective against ticks and can be sprayed directly on your skin. Remember that higher concentrations of DEET are not recommended for infants and small children. Insect repellents containing permethrin, a strong chemical that kills ticks on contact, can be put on clothes, especially pants, socks, and shoes. However, avoid putting products containing permethrin directly on your skin.
• Take steps to control ticks on your property if you live in an area where Lyme disease is prevalent. Clearing leaves, brush, tall grasses, woodpiles, and stone fences from around your house and the edges of your yard or garden may help reduce the tick population and the rodent population that the ticks depend on. Remove plants that attract deer, and use barriers to keep deer—and the deer ticks they may carry—out of your yard. Treating yards with chemicals that kill ticks (ascaricides) is sometimes effective but exposes you and your pets to chemicals that may not be safe. You may choose to treat your lawn for ticks with nonchemical or environmentally safe methods instead. Call your local landscaping nursery or county extension office for more information.

Checking for ticks

• When you come in from outdoors, check all over your body for ticks, including your groin, head, and underarms. If no one else can help you check for ticks on your scalp, comb your hair with a fine-toothed comb. This should remove most ticks that are present. Don't forget to check for ticks on any gear you had with you in the woods.
• At the end of the day, take a shower and use a washcloth to clean your body. This will knock off any ticks that are loosely attached to your body. Remember, it takes about 24 hours for a tick to attach itself to the skin.
• If you live in an area where Lyme disease is prevalent, check your children daily for ticks, especially during the summer months.
• Check your pets for ticks after they've been outdoors. Not only can your pet get Lyme disease, but it can carry infected ticks indoors where the ticks might fall off your pet and attach to you.
• When hiking in the woods, carry a small jar filled with rubbing alcohol. If you find a tick on your body, properly remove the tick and keep it in the alcohol so you can give it to your doctor if symptoms develop. The tick can be tested to learn whether it is carrying the bacteria that causes Lyme disease.

Removing ticks

• Use fine-point tweezers to remove the tick . Grasp the tick as close to its mouth (the part that is embedded in your skin) as possible.
• Slowly pull the tick straight out (don't twist or yank) until its mouth is released from your skin.
• Avoid pushing on or squeezing the tick's swollen abdomen. Squeezing it can push bacteria into your body.
• If the tick breaks and part of it stays under your skin, do not try to remove the rest of it by digging under the skin. This just causes more skin damage. Your doctor may be able to remove it. If the rest of the tick cannot be removed, it will be expelled by the skin naturally in a few weeks.
• Use soap and water to wash the area where the tick was attached.
• Do not try to suffocate the tick with petroleum jelly, nail polish, or rubbing alcohol. This may increase your risk of infection.
• Do not try to burn the tick with a cigarette or match while the tick is attached to your skin.
• Watch for signs of infection, such as an expanding red rash and flu-like symptoms. Keep in mind that most tick bites do not lead to infection—deer ticks usually have to feed for at least 36 hours before they can pass on bacteria that cause Lyme disease.

Vaccine for Lyme disease

A vaccine was developed for use in high-risk areas; however, it is no longer available. It was removed from the market because of uncertainty over its effectiveness and lack of demand.

There is no effective way to treat Lyme disease at home. After your doctor has evaluated your symptoms and diagnosed Lyme disease, you may want to use a nonprescription pain reliever (such as aspirin or ibuprofen) to relieve joint or muscle pain. Talk with your doctor about the best choice for you. Do not give aspirin to anyone younger than age 20 because it has been linked to Reye's syndrome.

The Lyme disease rash may be warm to the touch, but it is not uncomfortable and does not require special treatment. When antibiotics begin to rid the body of infection, the rash will clear up.

Antibiotics, such as doxycycline or amoxicillin, are the main treatment for Lyme disease.

The goals of treatment are to eliminate the infection and prevent complications of Lyme disease, such as problems involving the skin, joints, nervous system, or heart.

The type of antibiotic prescribed, the amount, and whether the medicine is taken orally, as an injection, or through a vein (intravenous or IV) depends on how bad your symptoms are and how long you've had Lyme disease. Oral antibiotics are prescribed for early Lyme disease. Either oral or intravenous antibiotics may be used to treat late Lyme disease symptoms.

Intravenous (IV) antibiotics are the treatment of choice if your nervous system is affected by late Lyme disease and you have bad headaches, neck pain, weakness or numbness in the arms or legs, or problems with thinking or memory. IV antibiotics are also used if the Lyme disease bacteria or antibodies against the bacteria have been found in your spinal fluid.

Oral antibiotics are usually prescribed first for chronic Lyme arthritis (recurring swelling and joint pain), but IV antibiotics may be tried if the oral antibiotics do not work.

