Have a Vigilant Care ...

"The majority of children never knew they were bitten by a tick. Arthritis was the very first presenting symptom of their Lyme disease."
"There have been some families who have been surprised, definitely."
"It's not like we learn about Lyme disease when we're in training."
"You could almost see pediatric arthritis as like the canary in the coal mine. You start seeing arthritis in one joint in a bunch of kids and that should trigger you to look for Lyme disease."
Dr. Elizabeth Stringer, rheumatologist, Halifax IWK Health Centre

Lyme disease is a fairly recent entrant to Canada. It was far more familiar in the New England States. But it has migrated, as such pathologies tend to do, into another geography, over a border, since deer, ticks that feed on them, and climate do not recognize borders. Lyme disease is caused by borelia burgdorfero -- a "spirochete" bacteria with relations to the Syphilis bug. It is spread by deer ticks, in early spring. The tick is minuscule, unlike other more robust ones that don't spread the bacterium.

If the tick is discovered clinging to the skin, it must be removed very carefully, to ensure that the entire head comes with the body along with the mandibles dug into the skin. It seems that removal within 24 hours is essential to ensure that contamination by the bacterium does not occur.

• Use fine tweezers to grasp the tick as close to the skin surface as possible.
• Pull backwards gently but firmly, using an even, steady pressure. Do not jerk or twist.
• Do not squeeze, crush, or puncture the body of the tick, since its bodily fluids may contain infection-causing organisms.
• After removing the tick, wash the skin and hands thoroughly with soap and water.
• If any mouth parts of the tick remain in the skin, these should be left alone; they will be expelled on their own. Attempts to remove these parts may result in significant skin trauma.

Tick comparison

The top row shows deer ticks. These are the kind of tick that can cause Lyme disease. The first tick on the left in the top row is a "nymph", an immature tick. Next are an adult male, an adult female, and an adult female that has been feeding and is full of blood (called "engorged".) The bottom row shows dog ticks, which do not transmit Lyme disease. From left to right, the ticks on the bottom row are an adult male, an adult female, and an engorged adult female. Adult dog ticks are larger than adult deer ticks and have white markings on their back. Lyme Disease Research Laboratory, Maine Medical Center Research Institute, 13 Charles Street, Portland, ME 04102.

 

If the tick goes undetected and is not removed in time, people can experience a bulls-eye-like rash around the location of the bite followed by sores and fever in the early stages. If untreated, later may follow neurological symptoms like face-paralyzing Bell's palsy, heart problems or arthritis. A new study out of Halifax, Nova Scotia to be presented in Florida at an American College of Rheumatology conference documented child arthritis patients in the province's Lunenburg County.

 

The children had experienced no other symptoms and indeed were completely unaware that they had ever been exposed to Lyme disease until complaints of swollen, painful joints surfaced and they were referred to a rheumatologist where blood tests followed, indicating that they had acquired the infection. Some of the children were diagnosed additionally with related neurological conditions. It appears that Nova Scotia and southern Ontario have seen a five-fold increase in cases in the past year.

 

Endemic areas in New Brunswick, Nova Scotia, Quebec, Ontario, Manitoba and British Columbia have arisen over the last several years as the tick has moved deeper into Canada from parts of the United States. An increase in the number of infected Canadians relayed to authorities has risen from 128 in 2009 to 315 in 2012, according to the Public Health Agency of Canada. (A "huge" jump in children diagnosed with juvenile rheumatoid arthritis around Lyme, Connecticut originally led to the discovery of the illness in the mid-1970s.)

 

Half of the children being treated had their symptoms disappear in the wake of one course of IV antibiotics. The remainder of the children required two or three courses. Two patients still had arthritic symptoms limiting their functioning capabilities five months after remediative treatment. Doctors from Hershey, Pennsylvania published a paper in 2011 concluding that about 25% of children treated for Lyme arthritis will go on to suffer chronic musculoskeletal inflammation. 

"There is often a delay in diagnosis, so [arthritis] is not at all uncommon. It can be quite severe, actually. Patients who go on to the third stage can have chronic arthritis for months or years."

Dr. David Colby, Chatham-Kent Health Unit, Ontario

Need for treatment — The clinician will review the description of the tick, along with any physical symptoms, to decide upon a course of action. The Infectious Diseases Society of America (IDSA) recommends preventive treatment with antibiotics only in people who meet ALL of the following criteria:

• Attached tick identified as an adult or nymphal I. scapularis (deer) tick
• Tick is estimated to have been attached for ≥36 hours (based upon how engorged the tick appears or the amount of time since outdoor exposure)
• The antibiotic can be given within 72 hours of tick removal
• The local rate of tick infection with B. burgdorferi is ≥20 percent (known to occur in parts of New England, parts of the mid-Atlantic states, and parts of Minnesota and Wisconsin)
• The person can take doxycycline (eg, the person is not pregnant or breastfeeding or a child <8 age="" font="" of="" years="">

 

Tick sizes and appearances

• Only ticks that are attached and have finished feeding or are near the end of their meal can transmit Lyme disease. After arriving on the skin, the tick that spreads Lyme disease usually takes 24 hours before feeding begins.
• Even if a tick is attached, it must have taken a blood meal to transmit Lyme disease. At least 36 to 48 hours of feeding is required for a tick to have fed and then transmit the bacterium that causes Lyme disease. After this amount of time, the tick will be engorged (full of blood). An engorged tick has a globular shape and is larger than an unengorged one.

Centers for Disease Control and Prevention. http://www.cdc.gov/lyme/transmission/blacklegged.html.