CASE HISTORY:

MR. Saurav Pratapsingh 30 yrs who admitted in Sri Ramakrishna hospital with unconscious not responding to stimuli since 26.12.2013 at 10 pm, bluish discoloration of tongue, bells phenomenon. He had quadriplegia since 2011. Investigation reveals mitral valve prolapsed, his parameters were spo2: 67 with 60% oxygen. He left with cardio pulmonary arrest on 21.01.2014.ayoung cute girl married him with known history, she sacrificed her life.

INTRODUCTION:

Lyme disease (Lyme borreliosis) is an infectious disease caused by at least three species of bacteria belonging to the genus Borrelia. Borrelia burgdorferi sensu strictois the main cause of Lyme disease in North America, whereas Borrelia afzelii and Borrelia garinii cause most European cases. The disease is named after the towns of Lyme and Old Lyme, Connecticut, US, where a number of cases were identified in 1975. Although it was known that Lyme disease was a tick-borne disease as far back as 1978, the cause of the disease remained a mystery until 1981, when B. burgdorferi was identified by Willy Burgdorfer.Lyme disease is the most common tick-borne disease in the Northern Hemisphere. Borrelia is transmitted to humans by the bite of infected ticks belonging to a few species of the genus Ixodes ("hard ticks"). Early symptoms may include fever, headache, and fatigue. A rash occurs in 70–80% of infected persons at the site of the tick bite after a delay of 3–30 days (average is about 7 days), and may or may not appear as the well-publicized bull's-eye (Erythema migrans). The rash is only rarely painful or itchy, although it may be warm to the touch. Approximately 20–30% of infected persons do not experience a rash. Left untreated, later symptoms may involve the joints, heart, and central nervous system. In most cases, the infection and its symptoms are eliminated by antibiotics, especially if the illness is treated early.

Delayed or inadequate treatment can lead to more serious symptoms, which can be disabling and difficult to treat.

Epidemiology:

Countries with reported Lyme disease cases. Lyme disease are endemic in Northern Hemisphere temperate regions. Africa, Asia, Europe, United Kingdom, North America, Mexico, United States, South America The evolutionary history of Borrelia burgdorferi genetics has been the subject of recent studies.

Signs and symptoms:

An estimated 70% to 80% of persons infected with Lyme disease have a rash 3-30 days after being bitten by an infected tick. The rash gradually expands over a period of several days, and parts of the rash may clear as it enlarge, resulting in a bull's-eye appearance.

This "classic" bull's-eye appearance is also called Erythema migrans. A rash caused by Lyme does not always look like this. Approximately 20% to 30% of persons who are infected with Lyme disease may have no rash at all.

Raised, red borders around indurated central portion.

Borrelial lymphocytoma on the cheek (very uncommon)

The incubation period from infection to the onset of symptoms is usually one to two weeks, but can be much shorter (days), or much longer (months to years).Symptoms most often occur from May to September, because the nymphal stage of the tick is responsible for most cases. Asymptomatic infection exists, but occurs in less than 7% of infected individuals in the United States Asymptomatic infection may be much more common among those infected in Europe. Various acute neurological problems, termed neuroborreliosis, appear in 10–15% of untreated patients. These include facial palsy, which is the loss of muscle tone on one or both sides of the face, as well as meningitis, which involves severe headaches, neck stiffness, and sensitivity to light. Radiculoneuritis causes shooting pains that may interfere with sleep, as well as abnormal skin sensations. Mild encephalitis may lead to memory loss, sleep disturbances, or mood changes. In addition, some case reports have described altered mental status as the only symptom seen in a few cases of early neuroborreliosis. The disease may also have cardiac manifestations such as AV block.

Late disseminated infection:

After several months, untreated or inadequately treated patients may go on to develop severe and chronic symptoms that affect many parts of the body, including the brain, nerves, eyes, joints and heart. Many disabling symptoms can occur, including permanent paraparesis (impairment of motor or sensory function of the lower extremities) in extreme cases. The associated nerve pain radiating out from the spine is termed

Bannwarth syndrome named after Alfred annwarth. Ixodes scapularis, the primary vector of Lyme disease in eastern North America. A Lyme disease spirochete also resembles an agent of syphilis.

Transmission: Nymphal and adult deer ticks can be Carriers of Lyme disease. Nymphs are about the size of a poppy seed. Lyme disease is classified as a zoonosis, as it is transmitted to humans from a natural reservoir among rodents by ticks that feed on both sets of hosts. Hard-bodied ticks of the genus Ixodes are the main vectors of Lyme disease (also the vector for Babesia).Most infections are caused by ticks in the nymphal stage, as they are very small and may feed for long periods of time undetected. Larval ticks are very rarely infected. Although deer are the preferred hosts of deer ticks, and the size of the tick population parallels that of the deer population, ticks cannot acquire lyme disease spirochetes from deer. Rather, deer ticks acquire Borrelia microbes from infected rodents, such as the white-tailed mouse. Within the tick midgut, the borrelia's outer surface protein A (OspA) binds to the tick receptor for OspA, known as TROSPA. When the tick feeds, the borrelia downregulate OspA and upregulate OspC, another surface protein. After the borrelia migrate from the midgut to the salivary glands, OspC binds to Salp15, a tick salivary protein that appears to have immunosuppressive effects that enhance infection Successful infection of the mammalian host depends on bacterial expression of OspC.

