Lyme Disease: A Whodunit Tale

Some medical advances begin with old-fashioned detective work. Lyme disease, which was unknown in this country prior to 1975 is a good example.  That fall, two mothers from Old Lyme, Connecticut convinced the state Department of Public Health and Yale University to explore a mysterious outbreak of cases of inflammatory arthritis among the town’s children, because they were unsatisfied with the explanations they had been given for the cause. The investigation that winter centered on thirty-nine children and twelve adults from Old Lyme, all of whom had developed painful swelling of one or more joints between June and September.

Clues in clinical histories

Although blood tests and physical exams of the affected people had not previously revealed any known cause for the painful, swollen joints, investigators noted that there were striking similarities in the patients’ histories. Especially notable was a peculiar spreading rash that appeared about a month prior to the development of the arthritis and resembled an archer’s bull’s eye target. The affected people also lived close to one another, all in heavily wooded areas. The researchers concluded that the area where the cases clustered and the time of year in which they occurred were both crucial clues to the mystery. They believed that the illness could be an unknown type of infection but would have to await the next disease “season” for confirmation of this theory.

More clues in old European medical literature

In the meantime, investigators began combing through European medical literature, where they discovered similar descriptions of rashes going back to 1909. Over time, the Europeans had named the skin lesion erythema migrans and associated it with an illness that was similar to the one being reported in Connecticut, although without the arthritis. Some European reports mentioned tick bites in conjunction with the rashes, as well as successful treatment with antibiotics. Back in Connecticut, the next summer produced thirty more cases of what was by then being called “Lyme arthritis,” which investigators now believed was some kind of infection transmitted during outdoor activity.

Figuring out the tick relationship

The next pieces of evidence came from field studies of ticks. The distribution of a particular type of tick called Ixodes scapularis (variously known as the blacklegged tick, deer tick, or bear tick) near Old Lyme matched the distribution of local arthritis cases. Tick autopsies conducted in New York on Shelter Island, another hot spot for this mystery arthritis, showed that most of the ticks carried a spiral-shaped bacterium called Borrelia burgdorferi. Blood tests on affected individuals for antibodies to this organism tied it to the clinical cases of arthritis. Over the next two decades, the explosion of the deer population carrying the tick made the disease more common and widely known.As knowledge about and experience with the new disease accumulated, Lyme arthritis was renamed Lyme disease.

Early  Lyme disease symptoms

Lyme disease symptoms include an early stage of fatigue, muscle and joint pains, swollen glands, and headaches and fever that begin days to weeks after the infected tick bite. These symptoms represent the immune system’s response to the bacterial invasion. If a bull’s eye rash at the site of a former tick bite is present, diagnosis is easy. If not, diagnosis depends on a clear history of a tick bite and on the development of antibodies to the organism, which usually occurs later than the first few weeks of the illness.

Later symptoms

Left untreated, some, but not all infected patients develop symptoms within the next few weeks to months after the infected tick bite. Symptoms include arthritis, nerve pains, facial nerve paralysis, heart palpitations, shortness of breath, and chest pains. An even less common late phase that can occur up to two years after an infected tick bite might include migrating joint pains, muscle aches, abnormal muscle movements, weakness, heart arrhythmias, and cognitive complaints such as memory problems. These symptoms are not well understood and may represent a combination of the body’s ongoing fight against persistent bacteria and an autoimmune response that they trigger.


Treatment of Lyme disease with oral antibiotics, either doxycycline or amoxicillin, is usually curative. If an infected tick is attached for more than thirty-six hours (the least amount of time it takes for transmission of the infection) and was encountered in an area where more than 20 percent of the deer tick population carries Borrelia burgdorferi, most patients are given a prophylactic one-time dose of doxycycline. Otherwise, treatment with antibiotics for two to four weeks begins as soon as the diagnosis of Lyme disease is made. The earlier the treatment, the faster the disease responds and symptoms subside. Late-phase treatment of neurological, cardiac, or arthritic symptoms may require intravenous delivery of antibiotics over longer periods. Although rare cases of persistent symptoms after treatment exist, no study has yet shown enough benefit from very long-term antibiotic use to justify the potential adverse effects of such a treatment.

