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DESCRIPTION
This disease takes its name from the town of Lyme, Connecticut, where it was first identified in the mid-1970s and was named in 1977. Since that time, the locations and the number of cases of Lyme disease have continued to increase. Lyme disease is caused by the bacterium, Borrelia burgdorferi. These bacteria are transmitted to humans by the bite of infected deer ticks and cause more than 16,000 infections in the United States each year.
A HISTORY OF LYME DISEASE
Early in the 20th century, European health practitioners observed patients with a red, slowly expanding rash (called erythema migrans or EM), associated this rash with the bite of ticks, and postulated that it was caused by a tick-borne bacterium. Then in the 1940s, similar tick-borne illness was described that often began with EM and developed into multi-system illness. Later that decade, spirochete-like structures were observed in skin specimens leading to the use of penicillin for treatment.
Aware of these findings, a health practitioner in Wisconsin diagnosed a patient with EM and successfully treated it with penicillin in 1969. In the mid-1970s, health care providers observed clusters of children with arthritis in and around Lyme, Connecticut. Other clinical symptoms and environmental conditions suggested that this was a distinct illness probably transmitted by an arthropod. Researchers linked the presence of EM rash lesions to preceding tick bites and determined that early treatment with penicillin not only shortened the duration of EM but also reduced the risk of subsequent arthritis.
In 1982, spirochetes were identified in the midgut of the adult deer tick, Ixodes dammini (referred herein by its original name, the black-legged tick, Ixodes scapularis) and given the name Borrelia burgdorferi.
From Left to Right: The deer tick (Ixodes scapularis) - Adult Female, Adult Male, Nymph, and Larva on a centimeter scale.
Finally, conclusive evidence that B. burgdorferi caused Lyme disease came in 1984 when spirochetes were cultured from the blood of patients with EM, from the rash lesion itself, and from the cerebrospinal fluid of a patient with meningoencephalitis and history of prior EM. Centers for Disease Control and Prevention (CDC) began surveillance for Lyme disease in 1982 and the Council of State and Territorial Epidemiologists (CSTE) designated Lyme disease as a nationally notifiable disease in January 1991.
Borrelia burgdorferi are helical shaped bacteria about 10-25µm long.
In 1983, the year after the national surveillance began, 48 cases were reported to the national Centers for Disease Control and Prevention (CDC) in Atlanta. By 1991, this number had risen to 9,344 - a nearly 200-fold increase in eight years - with only Alaska, Arizona, Hawaii, Montana, and Nebraska remaining free of the disease. Approximately 90 percent of all known cases in the United States have occurred in California, Connecticut, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, and Wisconsin. It also occurs in Europe, Russia, China, Japan, and Australia.
Vector: Black-legged ticks (Ixodes scapularis) are responsible for transmitting Lyme disease bacteria to humans in the northeastern and north-central United States. On the Pacific Coast, the bacteria are transmitted to humans by the western black-legged tick (Ixodes pacificus). Ixodes ticks are much smaller than common dog and cattle ticks. In their larval and nymphal stages, they are no bigger than a pinhead. Ticks feed by inserting their mouths into the skin of a host and slowly take in blood. Ixodes ticks are most likely to transmit infection after feeding for two or more days.
CAUSES
Lyme disease is the most common tick-borne illness in the United States. The bacteria that cause it, spirochetes called Borrelia burgdorferi, are transmitted by the deer tick (carried by deer and mice) in most places. In California, however, they are transmitted by the closely related black-legged tick, which is also carried by wood rats. Both deer ticks and black-legged ticks are very tiny; an adult tick is less than one-tenth of an inch long, and the nymph is the size of a pinhead. They are hard to spot because they are so much smaller than the common dog tick. Because they are so tiny, they often go undetected. The nymphs and larvae feed primarily on white-footed mice, and the adults on white-tailed deer, although they may feed on many other animals as well, including birds, chipmunks, cows, horses, cats, dogs, lizards, and jackrabbits. The ticks fall off one host animal into grasses in marshes or fields, or into brush in wooded areas, from which they can be picked up by an unsuspecting passerby, whether human or animal, who becomes the next host. Not surprisingly, those most likely to be affected are people who spend time outdoors in or near wooded areas, where the ticks are prevalent, and the majority of cases occur in the summer and fall. Household pets like dogs and cats can pick up ticks and carry them into the home, where they can be transmitted to humans.