The lone star tick (Amblyomma americanum), which is found throughout the Southeastern United States as far west as Texas, is unlikely to transmit the Lyme disease Spirochaete Borrelia burgdorferi, though it may be implicated in a related syndrome called southern tick-associated rash illness, which resembles a mild form of Lyme disease. On the West Coast of the United States, the main vector is the western black-legged tick (Ixodes pacificus). The tendency of this tick species to feed predominantly on host species such as lizards that are resistant to Borrelia infection appears to diminish transmission of Lyme disease in the West

Transmission across the placenta during pregnancy has not been demonstrated, and no consistent pattern of teratogenicity or specific "congenital Lyme borreliosis" has been identified. As with a number of other spirochetal diseases, adverse pregnancy outcomes are possible with untreated infection; prompt treatment with antibiotics reduces or eliminates this risk.

Diagnosis:

Lyme disease is diagnosed clinically based on symptoms, Serological testing can be used to support a clinically suspected case, but is not diagnostic by itself. Diagnosis of late-stage Lyme disease is often complicated by a multifaceted appearance and nonspecific symptoms, prompting one reviewer to call Lyme the new "great imitator.

Lyme disease may be misdiagnosed as multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, lupus, Crohn's disease, HIV or other autoimmune and neurodegenerative diseases.

Laboratory testing:

The serological laboratory tests most widely available and employed are the Western blot and ELISA, CDC Polymerase chain reaction (PCR) tests for Lyme disease have also been developed to detect the genetic material (DNA) of the Lyme disease spirochete. New techniques for clinical testing of Borrelia infection have been developed, such as LTT-MELISA, although the results of studies are contradictory.

Magnetic resonance imaging (MRI), as well as single-photon emission computed tomography (SPECT) are two of the tests that can identify abnormalities in the brain of a patient affected with this disease

Prevention:

Protective clothing includes a hat, long-sleeved shirts and long trousers tucked into socks or boots. Light-colored clothing makes the tick more easily visible before it attaches itself. People should use special care in handling and allowing outdoor pets inside homes because they can bring ticks into the house.

Permethrin sprayed on clothing kills ticks on contact, and is sold for this purpose. Insect repellents with Picaridin, IR3535, DEET or Oil of Lemon Eucalyptus repel ticks as well. Lyme and all other deer tick-borne diseases can be prevented on a regional level by reducing the deer population on which the ticks depend for reproductive success. (Although deer ticks do acquire Lyme disease pathogens from rodents and not from deer, the size of the tick population tends to parallel that of the deer population.) This has been demonstrated in the communities of Monhegan, Maine and Mumford Cove, Connecticut

Action can be taken to avoid getting bitten by ticks by using insect repellants, for example those that contain DEET (N,N-Diethyl-meta-toluamide). Prevention of Lyme disease is an important step in keeping dogs safe in endemic areas. Prevention education and a number of preventative measures are available. First of all, for dog owners who live near or who often frequent tick-infested areas, routine vaccinations for their dogs is an important step.

Another crucial preventive measure is the use of persistent acaricides, such as topical repellents or pesticides that contain triazapentadienes (Amitraz), phenylpyrazoles (Fipronil), or permethrin (Pyrethroids). T-containing repellants are thought to be moderately effective in the prevention of tick bites.

Vaccination:

A recombinant vaccine against Lyme disease, based on the outer surface protein A (OspA) of B. burgdorferi, was developed by SmithKline Beecham. In clinical trials involving more than 10,000 people, the vaccine, called LYMErix, was found to confer protective immunity to Borrelia in 76% of adults and 100% of children with only mild or moderate and transient adverse effects. LYMErix was approved on the basis of these trials by the Food and Drug Administration (FDA) on December 21, 1998.

Treatment:

Antibiotics doxycycline is widely recommended as the first choice, as it is effective against not only Borrelia bacteria but also a variety of other illnesses carried by ticks. Doxycycline is contraindicated in children younger than eight years of age and women who are pregnant or breastfeeding; alternatives to doxycycline are amoxicillin, cefuroxime axetil, and azithromycin. Individuals with early disseminated or late infection may have symptomatic cardiac disease, refractory Lyme arthritis, or neurologic symptoms like meningitis or encephalitis.

Prognosis:

For early cases, prompt treatment is usually curative. However, the severity and treatment of Lyme disease may be complicated due to late diagnosis, failure of antibiotic treatment, and simultaneous infection with other tick-borne diseases (coinfections), including ehrlichiosis, babesiosis, and immune suppression in the patient.

Society and culture:

Urbanization and other anthropogenic factors can be implicated in the spread of Lyme disease to humans.

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Received on 18.02.2014 Modified on 12.04.2014

Int. J. Nur. Edu. and Research 2(2): April- June 2014; Page 160-163