Ashlee Williams, MD (Host): A walk in the woods or even time spent in the backyard could lead to a tick bite that you might not even notice. Thanks to warming temperatures, new species of ticks are becoming more common in our region, and many carry diseases that can affect your joints, your heart, your nervous system, and even your ability to eat meat.

Welcome to the Healthier You podcast. I'm Dr. Ashlee Williams. And today, we're talking with Dr. Metti Kanno, a board-certified infectious disease physician here at Kaiser Permanente, about Lyme and other tick-borne illnesses. We'll talk about the best ways to avoid bites, symptoms to watch out for, and what to do if you're bitten. Dr. Kanno, thank you so much for joining us today.

Mettassebia (Metti) Kanno, MD: Thank you for having me. I'm happy to join.

Host: So, how common are tick-borne illnesses in our area?

Mettassebia (Metti) Kanno, MD: Very common. The DC, Maryland, and Virginia areas have one of the highest rates of Lyme disease in the country. There are several species of ticks that can cause infection, or transmit disease to humans. Thanks to warming temperatures, as you had alluded to earlier, the tick infection timeframe that we see has shifted in the seasons during the months, and typically spring, late spring, early summer, starting through end of fall. That's usually the high tick activity and when we see a lot of tick-borne infections. But because of the warming effects, we're starting to see tick-borne infections earlier in the year and as late as later in the year because the temperatures stay warmer for longer periods of time. If you're spending time outside, outdoors walking, gardening, hiking, walking your dog, it is very important to take precautions during these months.

Host: Got it. What exactly is Lyme disease and how do people get it?

Mettassebia (Metti) Kanno, MD: So, Lyme disease is an infection that is caused by bacteria called Borrelia burgdorferi. The original host of this bacteria is the deer. The Lyme infection is transmitted from the deer to the human by the deer tick, or the black-legged tics in another term. These tics are common in the Mid-Atlantic and Northeast. Because the primary host is the deer, these ticks are very common in areas where deer are common, which are the grassy, wooded, and bushy and brushy areas.

The tick has to be attached for more than 24 hours to be able to cause infection in humans. The good news is if somebody's able to pull the tick off in less than 24 hours, the infection can be prevented by one dose of antibiotics, which is a preventative antibiotic course.

But if the tick is attached for more than 24 hours, the likelihood of that tick bite causing infection is high. And therefore, we do need to consider treatment or at least watching for signs and symptoms of early Lyme infection.

Host: That's a great segue into my next question, because I think most people don't know how long the tick has been attached to them. So, what kind of symptoms should people look out for if they've been bitten by a tic?

Mettassebia (Metti) Kanno, MD: The easy way to know whether a tick has been attached for a long period of time is if it's not easily picked off or if it's engorged with blood, then that would mean most likely it's been attached for longer than 24 hours. It's not exact science, but that's one of the indications. And the reason I say that is because the early symptoms of Lyme disease can mimic any viral infection. It's actually known as the summer flu. So fever, chills, headaches, myalgias, muscle and body aches, swollen lymph nodes can be part and parcel of the very early symptoms, which may be discounted by most people unless symptoms are associated with them finding a tick or pulling a tick off.

The second most recognizable symptom is after the tick has fallen off at the site of the bite, there is a rash, which is called a bull's eye rash because of its ring-like appearance. The name of the rash is erythema migrans, and it appears in about 70 to 80% of patients that have had a tick bite.

Host: Yeah, I think most people know about the bullseye rash. It's kind of like, "Oh, I think I have a rash. Is it Lyme disease?" Are there any other illnesses that can be caused by a tick bite?

Mettassebia (Metti) Kanno, MD: Yes. Before I go there though, I would like to say that the rash is completely painless, and it's also found in locations where sometimes it's hard to see. On the back, behind the leg, on the neck, where people can't see it. So, other people might find it, but the person that has the tick bite may not be able to see it. And that's why removing the tick early may not be possible, because if you don't know that the tick is there, you won't be able to remove it. And it's very important in the summer in kids, specifically in kids, to make sure that a total body check is done after kids have been running around outside to remove any ticks that may be on their bodies.

The terms of the question about other disease processes that the Lyme bacteria can cause is what we call Bell's palsy, which is paralysis of the facial nerve, which is the most common peripheral nerve infection that we see, followed by carditis or inflammation of the electrical system of the heart, AV nodes. We can see some heart blocks, some abnormalities in the EKG. Joints like the knee joints can get infected. It's usually one joint that gets infected by the Lyme bacteria, and patients can get arthritis, bacterial arthritis, which is similar to any other arthritis, which presents as a swelling of the knee, difficulty to move the knee, a limited range of movement, and pain.