Prevention of tick bites

Prevention of Lyme disease is the best way to deal with the illness, and there are things you can do to protect yourself. In the states where most cases occur (the New England states and New York, New Jersey, Maryland, Virginia, Wisconsin, and Minnesota), be aware that ticks tend to cling to high grasses and shrubbery in areas where deer roam. By hiking in the center of paths, away from tall grasses and shrubs, and wearing protective clothing, such as long sleeves and pants, you can reduce the chances of a tick bite. Shirt tails should be kept tucked in at the waist, sleeves should be kept closed at the wrists, and pants cuffs should be kept tucked into socks at the ankles. Additionally, spraying with insect repellent containing 20 to 30 percent DEET can help.

Self-examination is very important after potential tick exposure

The type of tick that transmits Lyme disease is Ixodes scapularis. It may be either a six-legged, immature tick nymph the size of a poppy seed or the slightly larger, eight-legged mature tick. Both forms excrete an anesthetic in their saliva that prevents you from feeling their bite, so close examination of your body is necessary after potential exposure. Bathe within two hours of coming inside and do a full body exam, with the aid of a mirror, paying close attention to areas covered with hair. Inspect all gear, clothing, and pets for ticks, and tumble clothing in a dryer at high heat to kill any hidden ticks.

Tick removal

Should you find an attached tick on your body, to remove it place the tip of a clean, fine-tipped tweezer as close to the skin as possible and pull gently, in a straight line. Dispose of all ticks in a toilet or drown them in alcohol and then seal them in a plastic bag for disposal. Clean bites with alcohol or iodine. Because the transmission of an infection from a tick to a human requires thirty-six to forty-eight hours of attachment, ridding yourself of ticks in the first twenty-four hours is effective prevention. Longer attachments that occur in high-risk parts of the country merit a single dose of doxycycline within seventy-two hours of a bite. Otherwise, be alert for symptoms or a rash, and seek treatment as soon as possible if they occur.  (See blow for a link to an interesting tick removal tool.*)

Research continues

The detective work surrounding the unraveling of the Lyme disease mystery continues today in the laboratory. Now researchers tend to focus on the rare people who, despite receiving adequate antibiotic treatment after contracting Lyme disease, experience persistent, unexplained, or recurring symptoms. These people remain almost as much of a mystery to researchers today as the initial thirty-nine children and twelve adult with arthritis were to researchers in the mid-1970s.


*Tick removal tool


Osteoarthritis – Time’s Marker

The garden-variety arthritis that afflicts millions of people is the great humbler – the nagging messenger that tells the truth about age. Joints are the junctions between bones that allow movement of the skeleton. Over time joints suffer from wear, tear and imperfect repair and the result is “osteo(bone)arthr(joint)itis(inflammation).”

The structure of joints: cartilage, synovial membranes, tendons and ligaments

You have 206 bones and over 230 joints. The more movement required at a junction between bones, the more complex the joint.  In freely moveable joints the ends of the bones are covered with cartilage, a smooth, tough and pliable tissue that lacks a blood supply. In some joints there are also cushions of cartilage – menisci or discs – between the bones.   Cartilage is the weak link in joints – the part that thins out and breaks down with age. Bone stripped of cartilage slides poorly and painfully over other bone. Old, dried out discs and menisci fragment and hurt.  Inflammation and more pain accompany the body’s attempts to repair the damage.

The synovial membranes lining joints make a thick, lubricating fluid that seeps into crevasses in cartilage, where it forms reservoir pools that keep the thin film of fluid between the bones even during movement. This synovial fluid carries nutrients and waste products and depends on joint movement for its circulation.

The ligaments that connect bone to bone, and the tendons that attach the muscles to bone form the joint capsule. Tendons and ligaments are tough and gristly and have poor blood supplies. They heal slowly, repairing themselves with stiff scar tissue. Time marks its progress in these structures by making them less flexible and more prone to damage.

