Diagnosing young children with Lyme disease, advice from a pediatrician

Lyme disease affects children more than any other age group, but the young ones are often difficult to diagnose, especially before they’ve developed the vocabulary to describe how they’re feeling. To help parents recognize symptoms and prevent serious illness, I chatted with Charlotte Mao, MD, a pediatric infectious disease physician who trained at Harvard Medical School and Boston Children’s Hospital, who currently serves as the Curriculum Director for Invisible International’s Medical Education Initiative. Here are some frequently asked questions that she encounters in her practice.

Q: What do I do if I find a tick on my child?

If you see a tick crawling on your child, simply grab it with a tissue and flush it down the toilet. If it’s embedded in the skin, position a fine-tipped tweezer where the tick’s head meets the skin, then swiftly pull it straight out. Do not grasp, squeeze, or twist the tick’s body. Then place it in a plastic baggie with a small piece of damp paper towel. Wash the extraction area and your hands thoroughly with soap and water.

To put your mind at ease, you’ll want to find out what microbes are inside the tick and whether they’ve been transmitted to your child as soon as possible. Because the current Lyme disease screening tests are unreliable in the first few weeks after a bite (it takes this long for humans to develop antibodies that can be measured), consider sending the tick to a lab to identify the infectious microbes that it is carrying. You can also go online to identify which tick species transmit various disease agents. Lyme disease is carried by blacklegged ticks, Ixodes scapularis in the Eastern United States and Ixodes pacificus in the West.

Some experts say that it takes a minimum of 36 hours for an attached tick to transmit Lyme bacteria to a host. This is the average time it takes for these bacteria to travel from a tick’s midgut into its saliva glands and into a host. Sometimes it happens sooner, specifically when a tick already has Lyme bacteria in its saliva from a previous attachment. This occurs in about 5 to 10 percent of infected ticks, according to the Lyme bacteria discoverer, Willy Burgdorfer. Other tick-borne microbes, such as the potentially deadly Powassan virus, can be transmitted in as little as 15 minutes after tick attachment.

Time is of the essence in preventing serious tick-borne disease. So, I personally advise parents to begin treatment before tick testing results come back, preferably within 48 to 72 hours of attachment. Over the following month, closely observe a child for symptoms, such as an expanding skin lesion at the bite site, fever, malaise, headache, mild neck stiffness, aches/pains in muscles, or joints aches. If these develop, visit your pediatrician.

Q: How can I tell if my child has Lyme disease?

Early signs of Lyme disease include flu-like symptoms, such as fever (often mild), chills, head and neck pain, body aches (muscle and joint), malaise, and fatigue. (Unfortunately, these symptoms can be mistaken for irritability or viral infections, such as the flu or COVID. Check your child for a Lyme disease rash and don’t forget to check the armpits, the scalp, skin folds behind the ears, and knees. Not everyone gets the classic “bulls-eye” rash; an expanding rash without central clearing is more common. You can find some sample rash images on the Internet.

Other classic Lyme manifestations that can develop early or later include a sagging of facial muscles (Bell’s palsy), intense headaches (meningitis), numbness, tingling, or weakness in extremities (neuropathy), eye and heart issues (especially cardiac rhythm abnormalities), and joint swelling or pain.

Q: What are some of the late-stage Lyme symptoms?

Physical complications can involve the joints, nervous system, eyes, and gastrointestinal tract. Lyme arthritis most commonly involves a single large joint, especially the knee. Fatigue and aches and pains are common in late and early disease. Lyme disease can also cause behavioral or personality changes in children. Some children develop neuropsychiatric manifestations such as anxiety, depression, panic attacks, or obsessive-compulsive disorders. All these symptoms can come and go, and this can be confusing to a patient, their family, and teachers. But trust that you know your child best, and if you suspect Lyme, visit your pediatrician.

Q: What are the best Lyme disease tests?

A Lyme disease diagnosis ultimately needs to be made based on a multifaceted clinical exam with lab work viewed as supportive, not definitive. My diagnosis is based on a comprehensive medical history, a physical exam, and a careful evaluation for other potential explanations.

For testing, I prefer to use Lyme specialty labs that provide more diagnostic information than standard commercial labs. I particularly like Medical Diagnostics Laboratory (MDLab.com) for Lyme antibody (Western blot) testing. Western blots detect the presence of specific blood proteins that develop once a person has been exposed to a target bacterium. Once detected, these proteins can be seen as dark bands on a blotting membrane or an imaging system. MDLab reports include more than the 10 CDC-specified Lyme bands and a photo of the patient’s actual immunoblot with an objective optical density score grading the intensity of each detected band. Fainter bands that do not meet the lab’s positivity threshold still might provide useful clinical information, increasing the suspicion of a past or present Lyme infection.