After a tick bites, it waits several hours before it begins to feed on the host's blood, and once it does, it feasts for three to four days. As it feeds, it may deposit its infectious cargo into the host's bloodstream. The longer the tick remains attached, the greater the risk of disease.
SYMPTOMS
The symptoms of Lyme disease are extremely variable, as is the incubation period, which may take anywhere from two to thirty-two days. The first sign may be the appearance of a red; circular lesion or rash on the skin. This is caused by the migration of the infecting organism outward through the skin, and it may appear anywhere from a few days to a few weeks after the bite. The lesion gradually expands in a circular pattern, while the center appears to clear up. For this reason, it is often referred to as a bull's-eye rash. In addition to the rash (or in some cases, instead of the rash), fatigue, flu like symptoms, difficulty sleeping, muscle weakness, achiness, headache, stiff neck, backache, and, occasionally, nausea and vomiting may occur. The disease then usually progresses through three stages, although not everyone experiences all three:1. Three days to three weeks after a tick bite, small raised bumps on the skin and/or a rash appears and may cover the entire torso, for as little as a day or two or as much as several weeks, and then fade. (If a rash appears immediately at the site of the tick bite, it may be a reaction to the bite itself and not to the bacteria that causes Lyme disease.) Fever, chills, nausea, sore throat, and vomiting may also occur.
2. Facial paralysis may occur weeks to months later. Enlargement of the spleen and lymph glands, severe headaches, enlargement of the heart muscle, and abnormal heart rhythm may also occur about this time.
3. Over the long term, persistent backache, stiff neck, joint pains that attack the knees, swelling and pain in other joints, and even degenerative muscle disease may be caused by Lyme disease.
Because tick bites are usually painless, the incubation period is so long, and the symptoms of Lyme disease are so varied, the disorder may go unrecognized for weeks or even months. A health care provider may fail to diagnose the disease before it is in its advanced stages. Lyme disease produces symptoms that resemble those of multiple sclerosis, gout, lupus, and chronic fatigue syndrome, and misdiagnosis is not uncommon. Once arthritis appears, the joint pain and stiffness can come and go, recurring even years later. An estimated 10 percent of those with Lyme disease arthritis are left with permanent stiffness in their joints.
Lyme disease is treatable and almost always curable if found in its early stages. If the disease is not treated in the early stages, however, enlargement of the spleen and lymph nodes, irregular heart rhythm, arthritis, and damage to the cardiovascular and central nervous systems can occur. Some people find that their symptoms slowly subside over two or three years; others develop chronic problems. Often, the symptoms leave and recur without another tick bite.
TREATMENT
PREVENTION & TREATMENT:
it is important to remember that prevention measures can be effective in reducing your exposure to infected ticks, and most patients can be successfully treated with antibiotic therapy when diagnosed in the early stages of Lyme disease.
A test has been developed to identify Lyme disease. A blood sample is used to measure the levels of certain antibodies that usually increase in number from three days to three weeks after infection.
RISK FACTORS
In the United States, Lyme disease is mostly localized to states in the northeastern, mid-Atlantic, and upper north-central regions, and to several counties in northwestern California. In 1999, 16,273 cases of Lyme disease were reported to the Centers for Disease Control and Prevention (CDC). Ninety-two percent of these were from the states of Connecticut, Rhode Island, New York, Pennsylvania, Delaware, New Jersey, Maryland, Massachusetts, and Wisconsin.
