Borreliosis (Lyme Disease) FAQ
Borreliosis / Lyme disease has until now been considered rare in the UK. It is for this reason that the amount of information available is predominantly from the United States of America. Although the different strains of Borrelia can produce varied symptoms, if treatment is not commenced as soon as an infection is suspected, the patient is at risk of suffering from long-term ill health and serious complications of the infection.
Below we have provided a response to frequently asked questions about Borreliosis. For more comprehensive information, see our "Diseases" section. For animal infections, see our "Pet Problems" section.
Follow the question links below to go to specific answers, or go straight to the first question and answer.
- What is the difference between Lyme disease and Borreliosis?
- What is the recognised means of diagnosing Lyme disease?
- Is the rash always the first symptom?
- Does the rash always look like a bull's-eye?
- What is the recognised treatment regime in Lyme disease?
- Can someone get Borreliosis / Lyme disease again after treatment?
- Is it only ticks that carry Borreliosis?
- Are the symptoms the same in everyone who is infected?
- Does a negative blood test mean that the patient does not have Borreliosis / Lyme disease?
- Is there a vaccine for Borreliosis / Lyme disease?
- As well as having Borreliosis, can humans be infected with another infection at the same time?
- Is there an acceptable time period to get treatment once a Borreliosis / Lyme disease infection is suspected?
- Is a full recovery certain?
- Are incidences of Lyme disease cases recorded?
- How accurate is the recording of Lyme disease cases?
- Should patients with Borreliosis / Lyme disease donate blood?
- What if I am, or become, pregnant?
Q.1 - What is the difference between Lyme disease and Borreliosis?
A.1 - Lyme disease (not Lymes) is a bacterial infection. The cause of Lyme disease is a spirochaete (a long, thin, spiral-shaped bacterium) called "Borrelia". The true Lyme disease pathogen is called "Borrelia burgdorferi (Bb) sensu stricto (s.s.), which means Bb in the strict sense. Bb was the cause of a sudden cluster of cases in Old Lyme, Connecticut, where Lyme disease gets its name from.
Later on, other sub-types of Borrelia burgdorferi were found in Europe and other areas and these were given different names. They all come under the umbrella term of "Borrelia burgdorferi sensu lato (Bb. s.l.), which means Bb in the broad sense.
In the UK and most of Europe, the most commonly found species of Borrelia include Borrelia burgdorferi, B. garinii, B. afzelii, and B. valaisiana. Of these species, hundreds of sub-types of differing strains exist. The various strains can produce differing symptoms. Bb. sensu stricto is known to result predominately in rheumatologic complications, while other strains have more predominately neurological and dermatological complications. The differing strains can also respond differently to antibiotics.
Many physicians and veterinarians prefer to use the term "Borreliosis" as an umbrella term for an infection of any strain. Sometimes the term "Lyme Borreliosis" is also used. Antibiotics are the treatment of choice no matter which strain of infection is present.
Lyme disease in the true sense is a zoonotic disease (a disease that can be transmitted between animals and people), which is transmitted primarily by a tick. However, it is possible for Borrelia bacteria to be passed from mother to baby in the womb; this would be classed as "congenital Borreliosis". Evidence suggests that it also may be passed through infected blood products during transfusion.
Borrelia bacteria have been isolated from insects (such as sand flies and fleas), and from stored semen, milk, urine, other body fluids and faecal matter in animal models. However, much more study needs to be done to establish if these could be modes of transmission.
Q.1 - References and Further Reading
Q.2 - What is the recognised means of diagnosing Lyme disease?
A.2 - Unfortunately there is a great deal of controversy regarding the diagnosis of Lyme disease and there are two opposing groups of doctors that believe in two different standards of care. Please see our section on "Bacterial Infections", for comprehensive information on Borreliosis diagnosis and treatment.
Q.3 - Is the rash always the first symptom?
A.3 - No. The rash, which is called an Erythema Migrans (EM), may appear at any time during early or late / chronic infections and may appear, or reappear, while the patient is on treatment. Some studies have demonstrated that fewer than 50% of infected people develop an EM rash and some strains of Borrelia do not appear to present with any skin involvement. Flu-like symptoms and excessive fatigue are often the first noticeable indications of infection. Progression of the illness can lead on to symptoms including cranial-nerve facial palsy, meningitis, heart problems, arthritis and encephalitis (inflammation of the brain), to name but a few. The onset of symptoms and presentation can differ for each individual.
Q.4 - Does the rash always look like a bull's-eye?
A.4 - No. The rash can be atypical (not like a bull's-eye). The bull's-eye rash is circular in shape, with a clearing from the centre. However, EM rashes can be irregular in shape, colour and size. It is thought that variation may be due to the differing sub-types of Borrelia burgdorferi. They can appear on any location of the body, including the scalp where they are often not observed when under the hair. Multiple rashes may appear in multiple locations.
Q.4 - References and Illustrations
Q.5- What is the recognised treatment regime in Lyme disease?