Q: What’s your treatment approach for young children?

As an infectious disease specialist, I typically see children who’ve already been treated by their pediatrician but have continuing symptoms after standard treatment courses. These more complex cases often require individualized management approaches.

If a child has not yet received an initial antibiotic course for Lyme disease, I start with recommended oral antibiotics—doxycycline, amoxicillin, or cefuroxime. (While doxycycline has traditionally not been prescribed for children under 8 years of age due to concerns of dental staining, studies have shown the risk of dental staining is much less with doxycycline than older tetracyclines. The American Academy of Pediatrics now says doxycycline can safely be used in children under 8 years for short durations, up to 21 days. Notably, doxycycline has long been the treatment of choice, regardless of age, for tick-borne rickettsial diseases such as Anaplasma, Ehrlichia, and Rocky Mountain Spotted Fever.

For acute central nervous system issues such as Lyme meningitis, I prescribe recommended intravenous antibiotics (typically ceftriaxone), which more effectively reaches therapeutic drug levels in the brain and nervous system. I also use intravenous ceftriaxone for Lyme arthritis when symptoms haven’t resolved after two courses of oral antibiotics.

To avoid gut issues, I prescribe probiotics and monitor for adverse effects such as diarrhea.

Q: What if symptoms continue after treatment?

In the U.S., ticks are known to carry 18 or more disease-causing microbes, and sometimes concurrent infections can cause lingering symptoms, even after recommended Lyme disease treatment. A considerable degree of overlap exists among the nonspecific manifestations of Lyme disease and other tick-borne infections, but there are certain symptoms that are more prevalent for specific co-infections. I routinely test for Bartonella, Babesia, Anaplasma/Ehrlichia, and Borrelia miyamotoi if the child has not already had this testing done.

Bartonellosis, an under-recognized bacterial infection that can be transmitted by fleas, lice, or cat scratches/bites, can cause a multitude of symptoms, some of them overlapping with those of Lyme disease. These might include fever; swollen lymph nodes; an enlarged liver or spleen; skin “tracks” that may resemble striae or stretch marks; “evanescent” rashes that come and go; and neuropsychiatric symptoms, especially anxiety, anger/aggression/rage, and obsessive-compulsive disorders. Other potential symptoms include tremors; jerky movements; sudden muscle weakness (e.g., “legs giving way”); a sensation of internal vibration; seizures; musculoskeletal pain, including in soles of the feet or shins (the latter is a reported feature of trench fever, caused by Bartonella quintana); abdominal pain; and eye issues (including uveitis and retinitis, both also seen with Lyme). Lab findings occasionally seen with Bartonella, all typically mild, include decreases in white blood cell count; increased eosinophils or monocytes; hemolytic anemia (rarely); increased C-reactive protein levels; and liver enzyme elevations.

Common babesiosis symptoms, caused by a parasite that infects red blood cells, include night or day sweats, fevers (can be high), chills, fatigue, malaise, hemolytic anemia and low platelets. Less common symptoms include headache, dry cough, shortness of breath (sometimes described as “air hunger”), nausea, abdominal pain, vomiting, and diarrhea.

The combination of low white blood cell and platelet counts make me suspect Anaplasma or Ehrlichia.

I always ask about factors that increase risk for repeat exposure/infection, such as outdoor hobbies (hiking, camping, gardening) and exposures to animals and blood-sucking bugs such as ticks, fleas, and lice. For the child with persistent symptoms after recommended treatment regimen(s), I also explore the possibility of nutritional/vitamin deficiencies or environmental toxic exposures, such as water-damaged buildings with mold contamination. Mold toxins or mycotoxins, produced by certain mold species, can complicate Lyme disease or co-infections by causing overlapping symptoms or negatively impacting treatment response.

The decision to administer additional antimicrobial therapy in patients with persistent or recurrent symptoms following standard treatment for Lyme disease is a controversial issue. According to treatment guidelines of most major medical societies, there is no good evidence that these persistent “post-treatment” symptoms are driven by an active infection that might benefit from additional antimicrobial therapy. The topic is too complex to cover here, but I’ll say simply that I do not agree with this blanket statement. The question of how best to treat this subgroup of patients is an area that requires more research and funding.