Medication Choices

Antibiotics, such as doxycycline, amoxicillin, cefotaxime, or penicillin, are used to treat Lyme disease.

Taking doxycycline for 10 days rather than 20 days may effectively treat early Lyme disease.⁹ Also, if doxycycline is given within 72 hours after you are bitten by an infected tick, it may prevent Lyme disease. The type of antibiotic your doctor gives you and the number of days you take it depends on your symptoms and the stage of the disease. Talk to your doctor if you have any questions about your antibiotic treatment.

There used to be a vaccine for prevention of Lyme disease in high-risk areas, but it is no longer available because of uncertainty over its effectiveness and lack of demand.

What To Think About

Different antibiotics may be used to treat children and adults. Doxycycline is often prescribed for adults and children 8 years and older, while amoxicillin is usually preferred for treating younger children with Lyme disease.³

The decision to take medicines for Lyme disease may be based on one or more of these factors:

• You have symptoms of Lyme disease, especially the characteristic red, circular rash, and a history of exposure to ticks in geographic regions where Lyme disease is known to occur.
• Blood tests reveal antibodies to the Lyme disease bacteria in your blood, spinal fluid, or joint fluid.
• You are a pregnant or breast-feeding and are bitten by a tick.

In rare instances, Lyme disease symptoms may not go away even after antibiotic treatment has cured the infection. There are a number of possible reasons why symptoms may take longer to improve:

• Some symptoms simply take longer to resolve.
• Tissue or nerve damage caused by untreated Lyme disease may be severe or even irreversible.
• You may not actually have Lyme disease or may have another illness at the same time with symptoms that do not respond to antibiotic treatment. Lyme disease may trigger fibromyalgia or chronic fatigue syndrome, or you may be misdiagnosed as having Lyme disease when you really have a chronic fatigue condition.

The first course of antibiotics almost always cures the infection. If symptoms continue, an additional treatment with antibiotics may be needed.

There is no surgical treatment for Lyme disease.

In severe cases of chronic Lyme arthritis, removal of the lining of the affected joints (synovectomy) may be needed if the arthritis has not responded to antibiotics.

Currently, there is no other treatment for Lyme disease.

If you have problems with memory, concentration, or thinking as a result of late Lyme disease, you may benefit from therapy that helps you regain or improve your mental abilities (cognitive rehabilitation).

Online Resources

Organization

• Chronic Fatigue Syndrome
• Fibromyalgia
• Insect Bites and Stings and Spider Bites
• Juvenile Rheumatoid Arthritis
• Multiple Sclerosis (MS)
• Osteoarthritis
• Rash, Age 11 and Younger
• Rash, Age 12 and Older
• Rheumatoid Arthritis

Citations

1. Stechenberg BW (2004). Borellia (Lyme disease). In RD Feigin et al., eds. Textbook of Pediatric Infectious Diseases, vol. 2, pp. 1700–1708. Philadelphia: Saunders.

2. Centers for Disease Control and Prevention (2003). Lyme disease: A public information guide. U.S. Department of Health and Human Services. Available online: http://www.cdc.gov/ncidod/dvbid/lyme/index.htm.

3. Eppes SC, et al. (2002). Comparative study of cefuroximine axetil versus amoxicillin in children with early Lyme disease. Pediatrics, 109(6): 1173–1176.

4. International Lyme and Associated Diseases Society (2004). Evidence-based guidelines for the management of Lyme disease. Expert Review of Anti-Infective Therapy, 2(Suppl 1): S1–S13.

5. Edlow JA (2002). Erythema migrans section of Tick-borne diseases. Medical Clinics of North America, 86(2): 239–260.

6. Smith RP, et al. (2002). Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Annals of Internal Medicine, 136: 421–428.

7. Hwang MI (2000). Dangers of Lyme disease. JAMA, 283(5): 698.

8. Nadelman RB (2001). Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. New England Journal of Medicine, 345(2).

9. Wormser GP, et al. (2003). Duration of antibiotic therapy for early Lyme disease. Annals of Internal Medicine, 138: 697–704.

Other Works Consulted

• Hayes E, Mead P (2005). Lyme disease. Clinical Evidence (13): 947–955.

• Hayes EB, Piesman J (2003). How can we prevent Lyme disease? New England Journal of Medicine, 348: 2424–2430.

• Tompkins DC, Luft BJ (2005). Lyme disease and other spirochetal zoonoses. In DC Dale et al., eds., ACP Medicine, section 7, chap. 7. New York: WebMD.

Author:	Amy Fackler, MA Debby Golonka, MPH Sydney Youngerman-Cole, RN, BSN, RNC	Last Updated September 18, 2006
Medical Review:	Adam Husney, MD - Family Medicine Christine Hahn, MD - Epidemiology
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