Individuals who live or work in residential areas surrounded by tick-infested woods or overgrown brush are at risk of getting Lyme disease. Persons who work or play in their yard, participate in recreational activities away from home such as hiking, camping, fishing and hunting, or engage in outdoor occupations, such as landscaping, brush clearing, forestry, and wildlife and parks management in endemic areas may also be at risk of getting Lyme disease.
CONSIDERATIONS
Pregnant women need to be especially careful to avoid ticks in Lyme disease areas. The infection can be transferred to the developing fetus and, in rare circumstances, can cause complications such as miscarriage or the birth of a stillborn baby.
Prompt treatment with antibiotics can halt the course of Lyme disease. Many health care providers do not like to prescribe antibiotics unless a person develops the characteristic symptoms of Lyme Disease - a small red bump at the site of the tick bite, and a bull's-eye rash surrounding it, and flu like symptoms such as fatigue, chills, and join pain. If treatment is deferred until the onset of more advanced symptoms, such as involvement of the heart, brain, or joints, antibiotic therapy is not as effective. Overuse of antibiotics can also result in the patient developing a resistance to them, rendering the antibiotic ineffective. This is a major problem with children using antibiotics for an extended period of time.
There is a vaccine available against Lyme disease. It is not 100 percent effective, however, and must be given in 3 separate doses at specific times of the year. The U.S. Food and Drug Administration advises that the vaccine should not be considered a substitute for standard measures to protect against tick bites, such as wearing protective clothing and using insect repellent.
The long-term use of antibiotics often leads to candida infection. If you must take antibiotics, it is wise to take some form of acidophilus because antibiotics kill "friendly" bacteria along with "unfriendly" bacteria.
One study showed that of 788 people diagnosed with Lyme disease, over half actually had other problems. Health care providers blame current laboratory tests for the false-positive results. A urine test that may be more accurate should become available soon. It will detect the presence of the Borrelia burgdorferi bacteria that cause Lyme disease.
Pets can get Lyme disease, too. Call your veterinarian if your pet exhibits any of the following:
- Fever of 103°F to 106°F.
- One or more swollen, hot joints.
- A tendency to sit or lie in one place for longer periods of time than usual.
- Lameness that seems to come and go.
- Reluctance to move.
- Poor appetite.
- A hot, dry nose.
Recorded information on Lyme disease is available by calling the U.S. Centers for Disease Control and Prevention (CDC) at 404-332-4555. The CDC provides information on Lyme disease to health professionals and the public. CDC also works with state health departments to track cases of Lyme disease. Your state or local health department can tell you if Lyme disease has been reported in your area.
HERBAL & HOLISTIC RECOMMENDATIONS
HERBS
Alfalfa supplies needed minerals.
Dandelion Root, Ginseng, Hawthorn, Horsetail, and Marshmallow Root are all good for helping to rebuild the blood and damaged tissue.
Herbal Remedies: Hawthorn Information
Herbal Remedies: Hawthorn Supplements & Products
Herbal Remedies: Dandelion Information
Herbal Remedies: Dandelion Supplements & Products
Herbal Remedies: All Ginseng Herbs, Tea, Pills & Products
Herbal Remedies: Ginseng (Panax Ginseng) Supplements & Products
Herbal Remedies: Siberian Ginseng Supplements & Products
Herbal Remedies: Hawthorn Information
Herbal Remedies: Hawthorn Supplements & Products
Herbal Remedies: Hawthorn Information
Herbal Remedies: Hawthorn Supplements & Products
Echinacea is an immune enhancer.
Herbal Remedies: Echinacea Information
Herbal Remedies: Echinacea Root Supplements & Products
Goldenseal is a natural antibiotic. Take 1/2 dropperful of alcohol-free goldenseal extract three times a day for one week. It can be taken under the tongue for fast results or added to tea. Caution: Do not take goldenseal internally on a daily basis for more than one week at a time, do not use it during pregnancy, and use it with caution if you are allergic to ragweed.
Herbal Remedies: Goldenseal Information
Herbal Remedies: Goldenseal Supplements & Products
Milk Thistle extract protects the liver.