Joint symptoms

The pain of joint inflammation, the stiffness of ligaments and tendons, and the resulting limitation of joint movement are the cardinal symptoms of osteoarthritis.  Excessive bone formation, narrowing of joint spaces and irregularity of bony margins, seen mainly on X-rays are signs of the ailment.  In contrast to other more inflammatory joint problems, such as rheumatoid arthritis and gout, osteoarthritis produces no blood or joint fluid abnormalities.

Why are some people more affected than others by osteoarthritis?

If osteoarthritis is a result of age, then why are some people crippled at 60 and others still dancing at 90? As usual, genetic makeup counts. Some families pass arthritis down. Others pass along bowed legs and other skeletal builds that result in early joint deterioration. Osteoarthritis also creeps into joints injured long ago and into joints damaged by inflammation from infectious and immune system diseases. Obesity contributes to the load on weight-bearing joints, subjecting them to more damage.

Use joints or lose them: underactivity ages joints

While overuse at times predisposes joints to arthritis, under use is also a threat.  There is ample evidence in laboratory animals that joint immobility produces degeneration. Zookeepers have long known that elephants in captivity, deprived of their need to walk thirty miles a day in search of food, develop debilitating arthritis in their hips and feet. Joint cartilage gets nutrients from the surrounding tissues by diffusion through the joint fluids. Movement helps that diffusion, so optimal joint health depends in part on regular movement through a full range of motion.

Limited joint motion sets up a process of uneven wear that precedes arthritic change. In Eastern cultures, where squatting is frequent, thinning of cartilage in the hip joint occurs with age just as it does in the West, but hip degeneration is far less common. Squatting puts the ball-and-socket joint of the hip through the rotational movement for which it is designed, while walking and sitting in chairs requires flexion and extension in only one plane, wearing cartilage unevenly.


Osteoarthritis develops over many years.  There is no cure. Medical treatment focuses on maintaining the mobility that pain and stiffness reduce. Reduced movement causes muscle weakness, tightens tendons and ligaments, and deprives cartilage of synovial fluid circulation. Intervening in this cycle requires relief of pain and maintenance of activity.

Anti-inflammatory agents such as aspirin and ibuprofen are helpful – but often osteoarthritis involves little real inflammation and the potential hazards of chronic use of these medications (kidney damage) have to be weighed against their pain-relieving benefits.  Ice, heat, massage and topical agents like Ben Gay are substitutes. Supplements such as glucosamine and chondroitin – the building blocks of cartilage – are thought by some to be helpful. While there is no proof of their efficacy, there is also no indication that they are harmful. External devices such as knee braces and back supports are useful for stability in exercise.

Exercise is treatment

Exercise is crucial for joints. Properly carried out, exercise strengthens muscles and maintains range of motion. Stiffness improves as a joint “warms up.”  With time, patience and the proper exercises, range of motion can be increased and symptoms greatly reduced.  Exercise promotes weight loss, which relieves the load on hips, knees, ankles and feet. Because it reduces gravitational forces, water is a wonderful medium for exercise for arthritic patients.

Alternative treatments and joint replacement

Acupuncture might help some people. Cortisone injections provide transient relief, but weaken tissues further. Because osteoarthritis is common and often debilitating, patients are easy targets for sales pitches guaranteeing relief. Therapies like magnets and copper bracelets and a host of pain relieving supplements beckon everywhere. At the end of the line for a joint, there is the prospect of replacement. Artificial joints restore mobility and improve life significantly for many arthritis sufferers – but they are to be approached with the care and caution. Joint replacement is a major surgical procedure in which the original joint is permanently removed.   The recovery process is arduous and the new joint surfaces are also subject to wear and tear.  Time marches on in titanium as well as in bone.


  Useful Websites – Arthritis Foundation homepage – American College of Rheumatology – patient education page – Animated graphic representations of joints and arthritic processes.

No more posts.