Q: I’m pregnant. Can I pass Lyme disease to my unborn child?

Borrelia infections can be transmitted from a pregnant mother to her infant. How frequently this occurs and the range of potential health risks for the infant/child have not been well-established. Studies to-date indicate significantly fewer adverse outcomes in treated compared to untreated pregnant women. This is another area that has been under-studied and requires more research attention and funding.

Q: I’m sending my kids to summer camp. Any advice on keeping them safe?

 I recommend pre-spraying clothing with permethrin to keep ticks away. This typically remains effective for six to eight washings. Have them pack insect repellents and don’t forget to teach them how to do tick checks.

Q: What resource can I give my child’s pediatrician to learn more about tick-borne illness?

Invisible International has created the first-ever continuing medical education platform that focuses on tick-borne illness. It is accredited by the American Academy of Family Physicians. Courses on this platform are available at no cost to physicians and other providers. Learn more and share this with your child’s pediatrician. Invisible’s Medical Education Initiative is supported by the Montecalvo Foundation.

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Update on the Tick-borne Illness Diagnostics Incubator

Invisible International is supporting six teams in its “Tick-borne Illness Diagnostics Development Incubator,” a yearlong collaborative forum designed to help bring better diagnostics solutions to the market faster. This month, organized teams of researchers, diagnostics companies, patients, government representatives, and industry funders have been holding regular meetings to discuss needs, regulatory/technology roadblocks, and marketing strategies. The diagnostics companies participating include R.E.D. Laboratories, Flightpath Biosciences, Galaxy Diagnostics, TickPlex/Tezted, IGeneX, and LabCorp.

One of the new players in this space is a Belgium-based company, R.E.D. Laboratories. Their novel “Phelix Phage” Borrelia detection method (Patent WO2018083491A1) was co-discovered by Jinyu Shan, PhD, University of Leicester; Professor Martha Clokie, University of Leicester; and Dr. Louis Teulières, Phelix R&D. This test can used on blood, urine, biopsies, or ticks to detect the presence of specific phages, spider-like viruses that parasitically prey on targeted Borrelia bacteria. The phages are transmitted with Borrelia during a tick bite, and they can only survive if their bacterial hosts are alive. Detecting these specialized phages in blood or urine provides direct evidence of active Borrelia infections in both early- and late-stage patients. And preliminary studies are promising, showing a >90% sensitivity and 100% specificity, a huge improvement over the two-tiered testing used today.

Thus far, the lab has developed diagnostics for the Borrelia sensu lato group (the 18 Borrelia species that cause Lyme borreliosis), the relapsing fever Borrelia group, Borrelia miyamotoi, (a recently discovered, genetically distinct member of the relapsing fever group), and a broad range of rickettsias. They’re also using this approach to develop tests for other tick-borne pathogens.

Tanja Mijatovic, PhD, the Chief Scientific Officer of R.E.D. Laboratories, said, “After more than two years of using the Phelix Phage Borrelia test, we’ve discovered that far more patients (primarily late stage) have tested positive for the relapsing fever group (B. miyamotoi, B. hermsii, etc.) than the Borrelia sensu lato group.”

This raises an interesting scientific question — might patients with persistent Lyme symptoms have active, undetected infections caused by microbes that no one is looking for?

R.E.D. Labs is currently looking for partnerships with health-care facilities and practitioners involved in infectious diseases, to help challenge and validate their tests. Inquiries can be directed to Dr. Mijatovic: tmijatovic@redlabs.be

In future weeks, Invisible will profile other incubator teams and participants.

***
Invisible’s incubator is designed to complement the
LymeX Tick-Borne Disease Innovation Accelerator, which will be offering research prizes for the development for better early Lyme diagnostics over three phases. [LymeX is funded with $25 million from the Steven & Alexandra Cohen Foundation and co-managed with the U.S. Department of Health and Human Services (HHS).] The Invisible Incubator is helping diagnostic companies gain a competitive edge in this competition, by making it easy to engage with clinical, lab, and research collaborators, and by participating in forums where past and emerging technologies will be discussed.

This incubator program is a component of Invisible’s Lovell Innovation Platform, funded by a trailblazing donation by Mark and Eileen Lovell. Thanks to their generous support, Invisible International is delivering programs that will change the landscape of tick-borne illness and other invisible illnesses through community action, education, and research.

A historic case study on chronic Lyme disease

In this free medical education course, Kenneth Liegner, MD, a New York-based internist who has been treating tick-borne disease patients since 1988, discusses one of the earliest documented cases of chronic Lyme disease.