Herbal Remedies: Milk Thistle Information
Herbal Remedies: Milk Thistle Supplements & Products
Red clover cleanses the bloodstream.
Herbal Remedies: Red Clover Information
Herbal Remedies: Red Clover Supplements & Products
RECOMMENDATIONS
Include plenty of garlic in your diet or take garlic supplements. It is a natural antibiotic and immune-booster.
Use barley grass, bee pollen, and/or royal jelly to supply nutrients needed to repair tissue and rebuild the blood. Caution: Do not use bee pollen if you have allergies to pollens without consulting a health care provider.
Use "Green Drinks" to provide chlorophyll, which aids in detoxification, and other valuable nutrients and enzymes. Kyo-Green from Wakunaga is an excellent choice.
Nutrition Therapy: Juicing
If you develop a bull's-eye-type rash anywhere on your body, see your health care provider as soon as possible, even if you have no memory of being bitten by a tick. Early treatment is essential.
If antibiotics are prescribed, be sure to take some form of acidophilus supplement daily and include yogurt products in your diet daily.
Herbal Remedies: Acidophilus Supplement Powder, Non-Dairy, 3 oz. Bulk
Herbal Remedies: Acidophilus, 3 Billion, NOW Foods, 90 Tabs
Herbal Remedies: Lactobacillus Acidophilus Supplement, Non-Dairy, 100 Caps
Herbal Remedies: Lactobacillus Acidophilus, Kosher Liquid, All Natural, Vegetarian Medium, Lactose Free, Apple Strawberry Flavor, Dynamic Health, 16 fl. oz.
Take hot baths or whirlpool treatments. Heat relieves joint pain.
TAKING PRECAUTIONARY MEASURES
TO HELP PREVENT TICK BITES
When spending time in or near wooded areas, wear long pants and tuck them into your socks. Wear a long-sleeved shirt with a high neck or a scarf, plus a hat and gloves. Wear light-colored clothing so that any ticks will be more visible.
Use an insect repellant containing diethyl toluamide (deet) on your clothing, your neck, and any other exposed area except your face. Deet lasts longer and is safer when used on clothing than on exposed skin, so cover as much of the body with clothing as you can. Do not use excessive amounts of deet. Follow product label instructions carefully, and wash the repellant off as soon as you go indoors. Caution: Deet is extremely toxic and can be deadly if ingested. Be extremely careful when using it, especially if you are around small children. Do not use it on clothing or other items containing plastic or synthetics such as nylon or polyester, as it can permanently damage such materials (it can even dissolve certain types of paint and nail polish).
After spending time outdoors, check yourself (and any other family members such as children) carefully for any small raised bumps and for pinpoint-sized specks on clothing or skin. Do this right away; the longer a tick is attached, the greater the risk of Lyme disease.
Check children before they go to bed during the summer if they spend a lot of time outdoors. Look closely at their hair, ears, underarms, trunks, groins, and the backs of their knees. Have them shower when they come in from outdoors, and wash their clothes immediately.
Dry your laundry in an electric clothes dryer for half an hour to kill any ticks that may be present. Washing clothes, even in hot water and bleach, will not necessarily kill ticks.
Inspect pets before letting them indoors. They may carry ticks into the house that can fall off and bite family members.
In a wooded or overgrown area, try to stay near the centers of trails and out of wooded areas, especially in May, June and July.
Keep your lawn mowed and remove leaf litter and brush. Move woodpiles away from the house during the summer.
IF YOU FIND A TICK ON YOUR BODY
PROCEDURE FOR REMOVING TICK
1. Remove the tick with a pair of tweezers. Grasp the tick with the tweezers as close to the skin as possible and pull the tick straight out. Do not twist the tweezers as you pull, and do not squeeze the tick's body, or bacteria may be injected into the skin. If possible, save the tick in a small bottle or jar. Do not use a match to try to burn the tick out, or resort to other home remedies like kerosene or petroleum jelly.
