Borreliosis (Lyme Disease) FAQ
Borreliosis / Lyme disease has until now been considered rare in the UK. It is for this reason that the amount of information available is predominantly from the United States of America. Although the different strains of Borrelia can produce varied symptoms, if treatment is not commenced as soon as an infection is suspected, the patient is at risk of suffering from long-term ill health and serious complications of the infection.
Below we have provided a response to frequently asked questions about Borreliosis. For more comprehensive information, see our "Diseases" section. For animal infections, see our "Pet Problems" section.
Follow the question links below to go to specific answers, or go straight to the first question and answer.
- What is the difference between Lyme disease and Borreliosis?
- What is the recognised means of diagnosing Lyme disease?
- Is the rash always the first symptom?
- Does the rash always look like a bull's-eye?
- What is the recognised treatment regime in Lyme disease?
- Can someone get Borreliosis / Lyme disease again after treatment?
- Is it only ticks that carry Borreliosis?
- Are the symptoms the same in everyone who is infected?
- Does a negative blood test mean that the patient does not have Borreliosis / Lyme disease?
- Is there a vaccine for Borreliosis / Lyme disease?
- As well as having Borreliosis, can humans be infected with another infection at the same time?
- Is there an acceptable time period to get treatment once a Borreliosis / Lyme disease infection is suspected?
- Is a full recovery certain?
- Are incidences of Lyme disease cases recorded?
- How accurate is the recording of Lyme disease cases?
- Should patients with Borreliosis / Lyme disease donate blood?
- What if I am, or become, pregnant?
Q.1 - What is the difference between Lyme disease and Borreliosis?
A.1 - Lyme disease (not Lymes) is a bacterial infection. The cause of Lyme disease is a spirochaete (a long, thin, spiral-shaped bacterium) called "Borrelia". The true Lyme disease pathogen is called "Borrelia burgdorferi (Bb) sensu stricto (s.s.), which means Bb in the strict sense. Bb was the cause of a sudden cluster of cases in Old Lyme, Connecticut, where Lyme disease gets its name from.
Later on, other species (or sub-species) were found in Europe and other areas and these were given different names. They all come under the umbrella term of "Borrelia burgdorferi sensu lato (Bb. s.l.), which means Bb in the broad sense.
In the UK and most of Europe, the most commonly found species of Borrelia include Borrelia burgdorferi, B. garinii, B. afzelii, and B. valaisiana. Of these species, hundreds of sub-types of differing strains exist. The various strains can produce differing symptoms. Bb. sensu stricto is known to result predominately in rheumatologic complications, while other strains have more predominately neurological and dermatological complications. The differing strains can also respond differently to antibiotics.
Many physicians and veterinarians prefer to use the term "Borreliosis" as an umbrella term for an infection of any strain. Sometimes the term "Lyme Borreliosis" is also used. Antibiotics are the treatment of choice no matter which strain of infection is present.
Lyme disease in the true sense is a zoonotic disease (a disease that can be transmitted between animals and people), which is transmitted primarily by a tick. However, it is possible for Borrelia bacteria to be passed from mother to baby in the womb; this would be classed as "congenital Borreliosis". It also may be passed through infected blood products during transfusion.
Borrelia bacteria have been isolated from insects (such as sand flies and fleas), and from stored semen, milk, urine, other body fluids and faecal matter in animal models. However, much more study needs to be done to establish if these could be modes of transmission.
Q.1 - References and Further Reading
Microbiology
resource from Kenyon College, Ohio
Q.2 - What is the recognised means of diagnosing Lyme disease?
A.2 - Unfortunately there is a great deal of controversy regarding the diagnosis of Lyme disease and there are two opposing groups of doctors that believe in two different standards of care. Please see our section on "Bacterial Infections", for comprehensive information on Borreliosis diagnosis and treatment.
The NHS Primary Care Question Answering Service offers guidance
of the diagnosis of Lyme disease.
Key Recommendations:
"Since there is currently no definitive test for Lyme disease, laboratory results should not be used to exclude an individual from treatment. Lyme disease is a clinical diagnosis and tests should be used to support rather than supersede the physician's judgment.