If infection continues without detection or treatment, then there can be inflammation of the central nervous system and patients can present with what we call neuro Lyme or infection of the nervous system or central nervous system Lyme.

And then other nerves can be affected as a result of that, which would mean shooting pains, numbness, tingling of the hands and feet like a peripheral neuropathy. Those are all sort of infection that occurs untreated or unrecognized for more than 30 days, 60 days or so. But if the infection is recognized or the tick is found early, these can be prevented.

Host: Sounds like there's a large array of symptoms to look out for. And what specifically about other diseases? Like, is it only Lyme disease that we can get from ticks?

Mettassebia (Metti) Kanno, MD: There are several tick-borne infections that are transmitted obviously by ticks, and different types of ticks can be involved in spreading the other rickettsial infections. They're within the bacteria category, but they're also known as rickettsial infections, things like ehrlichiosis, babesiosis. So, ehrlichiosis is also a tick-borne infection. It causes infection of the central nervous system. It has predilection to the central nervous system. It can also cause liver inflammation. So, we typically see patients coming in with liver abnormalities, as well as specifically causing thrombocytopenia or low platelet count.

And so, the triad of symptoms, meaning the nonspecific flu-like symptoms in addition to liver enzyme abnormalities, low platelet count, plus minus CNS infection with confusion, delirium, a central nervous system can be ehrlichiosis in the right setting, in the right area. And there is a lot of ehrlichiosis within the DMV area as well. But a lot of people may not think about that because Lyme is much more common than ehrlichiosis, but they're both treated with the same antibiotic, but they cause very different clinical syndromes. Yeah.

Host: Okay. You talked about making sure when our kids are out to make sure we're checking them just because the tick can bite us in places that aren't really readily available to see. Do you have any other tips on prevention of tick bites?

Mettassebia (Metti) Kanno, MD: The main way to prevent tick bites is to wear protective clothing. Long sleeve, long pants. Tuck your pants into your socks when walking into tall, grassy, or brushy areas. Use insect repellents, tick repellents, mosquito repellents, like DEET, or oil of lemon eucalyptus, those kind of things. You can spray permethrin on boots, backpacks, and outdoor gear to prevent from ticks or other things like mosquitoes to attach to outdoor gear.

And the main thing is do tick checks. If people are living in areas where there's a lot of woods, a lot of grass, in these months, in the warmer months, summer months for sure, need to be doing pretty thorough tick, you know, after a day of being outside.

Host: Okay. So, let's say we've done the tick check and we find a tick. What is the best advice on how to remove them? Because they're so small, and I'm sure we're all in a panic trying to figure out how to get it off. What are your tips on how to remove a tick?

Mettassebia (Metti) Kanno, MD: So, the tips are you use a fine-tip tweezer to grab the tick close to the skin surface as possible, so that part of the tick doesn't break off when you're trying to pull the tick. Another tip is not to twist or jerk the tweezer so that the tick doesn't break off. And then after removing the tick, just clean the bite area with some rubbing alcohol, soap and water as well.

If you would like to save the tick and bring it in for analysis, you can do that in a little plastic bag. And the lab does do an identification of what type of tick it is. As I said earlier, if you're able to remove the tick easily, that would mean that the tick has been attached for less than 24 hours. So, the chances of infection from the tick is much, much lower than if the tick would have been harder to remove.

And after that, wait for signs and symptoms. If the tick has been attached for less than 24 hours, people can talk to the PCPs to get preventative medication, one dose of doxycycline 200 milligrams to prevent infection from setting in. If the tick is difficult to remove, then at that point, we recommend watching for signs and symptoms and not necessarily pulling the trigger on treatment for Lyme without signs and symptoms. But any signs and symptoms, I would say, would be a low threshold to treat for Lyme infection.

Host: So, you mentioned a couple of things. One, bringing the tick in and, two, treating once you've seen the tick. Is there testing that is recommended? Like, are doctors testing for Lyme disease in the office? What does that look like?

Mettassebia (Metti) Kanno, MD: Lyme disease testing is based on antibody formation. To form an antibody to a particular infection, the infection has to have set up shop. And for antibodies to present, it takes sometimes weeks, three weeks, six weeks for antibodies to form. So, testing at the time where a tick is found or a tick is removed is not going to show a positive test.

