Winter is over, and now we can go outdoors to enjoy the sunshine and fresh air. Unfortunately, as the weather warms up, so do the bugs. This includes ticks. In the Washington D.C. area, that means a high risk of Lyme disease. The CDC estimates that around 30,000 people in the United States have reported Lyme, and there may be many more cases that go unreported. Lyme is very prevalent in the Mid-Atlantic, including the Washington Metropolitan area. Loudoun County, in particular, is a hotbed for Lyme, with statistics showing that the number of incidents far exceeds the average number of cases in the rest of Virginia. If not treated immediately, those with this nasty infection can have ongoing problems requiring long-term treatments.

Symptoms of Lyme disease

Most people associate Lyme disease with a "bull's eye" rash, but more than half of those infected never show this symptom. Instead, they might get conjunctivitis (pink eye), fatigue, headaches, joint pain, muscle pain, fever, chills, swollen glands, neck stiffness, facial nerve paralysis or motor tics. Symptoms can appear as early as three days after the bite or months afterwards. The good news is that the majority of Lyme disease infections can be easily cured with a course of antibiotics. Patients who have had Lyme for a long time may need several courses of antibiotics and may have symptoms lasting for months or even years. The diagnosis of Lyme disease is made by a combination of symptoms and physical findings, as well as confirmatory lab tests. Often, there is no known history of a tick bite. I usually tell my parents that it's the tick that they don't see that causes Lyme.

Many years ago, I had a mom bring in her 9-year-old son because of what she thought was a bug bite on his face. When I examined him, the red area did look like a bug bite, but what really caught my attention was that when he smiled, only half of his face moved. My mind ran through all the possible causes, and I became concerned that he could have a tumor crushing one of his facial nerves. I quickly arranged for him to see a neurologist and decided to expedite the evaluation by getting blood drawn. As an afterthought, I added a Lyme titre to the long list of tests that I had ordered. The neurologist called me the next day to report that it wasn't a tumor, but probably a virus; a few days later, I got back the blood work showing that the patient did indeed have Lyme disease. I am glad to say that three weeks after starting on antibiotics, the boy recovered completely.

Types of ticks

What transmits Lyme disease to humans? The culprit is the deer tick, also called the blacklegged tick. The larger dog/wood tick does not transmit the disease, so distinguishing between the types of ticks helps in deciding if Lyme is really the correct diagnosis. Deer ticks are very small (smaller than a sesame seed), making them difficult to spot. They are either black or red and have long mouthparts. Wood ticks are larger and easier to see; they are brown and have short mouthparts. What makes it even harder is that ticks tend to attach themselves in hard-to-find locations like skin folds, the scalp and the groin area. For the deer tick to transmit the infection, however, it must remain attached for at least 36 hours. It basically needs to drink your blood; then it regurgitates before drinking again. Gross, I know, but that's the point when the tick transmits the infection to you.

Another tick to be aware of is the "Lone Star tick." It does not carry Lyme disease, but for some reason that researchers can't explain, it can sometimes cause a Lyme-like reaction. It is shorter in duration and goes away on its own. Some studies also suggest that this tick's bite can cause you to become allergic to red meat.

How to remove ticks

People tend to encounter ticks during the spring and summer months, when we're outdoors more often. Ticks tend to concentrate where deer and field mice live and feed. It is important to do a thorough "tick check" on your child every time he goes into an area that might have ticks. Check behind the ears, scalp, in skin creases and even in the genitals. Rapid removal is critical if you want to prevent someone from getting the infection.

Home remedies suggest using alcohol or acetone to make the tick loosen its grip, but these may not work since ticks breathe only about once an hour. AND PLEASE, DO NOT USE A MATCH to burn the tick off! The best way to remove a tick is to try to grab hold as close to the skin surface as possible and pull it straight out with a firm, but constant, motion. Using a good pair of forceps or tweezers will make it much easier to pull that pesky tick out. "Yanking" it out quickly may leave mouthparts still embedded in the skin. After removal, apply an antibiotic ointment like Neosporin to prevent secondary infection. Then watch the bite site for any signs of local infection.

Preventative measures

The best way to avoid getting Lyme disease is to keep from being bitten by an infected tick in the first place. Wear light-colored clothing so ticks can be spotted before they latch on. Tuck your child's pants legs into his socks or boots so that ticks can't easily get under his clothes. Use appropriate insect repellant when available and avoid known infested areas. Treat areas where ticks might be with permethrim or other approved, tick-killing insecticides.

The way you manage your landscaping can limit ticks from getting into areas of your backyard that you regularly use. You and your kids will have less exposure to ticks if you can keep tall grass mowed, reduce leaf litter, lay down gravel/woodchips to limit tick migration, and keep playground equipment away from yard edges.

It's a good idea to actually view a picture of what a deer tick looks like to make a better determination of the situation. Lots of images are available on the internet. As mentioned earlier, a full-grown deer tick is as large as a sesame seed, but the immature larval stages are even smaller and can barely be seen without a magnifying glass. Some resources recommend removing ticks before coming into the house, and then taking a shower afterwards. They also recommend washing the clothes in hot water and drying on the hot setting.

For more info on prevention and control, visit the following websites:

Treatment

If you suspect that you or your child may have Lyme disease, contact your doctor. If you have it, you'll be treated with antibiotics. The choice of antibiotics will depend on age - older patients, like adolescents and adults, are usually treated with Doxycycline, while younger patients are often treated with Amoxicillin, Augmentin or Cefuroxine. The length of treatment can last from 2-4 weeks, depending on the severity and duration of the infection. In some cases, IV antibiotics are required to adequately treat the infection. If we are dealing with chronic infections or recurrent infections, an infectious disease specialist may be consulted to help with management of the disease.

When someone comes into our office right away after a tick bite, we generally educate the parents on what signs and symptoms to watch for, and we ask them to return if these symptoms develop. Once we have documented signs and symptoms of Lyme, we will conduct blood testing to confirm the diagnosis and start treatment. You may ask why we don't do something right away on the first visit. A protocol currently exists for adults with deer tick bites, but it doesn't apply to children. Believe it or not, doing a blood test immediately is usually not helpful in making a diagnosis since the body has not yet had enough time to make the antibodies that we test for. Testing the tick for the disease also isn't very helpful, since the test result may be hard to interpret and doesn't necessarily mean the patient will actually have Lyme disease. We also don't start antibiotics to "prevent" the infection, since antibiotic use does have a chance of causing unintended problems like allergic reactions.

Sometimes when we see a patient for possible Lyme disease, we may diagnose similar and related infections, such as Rocky Mountain Spotted Fever or Ehrlichiosis. These are also tick-borne infections, but not as commonly seen in this area. The best medicine is prevention: minimize exposure to ticks, check for ticks, reduce places where ticks live and know what to look for. If Lyme disease is suspected, visit your child's pediatrician or your physician for evaluation and treatment. Don't let the fear of Lyme disease keep you and your family from engaging in outdoor activities. Knowing what to do will minimize your risks and allow you to continue enjoying the warmer weather.


Dr. Bill is a pediatrician at Capital Area Pediatrics - Herndon, located in the Woodland Park Crossing Shopping Center. For more information about Dr. Bill and/or his practice, visit CapitalAreaPediatrics.com.