A.5 - Unfortunately there is a great deal of controversy regarding the treatment of Lyme disease and there are two opposing groups of doctors that believe in two different standards of care. Please see our section on "Bacterial Infections", for comprehensive information on Borreliosis diagnosis and treatment.
Q.6 - Can someone get Borreliosis / Lyme disease again after treatment?
A.6 - Yes. Multiple bites may cause reinfection, or a patient may relapse after a lengthy remission. Either situation may require treatment equal to, or longer than, what was originally prescribed.
Cases of subclinical infection (without apparent symptoms) may become clinical if the immune system is compromised by injury or another infection.
Q.7 - Is it only ticks that carry Borreliosis?
A.7 - No. Borrelia bacteria have been isolated from insects (such as sand flies and fleas), and from stored semen, milk, urine, other body fluids and faecal matter. However, much more study needs to be done to establish if these could be modes of transmission.
Ticks can also carry other infections concurrently and so it is possible to contract more than one infection from a single bite.
Q.7 - References and Further Reading
Folia Parasitologica. 1998;45(1):67-72 Investigation of haematophagous arthropods for borreliae.
European Journal of Epidemiology 1996 Feb;12(1):9-11.
Unusual Features in the Epidemiology of Lyme Borreliosis.
Zentralbl Bakteriol Mikrobiol Hyg [A]. 1986 Dec;263(1-2):40-4
Transmission of Borrelia burgdorferi from Experimentally Infected Mating Pairs to Offspring in a Murine Model. Altaie, Mookherjee, Assian, Al-Taie, Nakeeb and Siddiqui.
The British Veterinary Journal. 1995 Mar-Apr;151(2):221-4
Viability of Borrelia burgdorferi in Stored Semen. Kumi-Diaka and Harris.
Q.8 - Are the symptoms the same in everyone who is infected?
A.8 - No. The symptoms of Borreliosis can be non-specific and they can wax and wane. Clinical infection can resemble other conditions. Treatment can often make the patient worse before they get better. This is called a "Jarisch-Herxheimer" reaction. Please see our section on "Bacterial Infections", for comprehensive information on Borreliosis diagnosis and treatment.
Q.8 - References and Further Reading
Q.9 - Does a negative blood test mean that the patient does not have Borreliosis / Lyme disease?
A.9 - No. All methods of testing have their limitations and can produce both false-positive and false-negative reactions. Antibodies may not be present for the first few weeks after infection so a negative test does not exclude infection. A second sample taken 2-4 weeks later may then go on to show seroconversion. In late stage disease, patients can be seronegative although this is considered a rare phenomenon.
Current blood testing techniques follow a two-tier protocol set out by the Centres for Disease Control and Prevention (CDC) in the US. The first step is an ELISA which is followed, if positive or equivocal, by a confirmatory western blot. However, the CDC states explicitly that "This surveillance case definition was developed for national reporting of Lyme disease; it is not intended to be used in clinical diagnosis".
A number of studies have revealed that as many as 50% of Borreliosis cases, confirmed by Borrelial DNA or Borrelial culture, were reported as negative when tested using the CDC's recommendations. In an interlaboratory comparison study of tests for the detection of B. Burgdorferi, by the College of American Pathologists, it was concluded that "these tests will not be useful as a screening test until their sensitivities are improved".
False-positive results can occur if the patient has antibodies to Bb without having a current infection (e.g. people who are occupationally exposed, such as foresters, or people who are recreationally exposed to tick bites). Other conditions such as glandular fever, syphilis, or certain neurological illness can also trigger a false-positive reaction.
The significance of any result, negative or positive, should be interpreted carefully by clinicians in the overall context of a patient's clinical findings and tick-exposure history.
Q.9- References and Further Reading
The Lancet. 1989 Feb 25;1(8635):441
Seronegative neuroborreliosis. Guy and Turner.
Q.10 - Is there a vaccine for Borreliosis / Lyme disease?
A.10 - No. Currently there is no vaccine available and much more study into the nature of Borrelia bacteria needs to be done to allow for the creation of a safe and reliable vaccine for all the strains. The US vaccine LYMErix was used but it was subsequently withdrawn.
Q.10 - References and Further Reading
Q.11 - As well as having Borreliosis, can humans be infected with another tick-borne infection at the same time?
A.11 - Yes. Multiple infections can be contracted, although recorded cases of co-infections are not common. Ticks in the United Kingdom can carry a variety of infections concurrently. These include Anaplasma / Ehrlichia species, and Bartonella and Babesia species, as well as the different Borrelia species. Other opportunistic infections can also result from the immune system being depressed by a Borrelial infection.
Q.11 References and Further Reading
Journal of Clinical Infectious Diseases. 2001, vol33,5, 676-685(118ref.)
Coinfecting deer-associated zoonoses: Lyme disease, babesiosis, and ehrlichiosis. Thompson, Spielman and Krause.