2. Once the tick is removed, thoroughly wash your hands and the bite area, and apply rubbing alcohol or other topical antiseptic to the bite. If you suspect the tick may be a deer tick, see your health care provider promptly. Take the tick with you for identification.
3. For the three weeks following a tick bite, be alert for any of the symptoms described in this section. If you have any doubts about your condition, consult your health care provider.
If you are being treated for Lyme disease but are not getting better, consider having yourself tested again. False-positive results are possible, and you may actually have a different problem.
NUTRITIONAL SUPPLEMENTS
Unless otherwise specified, the dosages recommended here are for adults. For a child between the ages of 12 and 17 years, reduce the dose to 3/4 the recommended amount. For a child between the ages of 6 and 12, use 1/2 the recommended dose, and for a child under the age of 6, use 1/4 the recommended amount.
LYME DISEASE SUPPLEMENTS
Information, supplements and products for Lyme disease, a long-term illness created by a bacterial infection spread by deer ticks and black-legged ticks.
AHCC (Active Hexose Correlated Compound), NOW Foods, Vegetarian, 500 mg, 60 VCaps
NOW Foods AHCC is a rich source of polysaccharides such as beta glucan 1,3 and activated hemicellulose produced by enzymatic modification of organic medicinal mushrooms, including shiitake.AHCC (Active Hexose Correlated Compound), NOW Foods, Vegetarian, 750 mg, 60 Caps
AHCC (Active Hexose Correlated Compound) is a proprietary extract produced from specially cultivated and hybridized mushrooms. AHCC supports immune system function through its effects on macrophages and NK (Natural Killer) Cells. NK cells and the intercellular mediators they produce are critical for the maintenance of healthy cell cycle function. AHCC has also been shown to possess antioxidant properties, and supports healthy liver function.AHCC 100% Pure Powder, NOW Foods, 2 oz.
AHCC (Active Hexose Correlated Compound) is a proprietary extract produced from specially cultivated and hybridized mushrooms. According to extensive research in humans, as well as numerous non-clinical studies, AHCC supports immune system function through its effects on macrophages and NK (Natural Killer) Cells.Alive! Whole Food Energizer, Multi-Vitamin & Mineral With Naturally Occurring Iron (No Iron Added), Nature's Way, 90 Tablets
No other supplement contains more life-giving nutrients than Nature's Way Alive Multi-Vitamin. Alive Multi-Vitamin is better absorbed into your blood stream because its tablets disintegrate up to 5X faster than other leading brands.Bio Defender, Antibacterial, Antiviral & Antifungal Formula, Balanceuticals, 56 Caps
This unique antibacterial, antiviral and antifungal formula is a clinical nutritionist response to bio terrorism such as anthrax.Cat's Claw Bark, Nature's Way, 485 mg, 100 Caps
Cat's Claw Bark is a traditional tonic herb for well being, Cat's Claw was historically used by the indigenous people of South America to stimulate the immune system in a variety of serious ailments.Cat's Claw Bark (Uncaria Tomentosa) Powder, 4 oz. Bulk
Cat's Claw Bark (Uncaria Tomentosa) was reputed to be a super drug in the Andean region of South America. It has a long history of indigenous use for arthritis and rheumatism as well as other types of inflammation associated with various stomach disorders and ulcers where it was clinically shown to be effective.Cat's Claw Tincture, 100% Organic, 2 fl. oz.
Cat's Claw is a rain forest herb that grows in the Peruvian Amazon; it has been used by native healers for many years.Cat's Claw Tea Spice System Builder, Regular, 100% Organic, Loose Leaf, 8 oz.
Reduces inflammation in arthritis, protects the body from harmful substances, supports the body while undergoing cancer treatments, helps to boost the immune system.Colloidal Silver Generator Kit, 1 Each
Colloidal Silver Generator is used to make your own colloidal silver, a natural suspended liquid silver supplement, at a low cost.Colloidal Silver, Liquid Silver Homeopathic Formula, SilvaSolution Advanced Immune System Activator For Colds and Flu, 8 fl. oz.
