The Tick on the Boy...and the Boy in the Tent...
The other day my ten-year-old son dutifully downed his last
dose of doxycycline. (How’s that for
alliteration?) He’d taken it twice daily
for 28 days and he was glad to be done with it.
This is not to say that he didn’t tolerate it well. Sure, it caused a few stomachaches, and some
of those hit at incredibly inopportune times (I found him doubled over on the
bench during one of his soccer matches).
But those were relatively infrequent.
On the other hand, it turned his face scarlet red. We had been told that it might cause photosensitivity
and, true to the warning on the label, it made him burn to a crisp on even the
most overcast of days. I slathered him
with sunscreen and made him wear a baseball cap, but it was no use. He looked like a ripe tomato, but he was a
happy tomato nonetheless. Fortunately, the
berry-flavored formula I got for him (doxy is not recommended for children
under 8 so it took some work to find a pharmacy with the liquid formulation in
stock) was pleasantly palatable and he enjoyed measuring it out by himself almost
as much as he enjoyed the spotlight he commanded as we watched him do this little
ritual each day. Apparently, his friends
got a kick out of watching him, too, as a mom who hosted him on a sleepover would
recount to me afterwards.
So why was this April a month of stomachaches and
sunburns? Well, it seems that a nasty
little deer tick latched on to my son on one of our family outings last fall
and transmitted the bacteria that causes Lyme disease to him in the
process. He took the whole thing in
stride, and our pediatrician’s amazing bedside manner helped immensely in this
regard. However, the diagnosis threw me
for a loop, especially when the doc said that the bacteria had had a few months
to gain a foothold in my child’s body. I
was less astonished than I would have been a few years ago, before my cancer
diagnosis. However, I was more
astonished than any mother with a young child who likes to go camping ought to be. I had grown up in New England,
for cryin’ out loud. But I had never
heard of anyone contracting Lyme disease until I went off to college and even
then that was someone who lived on Martha’s Vineyard. I was separated from those nasty ticks by a
great big body of water! On the plus
side, this meant that I had avoided most of the sensationalist literature on
Lyme (of which there is a LOT) until after getting the
scoop from our pedi. At that point I was
able to take the more far-out stuff with a pinch (more like a shaker) of salt. “Dr. Matt” declared the treatment straightforward
and the prognosis excellent and we heaved a sigh of relief. Medical research would appear to back him up and
I can only assume that we will never have to revisit this in the future.[i]
That, however, is not what most people think when they hear the
word Lyme. Sadly, there is a lot of hype
and mania surrounding this condition.
This is not to make light of the very real symptoms that people with
chronic Lyme disease experience, but to point out that many people who have
never been diagnosed with Lyme in their lives attribute all sorts of maladies
to it in the absence of any evidence whatsoever. Dr. Matt told us about a young patient of his
who has never tested positive for Lyme, but whose mother brings him to Vermont
each summer for expensive “magnet therapy” because she is convinced that his
fatigue is due to undetected Lyme. People
with non-specific symptoms are understandably eager for an explanation for
their suffering. In Lyme, some find an
answer that makes sense to them. Unfortunately,
the tendency to attribute all sorts of problems to Lyme renders it larger than
life. There is yet another reason for
the gap between public perception and scientific research. Namely, misdiagnosis used to be more common in
the past than it is today and the failure to detect Lyme early on made it that much
harder to treat. Simply put, people hear
Lyme and they conjure up “the bad old days” when it was often left unchecked to
roam around the body. The key to effective
treatment is early detection.
By now most people are aware that they should wear long
pants, use bug spray, and do full body checks after spending time in or near
the woods. They might not always follow these precautions, but at least
they know that they should. Some parents I know have found ticks on
themselves and/or on their kids. In our
case, we never saw the tick in question.
Ticks can hide out in hard-to-see places and the nymphs are especially hard
to detect since they are about the size of a poppy seed. Even if you find a tick, you really need to
know how long it has been there. Research
shows that a tick must be attached for about 36-48 hours in order to transmit
Lyme. Blood tests are inadequate in the early
stages because the body takes 2-3 weeks to make IgM antibodies to the invading spirochete
(called Borrelia
burgdorferi) and 4 weeks or more to make IgG antibodies. For this reason some doctors err on the side
of treating all patients who have had ticks feasting on them for more than 48
hours as if they were infected. A short course of doxycycline (or another
antibiotic) can nip early infections in the bud. Other doctors will not begin treatment unless
they know for sure that the tick in question was carrying Lyme. Some labs will test ticks for Lyme, although
it’s not clear how reliable most of those lab tests are.
Some people will develop symptoms that tip them off to a recent
Lyme infection even if they overlook the tick.
