From your colleagues

From a Scottish GP Practice: this presentation from one of the James Lind Alliance Partnership Awareness Days, by Dr Dave Ashcroft of Aberfeldy, illustrates many useful lessons learned in a Scottish GP Practice. Five clicks will take you through the Aberfeldy experience: you can assimilate it in less than 5 minutes.

Useful sources of information

The Royal College of General Practitioners (RCGP) launched a Lyme Disease e-learning course in September 2014 which is freely available to all health professionals – 0.5 CPD credits.

Quotes from GPs -

I have to admit to knowing very very little about this disease pre course, and found it highly informative. thank-you.

I thought that this was very interesting. We have had a couple of cases in our very urban practice recently and I knew very little about it- assuming that I would rarely see… So I am now in a much better position to do miss.

Excellent thorough and interesting with clear guidance on treatment and referral criteria.

None of the existing guidelines incorporates all the published knowledge on Lyme disease. The best official UK sources of information are

Public Health England produced a Suggested Referral Pathway summary (PDF) for Lyme disease 2014 and also a factsheet about ticks and where they can be found.

See also the About Lyme menu for useful information, including genuine reasons why serology tests may be negative in some cases. There are articles about Lyme serology in our newsletters of  May 2015 (A better approach to serology) and January 2015 (negative Lyme disease serology).

If you have a questionyou can email our. We cannot make clinical recommendations for individual patients but may be able to provide a perspective on difficulties facing patients and their treating clinicians. We can provide you with evidence based, referenced information on many aspects of Lyme disease.

Initially providing information by email, LDA’s Medical Director can also discuss with you on the phone.

Be aware in practice:

Occupationally acquired cases should be notified to the Health and Safety Executive (HSE), under the RIDDOR regulations. This also applies to self employed individuals who may need to have this drawn to their attention.

Jarisch-Herxheimer Reaction

Patients should be warned they might experience a worsening of symptoms on starting treatment. CKS[2] states “People may mistake this for an allergic reaction and stop their antibiotics. Provided the symptoms are not severe and there is no evidence of an allergic reaction (such as urticaria), they can be advised to continue.”

Note that a European trial found that unlike syphilis, in which the JHR occurs in the first 24 hours of treatment, “We suggest that Jarisch–Herxheimer-like reactions may be prolonged and may occur late during treatment.” [5]

Psychiatric Manifestations

Doctors should be aware that patients can develop Lyme related mood disorders such as depression and anxiety, psychoses, disturbed behaviour and cognitive difficulties. For more detail see the page on Neurology & Psychiatry on the About Lyme section of this website.

Doctors should be alert to the real risk of suicide.

Paediatric Lyme Disease

Although >50% tick bites on adults are below the waist, 60% of bites on children are above the waist [4]. Ticks can attach in the hairline and on the scalp of children and remain undetected for longer than on adults.

Facial palsy with headache and fever has been shown to predict early Lyme disease in children during peak Lyme disease season in endemic areas (May – Oct) [6].

In children anxiety, emotional disorders and difficulties with attention and learning may develop if Lyme disease is undetected or untreated.

Lyme in Pregnancy

There is some evidence that congenital Lyme disease exists [1] but no international consensus.

For treatment in Pregnancy, see CKS [2] but note that this only covers patients with erythema migrans and without neurological, cardiac or joint symptoms.

A recent study in Hungary [3] concluded that “an untreated maternal Borrelia burgdorferi s.l. infection may be associated with an adverse outcome, although bacterial invasion of the fetus cannot be proven.”

References

1) For a 2008 review of literature on Lyme disease in pregnancy click here

2) NICE Clinical Knowledge Summaries CKS

3) Lakos & Solymosi Maternal Lyme Borreliosis and pregnancy outcome Int J Infect Dis. 2010 Jun;14(6):e494-8

4) Robertson JN, Gray J, Stewart P. Tick bite and Lyme borreliosis risk at a recreational site in England. Eur J Epidemiol. 2000;16(7): 647-652.

5) Oksi et al 2007. Duration of antibiotic treatment in disseminated Lyme borreliosis. European Journal of Clinical Microbiology and Infectious Diseases 2007, 26 (8) 571-81

6) Nigrovic et al 2008 Clinical predictors of Lyme disease among children with a peripheral facial palsy at an emergency department in a Lyme disease-endemic area. Pediatrics. 2008 Nov;122(5):e1080-5.

Doctor patients

Lyme borreliosis: perspective of a scientist–patient. Dr Ron Hamlen  (Full story only available through NHS Athens or to The Lancet Infectious Diseases subscribers.)

My Years with Lyme Disease Dr Chris Wilson RN (full story only available through NHS Athens or to BMJ subscribers.)

Lyme neuroborreliosis. A letter in response to a BMJ article. Dr Caroline Rayment relates her journey as a patient.