Early Lyme disease classically presents with a single erythema migrans (EM or "Bull's-eye") rash. The EM rash may be absent in over 50% of Lyme disease cases, however. Patients should be made aware of the significance of a range of rashes beyond the classic EM, including multiple, flat, raised, or blistering rashes. Central clearings were absent in over half of a series of EM rashes. Rashes can also mimic other common presentations including spider bite, ringworm, or cellulitis.
Physicians should be aware that fewer than 50% of all Lyme disease patients recall a tick bite. Early Lyme disease should also be considered in an evaluation of "off-season" onset when flu-like symptoms, fever, and chills occur in the summer and fall. Early recognition of atypical early Lyme disease presentation is most likely to occur when the patient has been educated on this topic".
Q.3 - Is the rash always the first symptom?
A.3 - No. The rash, which is called an Erythema Migrans (EM), may appear at any time during early or late / chronic infections and may appear, or reappear, while the patient is on treatment. Some studies have demonstrated that less than 50% of infected people develop an EM rash and some strains of Borrelia do not appear to present with any skin involvement. Flu-like symptoms and excessive fatigue are often the first noticeable indications of infection. Progression of the illness can lead on to symptoms including cranial-nerve facial palsy, meningitis, heart problems, arthritis and encephalitis (inflammation of the brain), to name but a few. The onset of symptoms and presentation can differ for each individual.
Q.4 - Does the rash always look like a bull's-eye?
A.4 - No. The rash can be atypical (not like a bull's-eye). The bull's-eye rash is circular in shape, with a clearing from the centre. However, EM rashes can be irregular in shape, colour and size. They can appear on any location of the body, including the scalp where they are often not observed when under the hair. Multiple rashes may appear in multiple locations.
Q.4 - References and Illustrations
|
A classic "bull's-eye" EM rash |
An atypical EM rash |
Picture gallery of several different types of rash.
Q.5- What is the recognised treatment regime in Lyme disease?
A.5 - Unfortunately there is a great deal of controversy regarding the treatment of Lyme disease and there are two opposing groups of doctors that believe in two different standards of care. Please see our section on "Bacterial Infections", for comprehensive information on Borreliosis diagnosis and treatment.
Q.5 - References and Further Reading
The NHS Primary Care Question Answering Service offers guidance
for the recognised treatment of Lyme disease.
Key Recommendations:
"The early use of antibiotics can prevent persistent, recurrent, and refractory Lyme disease.
The duration of therapy should be guided by clinical response, rather than an arbitrary (i.e., 30 day) treatment course.
The practice of stopping antibiotics to allow for a delayed recovery is not recommended for persistent Lyme disease. In these cases, it is reasonable to continue treatment for several months after clinical and laboratory abnormalities have begun to resolve and symptoms have disappeared".
Q.6 - Can someone get Borreliosis / Lyme disease again after treatment?
A.6 - Yes. Multiple bites may cause reinfection, or a patient may relapse after a lengthy remission. Either situation may require treatment equal to, or longer than, what was originally prescribed.
Cases of subclinical infection (without apparent symptoms) may become clinical if the immune system is compromised by injury or another infection.
Q.7 - Is it only ticks that carry Borreliosis?
A.7 - No. Borrelia bacteria have been isolated from insects (such as sand flies and fleas), and from stored semen, milk, urine, other body fluids and faecal matter. However, much more study needs to be done to establish if these are modes of transmission.
Ticks can also carry other infections concurrently and so it is possible to contract more than one infection from a single bite.
Q.7 - References and Further Reading
Folia Parasitologica. 1998;45(1):67-72 Investigation
of haematophagous arthropods for borreliae.
European Journal of Epidemiology 1996 Feb;12(1):9-11.
Unusual
Features in the Epidemiology of Lyme Borreliosis.
L. Angelov
Zentralbl Bakteriol Mikrobiol Hyg [A]. 1986 Dec;263(1-2):40-4
The
Prevelance and Significance of Borrelia Burgdorferi in the Urine of Feral
Reservoir Hosts. Bosler and Schulze
Transmission
of Borrelia burgdorferi from Experimentally Infected Mating Pairs to Offspring
in a Murine Model. Altaie, Mookherjee, Assian, Al-Taie, Nakeeb and
Siddiqui.
The British Veterinary Journal. 1995 Mar-Apr;151(2):221-4
Viability
of Borrelia burgdorferi in Stored Semen. Kumi-Diaka and Harris.