These symptoms include a bulls-eye rash, chills, fever, and aches that
occur within days to weeks of having been bitten. My son never had any symptoms of any sort,
though. In fact, if it hadn’t been for
his older brother, we might not have detected the Lyme as soon as we did. In March his brother had belly pain, which led
to an office visit, which led to an ultrasound and an emergency appendectomy,
the very next day. (I shudder to think
of what might have happened if I had packed him off to school that Monday). If a bellyache could morph into a life-threatening
emergency that suddenly, then who was I to shrug at a lousy swollen knee?
Yes, this all started with a swollen knee. About a month ago my son declared, on the
playground, that his knee hurt. Now, he’s
an active kid who plays basketball and soccer, so I assumed that he had just twisted
his knee or banged it up somehow. That
weekend he limped around on the basketball court and the soccer field, but I
told myself he was on the mend. By
Monday his knee had become so swollen and painful that he couldn’t walk. The affected knee (can no longer remember
which it was!) was now twice as large as the other so I gave him ibuprofen and iced
it throughout the day while he vegged out on Terraria and Clash Royale. Things did not, however, get any better. When he was unable to walk again on Tuesday, I
decided it was time to fork over fifty (our co-pay just went up to this ridiculous
sum) for some answers. In the past it might
have taken a bit more to get me to spring for the co-pay, but the appendicitis
episode had taught me that you can’t put a price tag on peace of mind. Our pediatrician looked at my son’s knee,
felt it, and declared matter-of-factly: “Ninety percent of the time this turns
out to be Lyme.” He ordered us to start doxycycline
that night and ordering two-tier blood testing that would later come back “strongly
reactive” to Lyme. More and more, it
would appear that doctors in Lyme-ridden areas like New England
know their stuff. Our pedi even
recounted how he had helped doctors in Italy
diagnose a teenage patient of his, who had been studying abroad and whose
symptoms had doctors there completely stymied. If you are reading this, and you are anxious
about Lyme, you should find this very
reassuring.
So that is how we ended up with the doxycycline that would
allow us to stamp out Lyme before it could do any more damage to my son’s body. Monoarthritis (arthritis on one side of the
body) of a large joint like a knee or an elbow is a classic symptom of early
disseminated Lyme, and the most common symptom in children. Left unchecked, Lyme can cause recurrent
arthritis and can penetrate deep into the nervous system, causing facial palsy
(found in 5% of kids with Lyme) and meningitis (found in 2% of kids with
Lyme). It can even affect the heart, though
this seems to be more common in adults and children over age 10. Doctors wonder to what degree so-called “chronic
Lyme” is due to treatment error (incorrect dosing or failure to take the entire
dose), re-infection (more common than once thought), lingering infection (in a
small number of cases), or an ongoing inflammatory response triggered by the
initial occurrence. One thing they do know
is that there has been an uptick in Lyme in recent years.[ii] As Lyme becomes more common, and makes
inroads into new areas of the United States,[iii]
doctors in those places will hopefully learn how to detect it as rapidly as
doctors in our neck of the woods do.
The other day my son went on a short hike in a wooded area
of town with his cub scout pack. While
his den leader would no doubt have discussed ticks at the meeting anyway, this
time my son got to bask in the spotlight once more. Only by then he was a bit more ambivalent
about the association. Sadly, the
experience has taught us that we will have to be more vigilant whenever we
venture into the great outdoors. We will use bug spray more liberally from
now on. We will look behind our knees and under our arms and behind our ears. We will
inspect freckles to make sure they are not moving (!). We will not,
however, freak out. We will simply do
our best while recognizing that we live in a world in which boys who go camping
are not inclined to do body checks, or wear long pants, or take showers, or
even brush their teeth or change their clothing, during the course of a weekend
camping trip.
Most importantly, we will forevermore sing that Irish
folksong, The Rattlin’ Bog,” with words that better reflect our local
ecosystem:
….THE TICK ON THE BOY…
AND THE BOY IN THE TENT…
AND THE TENT IN THE WOODS…
AND THE WOODS DOWN IN THE FOREST-O…
Okay, so technically the woods
are not in the forest, but it works…
Oh, and we never sing the version that devolves into the “blood in
the tick.” Far too gross.
Also, rest assured that there are many versions of the song and most versions stop with
the tick (or a “bug" or a “flea”) and do not (thankfully) delve into the whole cosmos within the tick.
[i] Gerber
MA1, Zemel
LS, Shapiro
ED. 1998. Lyme Arthritis in Children: Clinical Epidemiology
and Long-Term Outcomes. Pediatrics. 102(4 Pt 1):905-8.
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