1. Madison Zuis FNP student Nursing 652: Fall 2014

2.  Multisystem infectious disease caused by bacterium Borrela burgdorferi  Most common tick-borne illness in North America and Europe

3.  Contracted from a deer tick ( Ixodes) bite containing the Borrelia species of bacteria.  Ticks act as disease vectors  Borrelia bacteria is abundant in wild animals in which ticks feed  Species has evolved to survive in other warm blooded vertebrate hosts (ie deer, mice, chipmunks) ( Pearson, 2014)  Ticks attach via barbed mouthpiece called hypostome  Inject anti-inflammatory and anti-clotting agents that assist in feeding and transmission of Borrelia, thus furthering the bacterium’s survival ( Berende, et al 2010)

4.  Approximately 30,000 confirmed cases in US In 2012 ( CDC, 2013)  Incidence has been increasing  Climate changes  Changes in land management  Changes in biodiversity  Changes in human interaction with nature  Increasing awareness of Lyme disease ( Medlock, et al 2013)

5.  Most cases occur May- September  Ixodes tick is in the nymph stage  Increased outdoor leisure activities  In 2011, 96% of Lyme disease cases  Connecticut, Massachusetts, Maine, Vermont, new Hampshire, Minnesota, New Jersey, New York, Pennsylvania, Rhode island, and Wisconsin.  Connecticut, Maine, new Hampshire and Vermont have highest incidence = 0.5 cases/1,000 persons  Has been reported in all 50 states  Can effect any group, ethnicity (Schub & Lawrence, 2013)

6.  Spending time in wooded or grassy areas  Exposed skin  Tick bite  If the tick is infected, the chances of transmission increases with time, from 0% at 24 hours, 12% at 48 hours, 79% at 72 hours and 94% at 96 hours. ( CDC, 2013)  Not removing ticks properly (Duncan, 2014)

7.  Annular erythematous plaque with central clearing ( bulls-eye lesion)  Classic lesion in 80% of cases  Usually 5-68cm in diameter  Appear 3-30 days after tick bite (Owoloabi, 2014)

9.  Three stages  Early localized = influenza like symptoms- primary erythema migrans, fever, fatigue, general or regional lymphadenopathy, arthralgia, and myalgia.  Occurs 3-30 days after tick bite  Early disseminated stage= multiple lesions, arthralgia, stiff neck, photophobia, sensory loss, asymmetric back pain, poor memory, difficulty concentrating, myocarditis, cardiac conduction blocks, syncope, Belle’s palsy, encephalitis, peripheral neuropathy, anorexia, nausea  Occurs few days to 10 months after tick bite  Late stage = chronic arthritis ( especially knee joints)arthritis, severe fatigue, subacute encephalopathy, cognitive disturbances, sleep disturbances, headaches, paresthesia  Occurs months to years after tick bite (Schub & Lawrence, 2013)

10.  Bell’s palsy  Stroke  Polio-like syndrome  Parkinsons disease  Dementia  Motor neuron disease  Guillain-Barre syndrome  Systematic Lupus  Erthematousous  Sarcoidosis  ( Mylgland, et al 2010)

11.  Geographic location  Outdoor leisure activities  Pets ( CDC, 2012)

12. - Two tiered test - Enzyme linked immunosorbent assay ( ELISA) or indirect fluroscnet antibody ( IFA)  If positive or equivocal, Western blot test performed. If both positive- Lyme diagnosed  If ELISA/IFA negative, no further testing needed - Polymerase chain reaction ( PCR)  Highly specific, but insensitive as a result of low numbers of bacteria present in bodily fluids and tissues  CSF may be examined in patient with neurologic symptoms - CRP may be slightly elevated - EKG and/or ECHO if cardiac involvement suspected - CT, MRI, spinal tap if CNS involvement suspected  (Aberer & Schwanzter, 2012)

14. Non-Pharmacological - Education - Treatment options, referrals, completing abx therapy - Assessment for late disease manifestations - Referrals - Pain assessment - analgesics Pharmacological  Children under 12: Amoxicillin 25- 50mg/kg or cefuroxime 30-40mg/kg x 14 days  Adults/children over 12: Doxycycline 100mg po 2 x day for 14 days  Pregnant women: Amoxicillin 500mg po 3 x day or cefuroxime 500mg po 2 x day for 14 days ( Pearson, 2014)

15.  Fluctuating global muscle weakness, muscle/joint pain, muscle twitching  Aseptic meningitis  Encephalitis  Lyme carditis related to heart blocks or CHF; three deaths reported from 2012-2013 ( CDC, 2013)  Bell’s palsy  slurred speech, facial numbness, swallowing problems (Schub & Lawrence, 2013)