In 1987, Vicki Logan, a 39-year-old pediatric intensive-care-unit nurse from Goldens Bridge, New York, began suffering from headaches, fevers, fatigue, progressive paralysis, cognitive difficulties, and memory loss. Her doctors couldn’t figure out what was wrong, so she was left to cope with this debilitating chronic illness on her own.

Two years later, Dr. Kenneth Liegner of Pawling, NY, decided to take on Logan as a patient, in what may be one of the earliest and most scientifically validated case of chronic Lyme disease on record.

First, he tested Logan for Lyme disease, and all the tests came back negative. She had no history of tick bite or rash, but he knew that Logan lived in a hot spot for Lyme disease, so he decided to presumptively treat her with intravenous antibiotics. After three weeks of IV cefotaxime and four months of oral minocycline, he saw no improvement in her condition.

This started a long diagnostic process to figure out what was wrong with Logan. Along the way, Dr. Liegner consulted with experts in rheumatology, immunology, and neurology. Repeatedly he sent her cerebral spinal fluid (CSF) to pathologists, all of whom observed no bacterial infections. Finally, he sent a spinal fluid sample to the Centers for Disease Control (CDC), and, when the fluid was placed in a special BSK-II growth medium, spirochetes began multiplying. On Jan. 14, 1994, the CDC experts verified that this was the first “gold standard” proof that the Lyme bacterium, Borrelia burgdorferi, can survive in a patient after months of IV and oral antibiotic treatments.

Because Logan’s Lyme disease case was so well documented, her post-mortem tissues have been used in numerous research studies. These studies have shown that the Lyme bacteria had invaded her heart, liver, and brain. A more recent study suggests that Borrelia burgdorferi is able to withstand the administration of antibiotics by forming biofilm structures, protective clusters of microbes, polysaccharides, proteins, lipids, and DNA, around itself.

You can watch a first-hand account of this fascinating medical mystery story here.

***

This course is part of Invisible International’s Education Platform for Tick-borne Illness, funded by the Montecalvo Family Foundation. It currently offers more than 22 free, online Continuing Medical Education (CME) courses on the diagnostics, epidemiology, immunology, symptoms, and treatment of Lyme disease, Bartonellosis, and other tick-borne diseases.

Invisible International, a 501(c)(3) nonprofit organization, is committed to alleviating the suffering caused by invisible illnesses, through education, research, and community empowerment.

You can sign up to receive news and updates at https://invisible.international/mission

Other related courses: Borrelia persistence “Bench to Bedside” E-Colloquium, Antibiotic efficacy for treatment of Lyme disease, The impact of immune responses on diagnosis and treatment of Lyme disease

The state of tick-borne illness diagnostics: Learn, engage, and accelerate

Invisible International is launching a yearlong “Tick-borne Illness Diagnostics Development Incubator,” starting with an online briefing, “The State of Tick-Borne Illness Diagnostics: Learn, Engage, Accelerate.”When: Saturday, October 30, 1:00 to 2:30 p.m. EST.
Registration: https://www.hack.invisible.international/

The weak link in reducing the public health burden of Lyme disease and other tick-borne illnesses is the lack of fast, cheap, and reliable diagnostic approaches. Early Lyme diagnoses are often delayed because the Lyme screening tests aren’t reliable in the first month after infection and not everyone produces or notices a bullseye rash. In the later stages of the disease, antibody testing can be unreliable in the sickest patients, those whose antibody production may be hobbled by concurrent infections or a weak immune system. There’s also no simple diagnostic roadmap to follow when multiple tick-borne pathogens may be involved.

This briefing will mark the start of Invisible International’s “Tick-borne Illness Diagnostics Development Incubator,” a yearlong collaborative forum designed to bring together teams of multidisciplinary innovators to look at diagnostic protocols, processes, and tests anew, with an eye to accelerating better solutions. We’ll bring together researchers, diagnostics companies, patient representatives, government representatives, and industry funders to brainstorm on ways to remove roadblocks to innovation. We’ll also feature lectures covering areas such as concept seed funding, getting through the regulatory pipeline, and fundamentals of low-cost diagnostics design.

This incubator is designed to complement the LymeX Diagnostics Moonshot, which will be offering prizes for the development for better early Lyme diagnostics over three phases. [Lyme X is funded with $25 million from the Steven & Alexandra Cohen Foundation and co-managed with the U.S. Department of Health and Human Services (HHS). Competition details will be posted later this year at Challenge.gov. ] The Invisible Incubator is way to gain a competitive edge in this competition, by making it easy to engage with clinical, lab, and collaborators, and by participating in forums where past and emerging technologies will be discussed.

