According to recent research, ticks carrying Borrelia burgdorferi, the pathogen commonly associated with Lyme disease, have been found in Asheville, NC, a disease that has been slowly spreading from the Northeast over the past six decades. The study, performed on ticks harvested in nearby Biltmore Forest, found that about one-third of the tick samples carried the bacterium. This new information is all in good timing as we are well within tick season right now, which tends to spread more during warmer months.
Since this information has come out, I’ve had a few of my patients asking more about Lyme disease and what to do when you find a tick. Though Lyme disease is becoming more common in Western North Carolina, it remains far less prevalent than in highly endemic areas such as New England and the Upper Midwest.
Today, we will cover
- What to do when you find a tick on you
- Symptoms of acute Lyme disease
- *How to think about chronic Lyme disease
I found a tick on me (or my child) — what do I do?
I recommend doing a “tick check” regularly if you’re hiking or playing out in the yard. At our house, we tend to do these at night on our children as they are changing into their pajamas. Ticks tend to migrate to warm, moist areas, so pay special attention to
- the inner thighs and groin
- armpits
- scalp and hairline
- behind ears and knees
- waistband
- under the breasts and other skin folds
If you find a tick, there is no reason to panic. Do not try to burn or apply any chemicals to the tick prior to removal, as this only increases the risk of damaging your skin.
Here are the best ways to remove a tick:
1. Using tweezers, grab the tick as close to the attachment point as possible.
2. Pull with steady pressure until the tick pops off.
3. If you see any retained pieces in the skin, do not try to remove these. As the bite heals, these pieces will naturally be pushed out and off of the skin. There is no increased risk of Lyme disease transmission with retained parts.
4. Clean the bite with soap and water
5. Apply bacitracin (or other antiseptic ointment) to the bite 2-3x per day until it fully heals.
It is normal to see redness immediately around the bite for a few days.
What is Acute Lyme disease
Acute Lyme disease occurs when the Borrelia burgdorgeri pathogen is transmitted during a tick bite. This is a serious condition that must be treated urgently. However, it is important to remember that most tick bites will not cause Lyme disease. You have to both be bitten by a tick that carries the Borrelia pathogen and be attached to you long enough to transmit the pathogen.
What increases transmission rate of Lyme?
- You live in an area with endemic Lyme disease
- The tick is an Ixodes (deer) tick
- The tick was engorged or swollen when removed
- The tick was attached for >36 hours (very hard to estimate)
It’s worth stating again: most tick bites do not cause Lyme disease. According to the study above, around 33% of tested ticks carried the Borrelia pathogen. And CDC studies show that true infection rates are between 5-20%. Taking both of these statistics together, you can see that only a small number of tick bites from a small number of positive ticks will cause Lyme disease.
This. Is. Good. News.
If you happen to get Lyme disease, the symptoms are generally not subtle and come on within the first 2 weeks of a tick bite.
What are the symptoms of acute Lyme disease
Acute Lyme disease symptoms include:
- Fever
- Expanding red skin rash that spreads out from the bite site (it may not have the classic “bullseye” appearance)
- Fatigue
- Headache
- Muscle aches
- Joint pain
Testing for acute Lyme disease
If you develop fever, a spreading rash, facial weakness, severe headache, or flu-like symptoms within a month of a tick bite, contact your healthcare provider. Classic symptoms after a known tick bite can be treated without testing. However, testing can be very helpful when symptoms are more vague or delayed.
Typically, testing is done over two tiers to increase accuracy. The first tier (ELISA) is to ask the question, “Has the immune system created antibodies against Borrelia?” This one doesn’t tell you when, just if. If positive, the next tier testing (Western blot) is used to confirm that the Borrelia pathogen is Lyme-specific. One important limitation is that Lyme antibodies can stay positive for years after treatment and the body has recovered. Therefore, we do not have a test that can accurately tell us if you are having an active infection or not; and this is where the controversy around Chronic Lyme disease comes in.
Treatments for Lyme disease
Fortunately, most cases of Lyme disease are easily treated with antibiotics, often doxycycline or amoxicillin. But if left untreated, Lyme disease can spread into the nervous and cardiovascular system and cause serious complications. After treatment, most people will recover quickly from Lyme disease; but maybe 5-10% of cases will have prolonged, lingering symptoms.
Why can symptoms persist after Lyme disease?
Chronic Lyme disease would need an entire article (or series!) to do it justice, but I do want to give my thoughts around this condition. Now called Chronic Lyme is Post-Treatment Lyme Disease Syndrome (PTLDS), PTLDS is characterized by persistent symptoms after an appropriately treated Lyme disease infection.
Symptoms of PTLDS include
- Persistent fatigue
- Neurocognitive symptoms (i.e. brain fog)
- Pain syndromes
- Exercise intolerance
- Dizziness
- Sleep disturbances
What causes chronic Lyme symptoms?
What causes PTLDS and why some patients get this after appropriate treatment is still very much a mystery. Some clinicians believe there is persistent infection and will treat patients for months or years with antibiotics. I personally do not agree with this approach, mostly because of a lack of ability to distinguish active infection from a previous one as well as the direct harms that antibiotics will play on the microbiome.
My take on chronic Lyme disease
For me, I think there is a post-infectious activation and dysregulation of the immune system. We see very similar syndromes in conditions like long COVID, EBV syndromes, and chronic fatigue syndrome (ME/CFS). The theory is that, for some reason, the immune system remains active even after the infection has cleared, shifting the body into a chronic inflammatory state. The body senses this “threat,” forcing it into a permanent fight-or-flight mode that eventually disrupts proper control of systems like blood pressure and heart rate. If this theory is true, the idea is that because the immune and nervous systems are so energetically demanding, the body will eventually deplete in the nutrients and co-factors required for proper energy production, which drives a lot of the classic symptoms like fatigue, brain fog, rapid heart rate and blood pressure changes, and exercise intolerance.
Testing for PTLDS (Chronic Lyme)
Here’s the real hang-up in all of this — we simply have no good way of testing of active Lyme disease. All available testing to-date is just telling us whether or not you’ve been exposed to Borrelia (and other co-infections) in the past. Having a positive test, though, does not tell you if Lyme disease is active or not.
Your fatigue, brain fog, or exercise intolerance may be from a chronic infection or chronic immune system activation related to Lyme; or it may be from something completely different. Therefore, I personally do not like testing for Lyme unless there was a clear tick bite a few weeks ago and the patient is having more vague, newer symptoms. If you and your doctor believe you are suffering from a Chronic viral syndrome (Lyme, EBV, long-COVID, etc), I recommend shifting your attention to treating the underlying immune dysfunction and chronic inflammatory state rather than repeating courses of antibiotics.
My goal with this article was not to create fear around Lyme disease, but to provide a practical framework for thinking about it. Most tick bites are harmless, most Lyme infections are treatable, and persistent symptoms deserve thoughtful evaluation rather than assumptions. As our understanding of post-infectious syndromes continues to evolve, I suspect we’ll learn much more about why some people recover completely while others continue to struggle.