Q.8 - Are the symptoms the same in everyone who is infected?
A.8 - No. The symptoms of Borreliosis can be non-specific and they can wax and wane. Clinical infection can resemble other conditions and some patients have been previously misdiagnosed with such conditions as Glandular Fever (Epstein-Barr Virus), Chronic Fatigue Syndrome / ME, Multiple Sclerosis, Motor Neurone Disease / ALS, Alzheimer's and Parkinson's Disease, Lupus and Viral Meningitis. Treatment can often make the patient worse before they get better. This is called a "Jarisch-Herxheimer" reaction. Please see our section on "Bacterial Infections", for comprehensive information on Borreliosis diagnosis and treatment.
Q.8 - References and Further Reading
Lyme
disease: Symptoms and Characteristics (PDF
size 1.13MB)
Jarisch-Herxheimer
(J-H) and Lyme Disease
Q.9 - Does a negative blood test mean that the patient does not have Borreliosis / Lyme disease?
A.9 - No. Current blood testing techniques follow a
two-tier protocol set out by the Centres
for Disease Control and Prevention (CDC) in the US. The first step
is an ELISA which is followed, if positive or equivocal, by a confirmatory
western blot. However, the CDC states explicitly that "This surveillance
case definition was developed for national reporting of Lyme disease;
it is not intended to be used in clinical diagnosis".
A number of studies have revealed that as many as 50% of Borreliosis
cases, confirmed by Borrelial DNA or Borrelial culture, were reported
as negative when tested using the CDC's recommendations. In an interlaboratory
comparison study of tests for the detection of B. Burgdorferi, by the
College
of American Pathologists, it was concluded that "these tests
will not be useful as a screening test until their sensitivities are improved".
Borrelia bacteria have the ability to suppress the body's immune response. Seronegative infection (an infection where antibodies cannot be detected during tests) can occur in some patients, particularly if early antibiotic treatment has been prescribed. In addition, the use of certain other medications, such as steroid or cancer treatments, may affect the result of tests.
Q.9- References and Further Reading
The Lancet. 1989 Feb 25;1(8635):441
Seronegative
neuroborreliosis. Guy and Turner.
Lyme Disease Foundation - Change
in US law to prevent reliance on blood testing as the sole means of diagnosing
Lyme disease.
Q.10 - Is there a vaccine for Borreliosis / Lyme disease?
A.10 - No. Currently there is no vaccine available and much more study into the nature of Borrelia bacteria needs to be done to allow for the creation of a safe and reliable vaccine for all the strains. The US vaccine LYMErix was used but it was subsequently withdrawn.
Q.10 - References and Further Reading
Information
on Human Vaccine for Lyme Disease
Q.11 - As well as having Borreliosis, can humans be infected with another tick-borne infection at the same time?
A.11 - Yes. Multiple infections can be contracted. Ticks in the United Kingdom can carry a variety of infections concurrently. These include Anaplasma / Ehrlichia species, and Bartonella and Babesia species, as well as the different Borrelia species. Other opportunistic infections can also result from the immune system being depressed by a Borrelial infection.
Q.11 References and Further Reading
Journal of Clinical Infectious Diseases. 2001, vol33,5, 676-685(118ref.)
Coinfecting
deer-associated zoonoses: Lyme disease, babesiosis, and ehrlichiosis.
Thompson, Spielman and Krause.
Q.12 - Is there an acceptable time period to get treatment once a Borreliosis / Lyme disease infection is suspected?
A.12 - No. In Mandell, Douglas and Bennett's "Principles and Practice of Infectious Diseases, Alan Steere MD wrote:
"It has been shown that virulent strains of Borrelia burgdorferi are able to resist elimination by phagocytic cells, thereby evading the first line in the host defence system against infection". This assists an infection to disseminate quickly".
Dr Steere also wrote:
"Borrelia burgdorferi seems to cross the cell monolayer at intracellular junctions, although it can penetrate through the cytoplasm of a cell. In a rat model, permeability changes in the blood-brain barrier began within 12 hours after inoculation with the spirochete, and the organism may be cultured from the cerebrospinal fluid within 24 hours".