It doesn't mean that there is no Lyme infection. It just means that it's a little too early to test. After three to six weeks, especially after there are early symptoms, at that point, the antibody testing is likely to be positive, and we do recommend testing at that time when there are symptoms, not when the tick is pulled with no symptoms.

Host: So, let's talk about alpha-gal syndrome. What is it, and is there testing for it?

Mettassebia (Metti) Kanno, MD: Alpha-gal is not an infection. The syndrome is triggered by a tick bite. And the tick responsible for that syndrome is the lone star tick. The lone star tick is a tick that causes or is a vector for the Amblyomma americanum bacteria that causes anaplasmosis, which is one of the tick-borne infections. It can appear very similar to ehrlichiosis. It can present similar to the early stages of Lyme disease. Sometimes it's hard to distinguish between ehrlichiosis and anaplasmosis unless we do serology or testing. The treatment is the same, which is doxycycline, which is really good for most tick-borne diseases. The treatment is the same, which means when you're treating one tick-borne infection, most likely you will treat all the other ones except a few that doxycycline may not be an option for.

Going back to alpha-gal, it refers to the oligosaccharide, which is a large sugar molecule, galactose, alpha-1,3-galactose, which is present in non-primate mammals. So, humans and some non-primates do not have this oligosaccharide molecule. When this tick bites the human, it releases this particular sugar molecule into the human Because it's a foreign sugar molecule to the humans, there's an antibody response to it, like an allergic reaction response to it. The antibody response to it that causes the symptoms of an allergy is the IgE antibody towards this alpha-gal sugar molecule. That means that people that get bitten by the lone star tick and have this i allergic response triggered when they eat meat, dairy products such as yogurt, cheese, butter, and milk can develop an allergic reaction to the meat and to the dairy. And most of the time it's very difficult to diagnose. And patients may come to their physicians and complain about, you know, "When I eat meat, I have, you know, hives, nausea, diarrhea, vomiting, swelling of the lips and throat." And in severe cases, sometimes anaphylaxis can occur.

And to relate it to the tick bites sometimes, it takes years for physicians to find out. The only way to distinguish whether these allergic reactions are related to this alpha-gal syndrome is by checking a specific alpha-gal IgE antibody. And if that's elevated, then that could be an indicator that the alpha-gal syndrome exists. But I would like to make it clear that it's not an infection. It's not because of an infection. It's the tick bite itself triggers this response in a minority of patients.

Host: Okay, Dr. Kanno, you've given us a lot of information. Give us your biggest takeaways for what we should be doing when we're going outdoors this summer.

Mettassebia (Metti) Kanno, MD: Biggest takeaways are recognize that there are a lot of ticks in this area. The DMV area, the highest incidence, one of the highest incidence of ticks. Prevention is the best protection. Insect repellent, long sleeves, protective clothing, and tick checks, especially for kids after an outdoor activity. Pets can carry ticks as well. So, tick checks in pets is all very important.

Lyme disease, if diagnosed very early, is treatable without any complications. Important thing is to recognize early symptoms. the initial flu-like symptoms may be difficult to recognize. But in the setting of a tick bite, flu-like illness should clue us in that there might be early Lyme. If those symptoms are missed, then the rash is very classic. If you find a bullseye rash, you need to call your primary care provider for next steps immediately. If you find a tick, remove it properly so that it doesn't break off. If you need to send it in or bring it in for analysis, you can do that. But those are my last notes on this podcast.

Ashlee Williams, MD (Host): Those are all great. Thank you, Dr. Kanno. And thank you so much for helping us understand Lyme disease and other tick-related risk. Here are a few of the takeaways:

one, ticks are very common in the Mid-Atlantic region, especially in grassy, wooded, or bushy areas.

Two, prevention is the best protection. Use insect repellent, wear protective clothing, including long sleeves and pants, and check yourself, your kids, and your pets after spending time outside.

Three, Lyme disease is treatable, but a diagnosis is important. Watch for those rashes and flu-like symptoms. The summer cold could be from Lyme disease.

Four, tick bites can also lead to serious conditions such as alpha-gal syndrome, which can cause an allergy to red meat.

And five, if you find a tick, remove it properly and monitor symptoms in the following weeks.

For more information from our experts, visit kp.org/doctor and check out more episodes of Healthier You wherever you get your podcast. If you found this episode helpful, please subscribe and share it with others. And from all of us at Kaiser Permanente, be well.