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Nurse Role in Treating Long-Lasting Lyme Disease Symptoms

New research points to reinfection, not relapse.

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Difficult to diagnose, Lyme disease is transmitted when an infected tick bites a human.

Immediate symptoms include a telltale "bull's eye" rash (also known as erythema migrans), fever, headache, muscle and joint aches, stiff neck and fatigue.

In the days and weeks following an untreated tick bite, infection can spread from the site of the bite to additional parts of the body.

Other symptoms may come and go, such as additional erythema migrans lesions, facial or Bell's palsy, severe headaches and neck stiffness, pain and swelling in large joints, shooting pains, heart palpitations and dizziness.

In the months and years after infection, chronic neurological complaints, such as shooting pains, numbness or tingling in the hands or feet, and problems with short-term memory, may develop in up to 5% of untreated patients.1

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Researching Recurrences

In a 2003 study, 10% of patients who received standard Lyme treatment showed symptoms more than a year later.2 More recently, the same study team chose to take a further look into these recurrences.

Their follow-up to the 2003 study was recently published in the New England Journal of Medicine and looked at whether infection can linger in a chronic form after treatment, causing long-lasting symptoms.3

In the follow-up, the team studied 17 patients who received a diagnosis of erythema migrans, the most common manifestation of Lyme disease, between 1991 and 2011. The patients experienced recurrences of a rash no less than a year apart, sometimes many years apart.

During each episode, the team analyzed Lyme bacteria isolated from the patients' skin or blood, focusing on a specific protein that expresses shortly after infection: outer-surface protein C (also known as ospC).

During the first and second rash episode, the team found that the proteins were different. Thus, the researchers conclude "that repeat episodes of erythema migrans in appropriately treated patients were due to reinfection and not relapse."

That is, the patients weren't experiencing long-lasting infections; rather they were suffering new infections a year or more later on the same body parts during the same time of year.

As a CRNA in the OR, Nick Angelis, CRNA, MSN, nurse anesthetist at Sacred Heart Health System, Pensacola, Fla., sees patients who have been diagnosed with Lyme disease about every other month. 

He believes these findings don't impact patient care in a general way, because there is much more research needed before information is extrapolated to individual cases. 

"It's similar to how heart patients oscillated between real eggs and fake eggs and butter and margarine over the last few decades," he said.

"The concept that these parasites may work in synergy does mean that those previously affected with Lyme disease should take extra preventative measures and keep their immune system strong."

In addition, nurses should withhold judgment if patient complaints don't match standardized expectations for the symptoms and duration of Lyme disease, since the spirochete has a very complex relationship with its host as well as other pathogens, Angelis added. 

"After all, the causative agent for Lyme disease was only discovered 30 years ago," he said.

Standard Treatment

Brett B. Snodgrass, APRN, MSN, FNP-C, family nurse practitioner at a private practice in Bartlett, Tenn., typically sees several cases of Lyme disease each spring and summer.

"It is quite prevalent in Tennessee. And so a good history is vital, as people forget [they were bitten by a tick] or sometimes don't find them," she said. "Their recall of where they have been and what they have been doing is very helpful in diagnosing Lyme disease." 

Treatment is based on positive serology and symptoms the patient is displaying (or what organ is being affected). Fourteen to 21 days' worth of antibacterial doxycycline, amoxicillin or cefuroxime is the recommended treatment for adult patients with early localized or early disseminated Lyme disease associated with erythema migrans, in the absence of specific neurologic manifestations (such as Lyme meningitis), or advanced atrioventricular heart block.

Although anecdotally effective, it is inappropriate to use alternative medicine supplements and substances, such as bismacine, bee venom or hyperbaric oxygen, instead of antibiotics if blood work shows active infection, said Angelis.

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Encourage & Promote Prevention

The community nurse's role involves working with other agencies (e.g., free clinics, park rangers, homeless shelters, etc.) to educate and make sure all patients receive appropriate treatment, Angelis explained.

"Besides teaching all patients how to properly remove ticks, nurses need to also explain how to avoid being a tick magnet (exposed skin and lack of insect repellant), how to search oneself for ticks after a rousing hike through the woods, and the signs and symptoms of Lyme disease (the characteristic rash being the most obvious)," he said.

Snodgrass concurred. "Encourage patients to use bug spray when out in the woods, near lakes and rivers. It is important to wear long pants and long sleeves when out in tall grasses for extended amounts of time, in areas where Lyme disease carrying ticks are prevalent. After being out, it is helpful to check yourself or have another person check your body for any ticks and to remove them appropriately," she said.

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For those suffering with aches and pains even after treatment, Angelis recommends joining a support group. 

He adds that the emergency department, despite its frenzied pace, is often the best place for patient teaching, even if that consists of a flyer about ticks and Lyme disease. 

"Lyme disease education correlates well with all of the other self-checking we teach everyone to do, whether searching for mysterious lumps, color-changing moles, or greedy little ticks," he said, adding that the possibly fatal consequences of not seeking prompt treatment for Lyme disease should be a highlight of any education. 

"Nurses and nurse practitioners are stars when it comes to teaching patients about prevention. It is every healthcare provider's role to encourage and promote prevention," concluded Snodgrass.

References for this article can be accessed here.

Beth Puliti is a freelance writer.


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