TriMedica SilvaSolution Advanced Liquid Silver Homeopathic Formula integrates the basic principles of homeopathy and is a profound healing system designed to increase the body's ability to respond to immune challenges and restore optimal health.Colloidal Silver Liquid, SilvaSolution Super Strength Pro 50, 8 fl. oz.
Colloidal Silver Super Strength Liquid provides for a strong immune system, ears, sinuses, throat and lung support for the winter season.Colloidal Silver Lotion, SilvaSolution, Homeopathic, 4 fl. oz.
Effective for minor skin irritations, rashes, hives, insect bites, sores, burns, inflammation, skin swelling, and dry, itchy, cracked skin.Colloidal Silver Salve, SilvaSolution, 2 oz.
SilvaSolution Colloidal Silver Salve now contains added homeopathics that add a benefit that will enhance the SilvaSolutions effectiveness.Colloidal Silver, Trace Minerals, 8 fl. oz.
Trace Minerals Super Oxygenated Pure Colloidal Silver Supplement is in a Fast Absorbing Liquid Formula. Colloidal Silver is a dietary supplement with over 30 ppm per dose of pure Colloidal Silver.Colloidal Silver & Zinc Lozenges, SilvaSolution, 90 Lozenges
Now you can get powerful liquid silver in the most convenient form ever with new SilvaSolution Silver and Zinc Lozenges.Enzymes, All Complete, 250 mg, 90 Caps
All Complete Enzymes, dietary supplement, is an important combination of critical enzymes that help support normal digestive function, cholesterol levels, fat metabolism and more, all in one convenient tablet.Garlicin CF, Cold & Flu Formula, Odor-Free Garlic, Nature's way, 404 mg, 90 Enteric Coated Tabs
Garlicin CF Odor Free Garlic Immune Support Formula combines all the healthy benefits of high allicin release Garlicin with the added benefits of Echinacea, Ester-C, and OptiZinc.Garlicin HC, Healthy Circulation Formula With Odor Free Garlic Supplement, Nature's Way, 90 Enteric Coated Tabs
Garlicin HC garlic supplement supports cardiovascular health with the help of hawthorn, cayenne and vitamin E.Multi-Mineral Optimum Complex, Nature's Way, 100 Caps
Nature's Way Multi-Mineral Optimum Complex offers a complete carefully dosed blend of minerals vital to the body. This multi Mineral Optimum Complex provides nutritional support for normal bone development, muscle function, reproduction and metabolism.Multi-Vitamin & Multi-Mineral, Baby & Children's Liquid, Childlife, 8 fl. oz.
Children's liquid Multi-Vitamin & Multi-Mineral formula provides the optimal dosage of all the essential vitamins and minerals with trace elements for infants and children of all ages and it tastes great!Samento, Extra Strength (100 Times More Effective Than Cat's Claw), 600 mg, 30 Caps
Samento is beneficial in the treatment of a wide range of immune system related conditions; these include but are not limited to cancer, arthritis, bursitis, rheumatism, allergies, ulcers, systemic candidiasis, all forms of herpes, diabetes, lupus, chronic fatigue syndrome, intestinal disorders and HIV infection.Samento Liquid Extract, 1 fl oz.
Beneficial in the treatment of a wide range of immune system related conditions; these include but are not limited to cancer, arthritis, bursitis, rheumatism, allergies, ulcers, systemic candidiasis, all forms of herpes, diabetes, lupus, chronic fatigue syndrome, intestinal disorders and HIV infection.Samento (Uncaria Tomentosa), Extra Strength (100 Times More Effective Than Regular Cat's Claw), 0.5% POA, 600 mg, 30 Caps
Samento is beneficial in the treatment of a wide range of immune system related conditions; these include but are not limited to cancer, arthritis, bursitis, rheumatism, allergies, ulcers, systemic candidiasis, all forms of herpes, diabetes, lupus, chronic fatigue syndrome, intestinal disorders and HIV infection.
