YES LYME DISEASE EXISTS IN AUSTRALIA

Dr Peter James Mayne

1.

LYME DISEASE (Chronic)

Dr Mayne has always had an intense interest in the early initial infection that goes on to cause Chronic Lyme Disease, starting in 1992. This interest was sharpened by the dermatology diploma he did in 2005 in terms of early recognition of the disease and also the unique skin manifestation that can occur much later in the disease.

In October 2009 he was approached by a patient who was quite desperate with an advanced presentation after 102 tick bites in one day some years before. Her treatment (specialist directed) was failing after some initial success. Could he help? Could he take on the task of up skilling himself in this sad neglected area of medicine in Australia, where most doctors don't believe the disease exists?

The many pages to follow explore these questions with remarkable findings for both patients and doctors. For the latter this will be mainly for the medical gatekeeper, the patients GP. It is not intended that a patient will necessarily be able to understand the information presented within for doctors.

LYME DISEASE - FOR PATIENTS
LYME DISEASE - FOR DOCTORS
WANTED DOCTORS WHO HAVE HAD ERYTHEMA MIGRANS OR LYME DISEASE Either contracted in Australia or overseas - please email me at LMC@medemail.com.au

2.

LYME DISEASE INFORMATION FOR DOCTORS IN AUSTRALIA

Lyme disease in Australia can now be proven by nested PCR to both

Borrelia burgdorferi (Bb)
and Borrelia Garinii (Bg)

2 Proofs on this link, one by blood the other by tissue

ILADS The International Lyme and Associated Disease Society

Here is the main link to the society
http://www.ilads.org/

and this link is their treatment guidelines page
http://www.ilads.org/files/ILADS_Guidelines.pdf

A key Board member of ILADS is Joseph Burruscano MD a physician. He is the author of

"Advanced topics in Lyme disease"

The 2005 edition is available free on the net at ILADS
http://www.ilads.org/files/burrascano_0905.pdf

The 2008 edition you will have to pay for. I will be using information from the 2008 edition only, so sometimes it may not be in the 2005 edition.

I am going to attempt to give a brief overview on Lyme information. The topic is vast with many tangents and it takes very many hours to integrate this information into a sensible synthesis. I will heavily rely on the above information. Medical Practitioners have enough to do without taking on this subspecialty with its extreme time consumption, unless particularly motivated to learn more. The aim is to arm you with enough information to suspect this diagnosis.

Please follow these links
The precursor erythema migrans. Diagnosis and management from a
dermatological viewpoint.

The disease and its Co-infections. What we are seeing in Australia.
Patient History
Making the diagnosis - a clinical one
Confirmatory Lab tests
Treatment principles and options
Monitoring for successful treatment
Is there an endpoint?"

3.

ERYTHEMA MIGRANS - Its Diagnosis and Treatment

From a dermatological viewpoint this illness is very poorly identified by Australian General Practice. I have to admit I was one of those before 1992.

Forget the classic bulls eye - if you see one of those good luck to you. Borrelia infection following a tick bite is slow to develop, usually taking some 48 hours to produce erythema. Bear in mind your patient probably hasn't noticed it in this time if in less obvious places.

Unfortunately a large majority of bite reactions are described as ALLERGY in Australia. This is rather woeful. An urticarial rash of any description must be gone completely in 24 hours. Even if another forms. That is the fundamental definition of acute urticaria. Now your patient might have a local toxic reaction as in most insect bites, or even a small round induration suggesting trivial infection.

BUT if the lesion around the bite is more than 2cm and persistent more than 2 days then in our country it is either

BORRELIA INFECTION or

QUEENSLAND TICK TYPHUS

And definitely not ALLERGY.

Please review this brief CASE HISTORY presented at Cardiff University in 2004 regarding the distinction.

Induration is also a marked feature and if you remember the early phase of a BCG reaction then it is hard like that.

Removal of a tick within 24 hours is believed to prevent infection with Borrelia, but best within 12 hours.

