During a recent conversation a comment was made that got my wheels spinning. Medical students are given a triad of information for assessment purposes to focus on...so they are given three main 3 pieces to assist in differential diagnostic purposes. This is not to suggest this is all they are taught, but that these diagnostic triads are focal. Doctors pursue areas of interest and add to thier dianostic tool box as they mature, research and practice their craft. The greatest problem is doctors are not willing or feeling capable enough to go outside the box. If these 3 very limited and inaccurate boxes aren't ticked off, most will not treat.
These boxes for Lyme are:
1. Where? Having participated in high risk activities in endemic area. Location, location, location!
2. How Long? 24 hrs attachment time for transmission to occur with many still clinging to the previously listed 36 hrs timeframe.
3. Rash? An EM (Erythema Migrans) Bulls eye rash
Why Don't more Doctors
1. Heavy Price to Pay for Location
The plan in Canada currently is to work more efficiently on surveillance and to create an interactive, up to date map of factual HOT SPOTS. My hope is that with this multiple sourced (public and veterinarians contributions)interactive map, then the subsequent creation of proper prevention and awareness warnings needs to be effectively posted in these identified spots. Kingston events are still listing the risk as low because of the currently ineffective tracking method. By getting the public and other frontline workers involved in self reporting will be a great step in showing the REAL picture with a larger variety of contributors.
Current Risk Map
Not on this map? Many doctors deny lyme exsists outside of these risk areas, and site current mapping as evidence
2. Its a Matter of Time
We need the science to battle the transmission front. The founding father of Borrelia Burgdoferi aka Lyme Disease, Willy Burgdofer said there is no safe period in transmission.
I concur from logistics perspective. I subscribe to the chaos theory that there are too many variables to be able to accurately say at what point transmission occurs. Recently a study was published citing research done >2 yrs ago that is still is fighting for recognition in the medical and Medipolitical community.
Recent Attachment Time Review
Cook, Michael J. “Lyme Borreliosis: A Review of Data on Transmission Time after Tick Attachment.” International Journal of General Medicine 8 (2015): 1–8. PMC. Web. 29 July 2016.
A literature review has determined that in animal models, transmission can occur in <16 hours, and the minimum attachment time for transmission of infection has never been established. Mechanisms for early transmission of spirochetes have been proposed based on their presence in different organs of the tick. Studies have found systemic infection and the presence of spirochetes in the tick salivary glands prior to feeding, which could result in cases of rapid transmission. Also, there is evidence that spirochete transmission times and virulence depend upon the tick and Borrelia species. These factors support anecdotal evidence that Borrelia infection can occur in humans within a short time after tick attachment.
Although LB receives considerable attention and is the focus of this study, ticks transmit many diseases with 12 viral infections discussed by Lani et al including tick-borne encephalitis, Louping-ill, Colorado tick fever, and Alkhurma hemorrhagic fever, which has a mortality rate of 25%.11 Hard-bodied ticks of the genus Ixodesalso carry bacterial and parasitic diseases including: anaplasmosis, babesiosis, ehrlichiosis, rickettsiosis, and bartonellosis. Zhang et al investigated the microbiome of Ixodes persulcatus using rRNA sequencing and found 237 bacteria genera suspected of being pathogens to vertebrates.12 Many studies have found ticks infected with two or more of these pathogens and this increase in pathogen burden can result in more serious symptoms and post-treatment sequelae.13–16 An important emerging pathogen is Candidatus neoehrlichia mikurensis,17 and in a survey of Canadian residents, 62% of respondents reported at least one coinfection and 15% reported three coinfections with Bartonella and Babesia the most common.18 The attachment time for transmission of almost all of these pathogens is unknown; however, there are studies that indicate rapid transmission of some. Ebel and Kramer demonstrated Powassan virus infection with 15 minutes of tick attachment19 and although Saraiva et al found that transmission of Rickettsia rickettsii by unfed Amblyomma aureolatum ticks required >10 hours attachment time, they found that transmission could occur in as little as 10 minutes with fed ticks.20)
3. Not your average Bulls Eye
The primary symptom physicians are having is the diagnosis of the famous EM (Bull's eye rash). Biggest hurdle is the very nickname that they have been given.
I have heard of cases going to biopsy to clarify the diagnoses of Lyme. Even many dermatologists are confused and bewildered by the multiple presentations of th EM rash.
Besides the general appearance of the EM there is the ongoing controversy about how frequently and common it is for any rash to appear during an infection. Many statistics have suggested that 70-80% of those who have been exposed to the Lyme bacteria (Bb) will present with a rash. Like the Elisa test, our bodies’ immune systems are the deciding factor. Every individual’s immune system has its own strengths and weaknesses. With today's high level of public interaction we are exposed to so many viruses and parasites as well as a multitude of bacteria every day. These environmental factors in combination with GMO, pesticides and other environmental toxins, and poor lifestyle choices of most people have a limiting effect on the body’s ability to respond to threats, both real and perceived (Autoimmunity Diseases) and have our first line response systems all out of whack.
How then can we rely on either a testing system or visual cues of a biological function that isn't reliable?
Testing methods are evolving and science is making advancements in isolating bacterium in other tissue and bodily secretion such as urine, synovial and reproductive fluids. More testing looking for the presence of the bacteria and not the body’s response is needed. See more
The Many Faces of Solitary and Multiple Erythema Migrans
We conclude that EM is commonly underdiagnosed even in endemic areas. The multifaceted appearance of both SEM and MEM, combined with the fact that most patients do not recall having a tick bite, can cause difficulties in diagnosing LB in primary healthcare. In addition, the high percentage of seronegativity at the initial stage may be misleading. In this Finnish cohort of highly selected patients with PCR-confirmed LB presenting with clinically atypical SEM or MEM, more than half of the patients were not diagnosed for LB before arrival to the Department of Dermatology. This is important, since LB should be treated early, and since inadequate antimicrobial treatment might initially cause an atypical clinical picture that makes diagnosis more difficult. MEM might appear more frequently in Europe (8) than previously thought. It is likely that LB will become endemic in several parts of the world, because of climate changes that are favourable for ticks and their host animals (37). Therefore, it is important that physicians are aware of tick-borne diseases. Prospective research should be performed in order to determine whether patients with pre-existing autoimmune diseases need different treatment for LB. more