HerbalRemedies: Lyme Disease Information
HerbalRemedies: Lyme Disease Supplements & Products
HerbalRemedies: Arthritis / Joint Pain / Stiffness Information
HerbalRemedies: Arthritis / Joint Pain / Stiffness Supplements & Products
HerbalRemedies: Rheumatism / Rheumatoid Arthritis Information
HerbalRemedies: Rheumatoid Arthritis Supplements & Products
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You have had exposure to any ticks or have been bitten by a tick.
You have any symptoms or an increase of symptoms or other signs of inflammation or infection.
You have any unexpected or unusual symptoms. Some people may have sensitivity, allergies, or other health conditions which would prevent them from using certain herbs or other treatments.
OTHER TICK-BORNE DISEASES
Southern Tick-Associated Rash Illness (STARI)
Babesiosis
Ehrlichiosis
Rocky Mountain Spotted Fever
REFERENCES
Barbour AG. Lyme Disease: The Cause, the Cure, the Controversy. 1996. The Johns Hopkins University Press, Baltimore, MD.
Benach JL, Bosler EM, Hanrahan JP, et al. Spirochetes isolated from the blood of two patients with Lyme disease. N Engl J Med. 1983;308:740-742.
Burgdorfer W. How the discovery of Borrelia burgdorferi came about. Clin Dermatol. 1993 Jul-Sep;11(3):335-338.
Burgdorfer WA, Barbour AG, Hayes SF, et al. Lyme disease - a tick-borne spirochetosis? Science. 1982;216:1317-1319.
Centers for Disease Control and Prevention. Appendix Methods Used for Creating a National Lyme Disease Risk Map. MMWR. 4 Jun 1999;48(RR07);21-24.
( Also available in PDF format [742 KB, 39 pages].)
Centers for Disease Control and Prevention. Lyme Disease: United States, 1999. MMWR. 16 Mar 2001;50(10):181-185.
( Also available in PDF format [1.47 MB, 20 pages].)
Hellerstrom S. Erythema chronicum migrans Afzelius with meningitis. Southern Med J. 1950;43:330-335.
Nadelman RB and Wormser GP. Lyme borreliosis. Lancet. 1998;352:557-565.
Orloski KA, Hayes EB, Campbell GL, Dennis DT. Surveillance for Lyme disease--United States, 1992-1998. Mor Mortal Wkly Rep CDC Surveill Summ. 2000 Apr 28;49(3):1-11.
Rahn DW, Evans J eds. Lyme Disease. 1998. American College of Physicians, Philadelphia, PA.
Scrimenti RJ. Erythema chronicum migrans. Arch Dermatol. 1970;102:104-105.
Sood SK, Salzman MB, Johnson BJ, Happ CM, Feig K, Carmody L, Rubin LG, Hilton E, Piesman J. Duration of tick attachment as a predictor of the risk of Lyme disease in an area in which Lyme disease is endemic. J Infect Dis. 1997 Apr;175(4):996-999.
Steere AC. Lyme disease. N Engl J Med. 1989 Aug 31;321(9):586-596.
Steere AC. Lyme disease. N Engl J Med. 2001 Jul 12;345(2):115-125.
Steere AC, Grodzicki RL, Kornblatt AN, et al. The spirochetal etiology of Lyme disease. N Engl J Med. 1983;308:733-740.
Steere AC, Malawista SE, Hardin JA, et al. Erythema chronicum migrans and Lyme arthritis: the enlarging clinical spectrum. Ann Intern Med. 1977;86:685-698.
Steere AC, Malawista SE, Newman JH, et al. Antibiotic therapy in Lyme disease. Ann Intern Med. 1980;93:1-8.
Steere AC, Malawista SE, Snydman DR, et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. Arthritis Rheum. 1977;20:7-17.
Wang G, van Dam AP, Schwartz I, Dankert J. Molecular typing of Borrelia burgdorferi sensu lato: taxonomic, epidemiological, and clinical implications. Clin Microbiol Rev. 1999 Oct;12(4):633-653.
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