With its ability to evade the host immune system, and its rapid penetration of the central nervous system, Borrelia has the ability to cause acute onset of neurological disease. Many experts would therefore agree that waiting for symptoms to appear before commencing antibiotic treatment gives the infection chance to become deep-seated and can lessen the chance of a full recovery. Taking a "watch and wait" approach to this disease can result in a chronic, recurrent and difficult to treat infection.
Q.12 - References and Further Reading
Lyme Info - Neuro-cognitive
Lyme Disease
Q.13 - Is a full recovery certain?
A.13 - No. The length of time a person has been infected
before treatment, whether the patient has been given sufficient treatment,
and whether there are co-infections present, can all have a big impact
on a patient's recovery. It is well documented, in both human and animal
cases, that apparent recovery can be followed by relapse at a later stage,
weeks, months, or even years later. However, in such cases the possibility
of reinfection should be considered.
Prompt and adequate treatment can help avoid long-term complications and
permanent tissue damage. Please see our section on "Bacterial
Infections", for comprehensive information on the treatment of
Borreliosis.
Q.14 - Are incidences of Lyme disease cases recorded?
A.14 - In Scotland, Lyme disease is classed as a notifiable disease. This requires that notification takes place on the basis of clinical suspicion; a diagnosis does not have to be laboratory confirmed. In the British Armed Forces, Lyme disease is likewise a reportable condition. For those employed as zookeepers, forestry workers, or in certain other types of employment, notification to the Health and Safety Executive is required. Throughout the rest of the UK, a voluntary monitoring scheme is in place by which the Health Protection Agency's Lyme Reference Section reports only laboratory confirmed cases of Lyme disease directly to the Zoonoses Surveillance Unit. For more comprehensive information, see our "Disease Notification" section.
Q.14 - Reference and Further Reading
Health Protection Scotland - Lyme
Disease: Surveillance
Q.15 - How accurate is the recording of Lyme disease cases?
A.15 - Lyme disease is the most frequently reported vector-borne illness in the United States, and the number of cases continues to rise. It is acknowledged by the Centres for Disease Control and Prevention (CDC) that surveillance figures reported may account for as little as a tenth of the actual incidences of Lyme disease in America.
In the UK, laboratory confirmed cases are reported but the recorded statistics do not account for cases diagnosed on clinical grounds alone.
In November 2004, a report by a National Expert Panel on New and Emerging Infections concluded that Lyme disease poses a significant public heath threat in the UK.
Q.16 - Should patients with Borreliosis / Lyme disease donate blood?
A.16 - Whilst it is commonly recognised that Hepatitis B virus, Hepatitis C virus, and retroviruses can be transmitted through blood products, other pathogens are emerging as potentially significant transfusion-associated infectious agents. Studies have demonstrated that Borrelia bacteria can survive in guinea pig blood at room temperature for 28-35 days and they can survive in human blood processed for transfusion at 4°C for up to 48 days.
In the US, donors with a positive and active infection of Borreliosis / Lyme disease cannot donate blood until such times as they are no longer symptomatic, having undergone a full course of antibiotic treatment, and are cleared by a physician.
In addition to Borrelia, protozoal infections such as Malaria and Babesia are reported to be transmittable through blood transfusion. The CDC has warned of the ability of Babesia to withstand current procedures employed to treat donated blood. People with confirmed cases of Babesiosis are permanently deferred from donating blood.
Q.16 - Reference and Further Reading
Public Health Agency of Canada - Material Safety Data Sheet: Infectious
Substances.
Transfer
of Borrelia burgdorferi s.s. infection via blood transfusion in a murine
model. Gabitzsch, Piesman, Dolan, Sykes and Zeidner.
Q.17 - What if I am, or become, pregnant?
A.17 - It is documented that transmission of Borrelia through the placenta from mother to foetus is possible. Autopsy and clinical studies have associated gestational Borreliosis / Lyme disease with various medical problems including foetal death, hydrocephalus, cardiovascular anomalies, neonatal respiratory distress, hyperbilirubinaemia, intrauerine growth retardation, cortical blindness, sudden infant death syndrome and maternal toxaemia of pregnancy. Under experienced supervision, and with appropriate antimicrobial treatment, it is possible to have children without passing on the infection.
Q.17 - Reference and Further Reading