16.  Close monitoring for disease progression  Improvement often gradual  Consider other diagnosis  Consider need for referral  Referrals  Neurologist  Infectious Disease  Rheumatology  Orthopedist  Physical therapy  Social worker  Mental health  Pain management

17.  Reducing risk of tick bites  Bug spray ( DEET)  long pants/sleeves ( tucked into socks), closed toed shoes  Clearing environmental brush  Avoiding contact with animals that carry ticks  Performing tick checks on persons/dogs after outdoor activity  Correct tick removal  Remove promptly ( <48 hours after attachment)  Grip as close as possible to skin, using tweezers ( or tick removal tool) without squeezing ticks body pull out  Clean skin with disinfectant and wash hands  Prompt medical attention  If symptoms appear ( CDC, 2013)

18.  #1 True or false  Lyme Disease is primarily seen from October – March  False- Lyme disease is most commonly seen in May-September when ticks carrying Borrelia are more common

19.  #2 If a patient with suspected Lyme disease has a positive ELISA test, what is the second test ordered confirm a Lyme diagnosis?  A. CRP  B. Western blot  C. PCR  D. CBC  B. Western Blot  If positive or equivocal, Western blot test performed. If both positive- Lyme diagnosed

20.  # 3 True or false- Lyme disease is the most common tick-borne disease in north America? - True Lyme disease is the most common tick-borne disease in north America and Europe

21.  # 4 Prevention of Lyme Disease includes:  A. DEET bug spray  B. Long sleeve shirt  C. Long pants tucked into socks  D. all of the above D. ALL of the above

22.  # 5 Lyme Disease classic lesion is described as a  A. red blistered rash  B. superficial petechial  C. Annular erythematous plaque with central clearing  D. Open pustules  C. Annular erythematous plaque with central clearing or a bull’s eye

23.  #6 In early stage Lyme disease, or early localized, common symptoms include:  A. fatigue  B. Fever  C. myalgia  D. primary erythema  E. all of the above  E - Early localized = influenza like symptoms- primary erythema migrans, fever, fatigue, general or regional lymphadenopathy, arthralgia, and myalgia.

24.  #7 How soon after a tick bite is late Lyme disease symptoms seen?  A. a few days  B. days to weeks  C. months to years  Late stage = chronic arthritis ( especially knee joints)arthritis, severe fatigue, subacute encephalopathy, cognitive disturbances, sleep disturbances, headaches, paresthesia  Occurs months to years after tick bite

25.  #8 A pregnant patient is recently diagnosised with Lyme disease, what is the appropriate medication and dosage?  A. Amoxicillin 500mg po 3 x day or cefuroxime 500mg po 2 x day for 14 days  B. Doxycycline 100mg po 2 x day for 14 days  C. Either  A- Pregnant women: Amoxicillin 500mg po 3 x day or cefuroxime 500mg po 2 x day for 14 days

26.  # 9 True or false- The longer a tick remains on your skin, the greater the risk of transmission?  T- If the tick is infected, the chances of transmission increases with time, from 0% at 24 hours, 12% at 48 hours, 79% at 72 hours and 94% at 96 hours. ( CDC, 2013)

27.  #10 True or false- A rare but serious complication of Lyme Disease includes cardiac complications such as CHF and heart blocks?  True- Complications from Lyme include heart blocks or CHF; three deaths reported from 2012-2013 ( CDC, 2013)

28.  Aberer, E. & Schwantzer G. ( 2012). Course of antibody response in Lyme borreliosis patients before and after therapy, ISRN Immunology, 14 ( 5) 11-13  Berende, A., Oosting, M., Kullberg, BJ., Netea, MH, & Joosten, L. ( 2010). Activation of innate host defense mechanisms by Borrelia, European Cytokine Network, 21 (1) 7-18  Center for Disease Control ( 2013). Lyme Disease, retrieved November 5 th, 2014 from http://www.cdc.gov/lyme/sign_symtoms http://www.cdc.gov/lyme/sign_symtoms  Center for Disease Control (2013). Three sudden cardiac deaths associated with Lyme Carditis, Morbidity and Mortality Weekly Report, 62(49) 994-996  CMAJ, (2014). Advice varies for suspected Lyme disease, Canadian Medical Association Journal, 2 ( 12) 186-187  Medlock, J., Hansford, K., & Bormane, A. (2013). Driving forces for changes in georgraphic distribution of Ixodes ticks in Europe, Parasites &Vectors,6 (1) 1-11  Mygland, A. (2010). EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. European Journal of Neurology, 17 (1) 8-16  Owolabi, T. ( 2014). An Annular Rash, American Academy of Family Physicians, 89 ( 7) 581-583  Pearson, S. ( 2014) Recognizing and understanding Lyme disease. Nursing Standard, 29 (1) 37-43  Schub,T. & Lawrence, P. ( 2013). Lyme Disease, Nursing, 43 ( 5) 28-34