Safest course of action is to prescribe the correct antibiotic immediately at presentation no matter how long after a tick bite. The case history reviews the use of tissue PCR but also recently I have found sampling the bite site after removal of the tick can return a positive PCR to Borellia
Treatment protocol (ILADS 2008)

Adults the standard is 200mg doxycycline for 28 days, alternatively amoxil 1gm tds for 28 days
Children Amoxycillin at standard dose for age 28 days
In pregnancy use erythromycin 500mg qid for 28days"


4.

DISEASE PRESENTATION

What I see in practice

Two strains of Borrelia are positively identified in the practice case load, Burgdorferi and Garinii. As to whether there is any difference in symptomatology I can not comment. The former is the predominant organism.

There is no arthritic disease as in North America. Rather we follow a disease pattern of marked neurological symptomatology which is the European and Asian pattern of the disease. There is also a biotoxin (refer Burruscano document) produced by the Borrelia which produces sometimes marked asymmetric muscle spasm and twitching. Cranial nerve involvement followed by upper cervical nerves accounts for most symptomatology.

In the same way as AIDS reduces the C3-8 cells there is a specific marker for Lyme disease CD57 (Burruscano again). Only Lyme disease suppresses this marker and like AIDS there is a marked propensity to harbour other important chronic infections in this state.

In practice I am finding Mycoplasma and Chlamydia Pn in a majority of patients. In the US there is quite a long list but I will just present these two here. It is most essential to look for these in every suspect case of Lyme disease. Even the standard IgG and M markers can be negative but the PCR's will be positive.

These infections are called Co-infections and most are believed to be transmitted with the tick bite."

5.

PATIENT HISTORY

A striking feature of Lyme disease is that a lot of patients either don't recall ever having a tick bite or report yes they have had a tick bite in the distant past and removed it themself or had it removed. These patients are not able to describe ever having the large local reaction after a bite that we know as erythema migrans.

The number of of doctors seen and the number or diagnosis made will be proprtional to the time interval of chronic symptoms. I had one at 7 years and another at 10 years. The last had a very impressive list of medical attendances but no mention of possible Lyme disease. She found her diagnosis herself on the Net. Past diagnosis will often revolve around CFS and fibromaylgia. This of course is not to suggest that Lyme is the fundamental underlying cause of these conditions.

Cardinal symptoms of Lyme Disease
Lethargy
Swollen glands – particularly neck
Sore throat
Thoracic wall pain
Dyspnoea
Cough
Myalgia
Muscle spasms- tetany type or twitching
Muscle cramps
Occulomotor abnormalities particularly with retro orbital pain. Also lateral object fixation at speed painful or impossible. Also can induce nausea like nystagmus reaction.
Hyperacusis
Headache
Creaking neck +/- stiffness

Common
Pyrexias – more at night
Abdominal pain
Palpitations
Paraesthesia
Facial paralysis (Bell’s Palsy)
Visual deficit

Less Common
Tinnitus
Vertigo
Imbalance
Gait disturbance
Arthralgia

More general symptoms

Presyncope, tremors, confusion, disorientation, disorientation, memory loss, mood changes, depression, insomnia, irritability"

LINKS TO OTHER PAGES
Making diagnosis
Confirmatory lab tests
Treatment options
Monitoring
Endpoint
Proofs


Dr Peter James Mayne

MBBS Sydney University 1973
DPD (Dermatology) Cardiff University 2005
IDD International Dermoscopy Diploma Graz University 2008 - Distinction
FACRRM Fellow Australian College Rural and Remote Medicine
Certificate Course Diabetes Management Monash University 2000
Honorary Tutor Dept Medicine Cardiff University (Dermatology and Dermoscopy)

Our Contact Information
Telephone 61 2 65599277
FAX 61 2 65597344

Postal address
89 Bold St Laurieton 2443 NSW Australia
Electronic mail
General Information and
Reception e-mail:
frontdesk.LMC@medemail.com.au
Dr Mayne LMC@medemail.com.au

Lyme pages are under development over many months from March 2010
Last update 10th July 2010"

First quote from website http://www.drmayne.com/Lyme.htm

Second quote from website http://www.drmayne.com/Fordoctors.htm

Third quote from website http://www.drmayne.com/em.htm

Fourth quote from website http://www.drmayne.com/disease_presentation.htm

Fifth quote from website http://www.drmayne.com/patient_history.htm