Q.12 - Is there an acceptable time period to get treatment once a Borreliosis / Lyme disease infection is suspected?
A.12 - No. In Mandell, Douglas and Bennett's "Principles and Practice of Infectious Diseases, Alan Steere MD wrote:
"It has been shown that virulent strains of Borrelia burgdorferi are able to resist elimination by phagocytic cells, thereby evading the first line in the host defence system against infection". This assists an infection to disseminate quickly".
Dr Steere also wrote:
"Borrelia burgdorferi seems to cross the cell monolayer at intracellular junctions, although it can penetrate through the cytoplasm of a cell. In a rat model, permeability changes in the blood-brain barrier began within 12 hours after inoculation with the spirochete, and the organism may be cultured from the cerebrospinal fluid within 24 hours".
With its ability to evade the host immune system, and its rapid penetration of the central nervous system, Borrelia has the ability to cause acute onset of neurological disease. Many experts would therefore agree that waiting for symptoms to appear before commencing antibiotic treatment gives the infection chance to become deep-seated and can lessen the chance of a full recovery. Taking a "watch and wait" approach to this disease is not advised.
Q.12 - References and Further Reading
Lyme Info - Neuro-cognitive Lyme Disease
Q.13 - Is a full recovery certain?
A.13 - No. The length of time a person has been infected before treatment, whether the patient has been given sufficient treatment, and whether there are co-infections present, can all have a big impact on a patient's recovery.
Some patients with Lyme disease still experience symptoms (such as fatigue, soreness and memory or concentration loss) after their treatment has finished. They are sometimes diagnosed as having chronic Lyme disease or post-Lyme Disease Syndrome. What causes these symptoms has become the subject of controversy. One side of the argument is that immunologic mechanisms are triggered by the initial infection, leading to long-term symptoms even after treatment (Post-Lyme Disease Syndrome). The other is that the stealth nature of the bacterium may lead to treatment failure and therefore some doctors believe that longer, more aggressive treatment is required. Both treatment failure and Post-Lyme Disease Syndrome have been poorly defined and currently no definitive test exists to determine whether an infection has completely resolved. Please see our section on "Bacterial Infections", for comprehensive information.
Q.14 - Are incidences of Lyme disease cases recorded?
A.14 - Yes. In Scotland, England & Wales, diagnostic laboratories report laboratory-confirmed cases of Lyme disease. In the British Armed Forces, Lyme disease is likewise a reportable condition. For those employed as zookeepers, forestry workers, or in certain other types of employment, notification to the Health and Safety Executive is required. In Northern Ireland a voluntary monitoring scheme exists. For more comprehensive information, see our "Disease Notification" section.
Q.14 - Reference and Further Reading
Health Protection Scotland - Lyme Disease: Surveillance
Q.15 - How accurate is the recording of Lyme disease cases?
A.15 - It is acknowledged by authorities who record laboratory-confirmed cases of Lyme disease, such as the Health Protection Agency, that the data is incomplete because they do not include cases diagnosed and treated on the basis of clinical features such as erythema migrans (the early rash of Lyme disease), without laboratory tests.
Q.15 - Reference and Further Reading
Q.16 - Should patients with Borreliosis / Lyme disease donate blood?
A.16 - Whilst it is commonly recognised that Hepatitis B virus, Hepatitis C virus, and retroviruses can be transmitted through blood products, other pathogens are emerging as potentially significant transfusion-associated infectious agents. Studies have demonstrated that Borrelia bacteria can survive in guinea pig blood at room temperature for 28-35 days and they can survive in human blood processed for transfusion at 4°C for up to 48 days.
In the US, donors with a positive and active infection of Borreliosis / Lyme disease cannot donate blood until such times as they are no longer symptomatic, having undergone a full course of antibiotic treatment, and are cleared by a physician.
In addition to Borrelia, protozoal infections such as Malaria and Babesia are reported to be transmittable through blood transfusion. The CDC has warned of the ability of Babesia to withstand current procedures employed to treat donated blood. People in the US with confirmed cases of Babesiosis are permanently deferred from donating blood.
Q.16 - Reference and Further Reading
Public Health Agency of Canada - Material Safety Data Sheet: Infectious Substances.
Transfer of Borrelia burgdorferi s.s. infection via blood transfusion in a murine model. Gabitzsch, Piesman, Dolan, Sykes and Zeidner.
Q.17 - What if I am, or become, pregnant?
A.17 - It is documented that transmission of Borrelia through the placenta from mother to foetus is possible. Autopsy and clinical studies have associated gestational Borreliosis / Lyme disease with various medical problems including foetal death, hydrocephalus, cardiovascular anomalies, neonatal respiratory distress, hyperbilirubinaemia, intrauerine growth retardation, cortical blindness, sudden infant death syndrome and maternal toxaemia of pregnancy. Under experienced supervision, and with appropriate antimicrobial treatment, it is possible to have children without passing on the infection.
Q.17 - Reference and Further Reading