Fevers are not that unusual in elementary schoolchildren and, in fact, nothing worrisome was turning up as the physician examined the 7-year-old. After a negative strep test and a reassuring office visit, the little girl was sent home with a diagnosis of viral syndrome and the usual instructions to call if she did not improve as expected.
The girl's fevers resolved relatively quickly. When she developed a rash a week later, after contact with an unusual fabric, no red flags went up since the rash seemed to respond to oral antihistamines.
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Several weeks later, when the youngster came in for her annual physical, her mother commented that the girl just didn't have her usual pep and had never really bounced back from her recent viral illness.
The girl's blood pressure and growth pattern were just fine and her physical exam was perfectly normal. That is, with the exception of her cardiac exam, which showed an "irregularly irregular" heart rate. When an EKG revealed an electrical disturbance referred to as heart block, cardiologists recommended immediate evaluation at the city children's hospital.
A battery of blood tests were drawn looking for infectious causes for the girl's cardiac arrhythmia. The little patient was then dosed with anti-inflammatory IV immunoglobulin, started on a beta blocker and discharged several days later with a plan for regular cardiac follow-up.
When the patient's Lyme disease titer came back positive, the specialists finally had their diagnosis and an explanation for the girl's carditis. After three weeks of IV antibiotics, several months of cardiac medication, and a full year of cardiology follow-up, the 7-year-old was cleared to return to all of her normal physical activities.
In the Tick Management Handbook, Connecticut entomologist Kirby Stafford explains that Lyme disease is caused by the bacterium Borrelia burgdorferi, which multiplies in the gut of the blacklegged tick and then migrates to the tick's salivary glands. Tick bites then spread the bacteria to human hosts.
Lyme disease is most common in the northeastern U.S., but the disease-spreading ticks are also found in the north central states as well as along the Pacific coast. Lyme disease has been reported in 49 states. Stafford reports that Lyme disease peaks during the summer months and is most often seen in patients younger than14 and those older than 40.
Infectious disease specialists from the American Academy of Pediatrics note that in children, early Lyme disease most commonly shows up as erythema migrans. EM is an expanding red lesion that begins at the site of the tick bite, and sometimes features a pale center, creating a classic "bull's eye" appearance.
EM occurs one day to one month after a tick bite and is often accompanied by fever, fatigue, headache, neck stiffness, and muscle and joint aches. Two to three weeks of oral antibiotics treats this early localized Lyme disease, and usually prevents the development of the later stages of the disease.
Other manifestations of Lyme disease include multiple EM lesions, uncomplicated arthritis and isolated facial nerve palsy, which are treated with three to four weeks of oral antibiotics. Persistent or recurrent arthritis, carditis (which is very rare in children) and meningitis usually require two to four weeks of IV antibiotics.
The good news, according to academy experts, is that even after a known deer tick bite, the overall risk of infection with the B. burgdorferi bacterium is less than 1 percent. Preventive antibiotics are not routinely recommended after tick bites in geographic areas at low risk for Lyme disease. Lyme disease risk does increase if an attached deer tick is found to be engorged, particularly if it has been attached for 72 hours or longer.
Simple precautionary measures can be helpful in Lyme disease prevention. The AAP recommends that children stay on cleared trails while hiking and cover exposed skin when in densely wooded areas. The insecticide permethrin can be sprayed on children's clothing, while DEET-containing insect repellents can be used on exposed skin. After kids come in for the night, bathing will wash off chemical products, and will allow time for parents to perform thorough scalp-to-toe tick checks.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.