The “The State of Tick-Borne Illness Diagnostics” briefing will feature:

Introductions: 

Mark Lovell, PhD, former Chairman and Chief Scientific Officer at ImPACT Applications, Inc.; Chair of Invisible’s Lovell Innovation Platform and Advisory Board

Valerie Montecalvo, President, Bayshore Recycling; Chair of Invisible’s Montecalvo Platform for Tick-Borne Illness Education and Strategic Initiatives

Keynote: The human cost of poor diagnostics
Nicole Bell, executive, entrepreneur, and author of What Lurks in the Woods: Struggle and Hope in the Midst of Chronic Illness, A Memoir

·Demystifying commercialization

Rhonda Shrader, Invisible International Innovation Chair; Executive Director, Berkeley Haas Entrepreneurship, UC Berkeley; and NSF I-Corps, Bay Area Node Director

Amanda Elam, CEO/Cofounder of Galaxy Diagnostics, Inc. and Entrepreneurship Research Fellow at Babson College

Why patient input is important

Emily Lovell, Invisible International Advisory Board and computer science researcher/educator

Perspectives from the diagnostic trenches

Representatives from three specialty labs will share their take on today’s diagnostic technologies today and what’s needed in the future

Invisible International

Nev Zubcevik, DO, CMO, Call for better diagnostic tools from the clinical trenches

Laura Lott, CEO, Learn, engage, accelerate: Why your team should join the challenge

The “Tick-borne Disease Diagnostics Innovation Incubator” is a component of Invisible’s Lovell Innovation Platform, funded by a trailblazing donation by Mark and Eileen Lovell. Thanks to their generous support, Invisible International is delivering programs that will change the landscape of tick-borne illness and other invisible illnesses through community action, education, and research.

When: Saturday, October 30, 1:00 to 2:30 p.m. EST.*
Registration: https://www.hack.invisible.international/

*This presentation will be recorded and posted on Invisible’s website after the event

Free online medical education course on early Lyme disease

Three patient case studies guide physicians on how to diagnose and treat early Lyme disease. This online course summarizes the latest research on disease risk, symptoms, and treatment options.

Diagnosing early Lyme disease cases can be notoriously difficult. Initial symptoms mimic those of the flu or Covid-19 — fever, chills, headache, and aches. The recommended antibody testing isn’t reliable in the first month. And many of those infected by a tick never see the tick or the most helpful diagnostic sign — an expanding erythema migrans rash at the bite site.

In the meantime, it’s more important than ever for physicians to keep up with clinically relevant information that will enhance their Lyme disease diagnostic and case management skills. Lyme disease is the fastest vector-borne illness in the United States, with an estimated 476,000 new cases a year, according to the Centers for Disease Control. Approximately 10 to 20% of those treated with antibiotics go on to experience disabling long-haul symptoms, such as severe fatigue, joint/muscle pain, brain fog, and neurologic symptoms. Prompt diagnosis and treatment of early Lyme disease results in better outcomes.

Case studies in early Lyme disease” is an online continuing medical education course that discusses disease risk in geographic regions, Lyme disease rashes, NIH-funded treatment trials, the basics on how Lyme bacteria evade the immune system, and the pros and cons of various patient treatment options. Participants’ diagnostic skills are tested with three real-life patient case studies. This course has been approved for 1.0 CME credit by the American Academy of Family Physicians.

Elizabeth L. Maloney, MD, the course’s author, is a Minnesota family physician focused on tick-borne disease education and policy. She is also the education director of Invisible International; the founder/president of the Partnership for Tick-borne Diseases Education; a former subcommittee member of the HHS Tick-borne Diseases Working group; and a peer reviewer for the Canadian Institutes of Health Research.

This project was funded by the Montecalvo Platform for Tick-Borne Illness Education, through Invisible International, a 501(c)(3) nonprofit foundation dedicated to reducing the suffering associated with invisible illnesses and social marginalization through innovation, education, and data-driven change projects. You can sign up to receive news and updates at https://invisible.international/newsletter

Other related courses: Basic principles of diagnostic testing, 7 years of blood-based Lyme disease testing, Serologic testing in Lyme disease.

Image credit: Tricia Shears 2009, Lyme rash on a 5-yr-old

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