Lyme Disease: Defining the Controversy, Part I

What is Lyme Disease? This question seems simple enough, and perhaps for the people who successfully recover on their own or with an antibiotic, the answer is simple. But for the 5% to 20% of individuals who develop persistent, debilitating symptoms for months to years after the initial infection, the definition is anything but simple. Depending on the circle you run in, the illness is called Chronic Immune Dysfunction (CID), Multi-Systemic Infectious Disease Syndrome (MSIDS), Post-Treatment Lyme Disease Syndrome (PTLDS), Chronic Lyme Disease, Persistent Lyme Disease, or it plain just doesn’t exist.In my experience with patients, the investigation often begins with multiple inconclusive tests and visits to Infectious Disease specialists, Internal Medicine specialists, and Rheumatologists. It may involve a Psychiatrist and concern for symptoms that are “all in your head”. It invariably includes a list of health conditions and illnesses that you don’t have, and a mixture of pain medications, anxiety medications, and sleeping pills that help with symptoms but not recovery. It may also include a fear of spending time outdoors and warnings to loved ones to avoid previously enjoyed past-times of hiking, camping, hunting, and gardening. It can be an isolating experience that sets up a mistrust of our healthcare system and our environment.

Let’s start by breaking down some of the misperceptions and myths associated with acute and chronic symptoms of Lyme disease.

Chronic Lyme Disease is not a single infection caused by Borrelia

Lyme Disease was first identified not too long ago, in 1975, by a physician practicing near the community of Lyme, Connecticut. He was suddenly confronted with multiple cases of a rare autoimmune arthritis in local children.  A fortuitous use of antibiotics in a little girl with the strange condition who also had a known tick bite, resulted in the discovery of the disease-causing (pathogenic) bacteria, Borrelia burgdorferi, about 7 years later. (Or at least that’s how the story is frequently told. At least one article credits the discovery to two “astute” mothers who sought help from investigators at Yale University.)¹

It wasn’t until the advancement of molecular technology in the 1980s that we were able to analyze genetic material of bugs and identify the hundreds more bacteria carried by ticks. In fact, we now know that each tick carries a community of bacteria and viruses collectively known as a microbiome that is influenced by where the tick lives and what animal it feeds on. Many of these bacteria have evolved with their tick host over millions of years and actually provoke the tick to change its physiology and create a happier environment for the microbe.² Only a few of these microbes cause disease in humans, but the process of linking individual tick microbes to specific diseases can take years. This was the case with at least two species of Borrelia: One called Borrelia miyamotoi, discovered in 1995 but not definitively linked to Lyme Disease until 2011, and Borrelia mayonii, discovered in 2016 after analyzing patient test samples dating back to 2003.^3-4  

We’ve identified at least 15 pathogens that commonly accompany Borrelia in the belly of a tick. Because we generally define Lyme Disease by the presence of Borrelia, we call these other pathogens “Lyme Disease co-infections” [1]. It’s common for infected individuals to carry multiple pathogens: Single infections inhibit our immune system which enables additional infections, and bugs work in teams to help each other survive. They might tag along together in the tick and be injected into the host at the same time or they might find a “friend” in the infected person – a latent virus such as herpes – and encourage each other’s growth and virulence.  (We haven’t even begun to explore how these pathogens interact with your own personal microbiome!) In other words, a person with chronic or late-stage Lyme disease is most likely to have multiple infections that work synergistically to create a unique symptom picture. This is very different than an acute or newly acquired infection, that our conventional medical model is most equipped to deal with.

The 24-hour Rule Doesn’t Apply

Many public health authorities suggest that anyone bitten by a black-legged tick may have contracted Lyme Disease if the tick was attached for more than 24 hours and engorged (meaning that it’s full of blood because it was feeding). These guidelines are based on some important foundational research on Borrelia’s behaviour inside a tick as it prepares to be transmitted to a host. For example, one study found that the Borrelia population in the tick’s gut grew from about 1000 bacteria to 6000 as the tick fed on a mouse for 2 days. About 20 of these Borrelia made it up to the tick’s salivary glands for a quick exit into the mouse to cause infection there.⁵ The amount of time a tick feeds on a person is a definite factor in the risk of acquiring Lyme Disease.

How the bacteria behave inside a tick is only part of the story, however. On looking more closely at tick behaviour, Lyme Disease advocates quote research in which ticks feed on multiple hosts over a 48-hour period, so that the bacteria migrate up the tick’s salivary glands with each feed, closer and closer to the “exit”, so that the next person grabbed by the tick experiences a much faster transmission of bacteria into their bloodstream. It’s also possible that tick behaviour has become more aggressive over the 30 years (!) since much of this research was conducted, given climate change and other environmental pressures.

Even if we agree that generally Borrelia transmission from a tick to a human requires 24 hours or more, we still need to account for transmission times of the co-infections. Bartonella for example, appears to live closer to the saliva glands of ticks, and the Powassan virus, currently considered rare but present in some ticks, is transmissible in only 15 minutes.

Overall, this means that the 24-hour rule is not a rule at all. Every tick bite should be treated in some manner (not necessarily with antibiotics), no matter how long the tick was present. Take a look at my prevention guidelines, here.

Read “Part II” of “Defining the Controversy.

[1] You may have read about the more common co-infections, such as Babesia, Bartonella, and Ehrlichia. Our website includes some resources for identifying symptoms associated with these infections.

1. Radolf et al. Of ticks, mice and men: understanding the dual-host lifestyle of Lyme disease spirochaetes. Nat Rev Micro. 2012;10:87-99. DOI:10.1038/nrmicro2714

2. Abraham N et al.  Pathogen-mediated manipulation of arthropod microbiota to promote infection. PNAS. 2017;E781-E790. DOI:/10.1073/pnas.1613422114.

3. Tijsse-Klasen E, Koopmans M, Sprong H. Tick-Borne Pathogen – Reversed and Conventional Discovery of Disease. Front Public Health. 2014;2:73.

4. Pritt BS et al. Identification of a novel pathogenic Borrelia species causing Lyme borreliosis with unusually high spirochaetaemia: a descriptive study. Lancet Infect Dis. 2016;16(5):556-564. doi: 10.1016/S1473-3099(15)00464-8.

5. Piesman J, Schneider B. Dynamic changes in Lyme disease spirochetes during transmission by nymphal ticks. Experimental and Applied Acarology. 2002;28:141-145.