The tick that passes Borrelia hermsii - relapsing fever - often difficult to
distinguish from Lyme disease- takes 20 minutes to feed.

georgia
_______

".....More than 60% of tick-bite victims removed {*filter*} ticks by 36 h of
attachment, but only 10% found and removed the smaller nymphal ticks within the
first 24 h of tick feeding. ..."

J Med Entomol 1995 Nov;32(6):853-8
Determining the duration of Ixodes scapularis (Acari: Ixodidae) attachment to
tick-bite victims.

yeh MT, Bak JM, Hu R, Nicholson MC, Kelly C, Mather TN
Center for Vector-Borne Disease, University of Rhode Island, Kingston
02881-0804, USA.

The duration of tick attachment is one factor associated with risk for human
infection caused by several tick-borne pathogens. We measured tick engorgement
indices at known time intervals after tick attachment and used these indices to
determine the length of time that ticks were attached to tick-bite victims in
selected Rhode Island and Pennsylvania communities where the agents of Lyme
disease and human babesiosis occur. The total body length and width as well as
the length and width of the scutum were measured on nymphal and {*filter*} female
Ixodes scapularis Say removed from laboratory animals at 0, 12, 24, 36, 48, 60,
and 72 h after their attachment. Three engorgement indices were calculated at
each time interval. In addition, engorgement indices measurements were recorded
for 504 ticks submitted to a commercial laboratory for pathogen detection
testing between 1990 and 1992. No detectable change was observed in the average
engorgement indices for either nymphal or {*filter*} ticks between 0 and 24 h of
attachment using any of the engorgement indices. After 24 h of tick attachment,
all engorgement indices continuously increased: average indices for nymphs
attached 36, 48, and 60 h were significantly different from those attached < or
= 24 h and from each other. Similarly, average engorgement indices for {*filter*}
ticks attached < or = 36 h were significantly different from those attached for
48 h or more. More than 60% of tick-bite victims removed {*filter*} ticks by 36 h of
attachment, but only 10% found and removed the smaller nymphal ticks within the
first 24 h of tick feeding.

PMID: 8551509, UI: 96102482

Title:Disseminated Lyme disease after short-duration tick bite
Authors:Patmas MA, Remorca C
Source:JSTD 1994; 1:77-78

Abstract:
Lyme disease, an Ixodes tick-borne spirochetal infection, has been the subject
of much controversy. One problematic area has been the prophylactic treatment
of deer-tick bites in endemic areas. Some have argued against routine
antimicrobial prophylaxis based upon the belief that transmission of Borrelia
burgdorferi is unlikely before 24-48 hours of tick attachment. Others have
suggested that it is cost effective to administer prophylactic antibiotics
against Lyme disease when embedded deer-tick bites occur in endemic areas.
Herein, a case of disseminated Lyme disease after only 6 hours of tick
attachment is presented. The current recommendation against treatment of
short-duration tick bites may need reconsideration, particularly in
hyperendemic areas. Color pictures.

Keywords:

Language: Eng

Unique ID: 940000AM
________________________
This is favorite of mine regarding tick attachment.  It is from the book
Lyme Disease 1991,  Patient/Physician Perspectives from the U.S. and Canada.

georgia

___________________________________

Tick Attachment-Infection Transmission   by Tina Lalosa

"Some very good studies have been done," he was saying, "that show a tick
has to be attached for at least 24 hours before infection takes place."
His voice trailed off.  I stopped listening.

What studies?  I just had to find out.

Since my eldest son was diagnosed with Lyme disease about 18 months ago.
I have collected many articles about Lyme disease.  Some are very
scientific;  others are simply meant to shock.  The length of time a tick
is attached as it relates to infectioon is mentioned quite often, stating
attachment times ranging from 6 hours, to more that 72 hours.  The two
articles I have found that list a source for this information, both list
the same study.  The study was done by Joseph Piesman(corresponding
author),  Thomas Mather, Richard Sinsky, and Andrew Spielman.  It was
published in the Journal of Clinical Microbiology, March 1987.  Off I  Went
to get a copy.

When I had a copy, I read quickly.  I wanted to get to the meat of the
study as fast as I could.  Then I read through it again slowly , wanting to
completely understand it.  

I this study, hamsters and mice were the hosts, Ixodes dammini nymphs were
the vectors conveying Borrelia burgdorferi.  The nymphs were allowed to
attach to the rodents for 24 hours, 48 hours, and until they had their fill
(72 hours or more).  One of the 14 animals became infected after 24 hours
of attachment;  five out of 14 became infected became infected after 48
hours; 13 out of 14 animals were infected when the nymphs were on for 72
hours or more.  There is a definite correlation between attachment times
and infection rates.  Conclusion:  prompt removal of Ixodes dammini will
reduce the chance for infection transmission.

This study was not aimed at finding a minimum time before which infection
does not take place.  In fact, this is clearly stated.  The minimum time
for this study was 24 hours.

Let me submit my own observations.  My family members were the hosts.
Ixodes pacificus {*filter*} females were the vectors.  Three hosts had bites
lasting less than 2 hours;  one host had a bite lasting less than 4 hours.
Results:  3 out of 4 became infected with Lyme disease.  The fourth host
has knee pain that is still being evaluated.  Infection became apparent in
as soon as three days for one host, and in over two years for another host.
 Conclusion:  At least 75% of Ixodes pacificus {*filter*} females inclined to
bite people, can transmit infection in less that 4 hours.  Please note:
This is not a scientific study, just my personal observation.

Recommendations:  Avoid areas known to have ticks, protect yourself by
using tick repellant sprays, long pants, and long sleeves;  check yourself
and those with you often, and promptly remove any ticks, attached or not."

____________________________________

VIII International Conference on Lyme Borreliosis and other
Emerging Tick-borne Diseases, Munich, Germany, June 25,1999

FATAL PROGRESSIVE ENCEPHALITIS FOLLOWING AN UNTREATED DEER TICK ATTACHMENT
ON A 7 YEAR-OLD FAIRFIELD COUNTY, CONNECTICUT CHILD.

Liegner KB & Jones CR. Private Practices, Armonk, NY & Hamden, CT, USA.

An engorged deer tick was removed from the right aspect of the neck of a 6
year old Fairfield County, Connecticut girl March 1995.  Parental request
for prophylactic antibiotic treatment was refused by the child's physician.
No eruption occurred at the tick bite site. Summer 1995 flu-like symptoms
and conjunctivitis developed and October 1995, headache, stiff neck, and
sleep disturbance.  November 1995 right supraclavicular lymphadenitis,
fever, lethargy and hypersomnolence developed.  Admitted to a local
hospital, focal seizures ensued. Phenytoin was administered.  Lumbar
puncture showed 3 white {*filter*} cells and normal glucose and protein.
Phenytoin, ceftriaxone, ampicillin, and acycolvir were administered.  Tests
for rabies and Lyme disease were negative.  MRI of brain was normal.
Transfer was made to a tertiary care facility where high dose pentobarbital
coma was required to control status epilepticus.  Feeding gastrostomy and
Boviac catheter were required for nutrition and medications.  Adenovirus
serology, arbovirus serology and CSF serology and culture and CSF serology,
culture, and PCR for HSV-1, HSV-2, ANCA, ANA, ASO, Bartonella, cold
agglutinins, febrile agglutinins, influenza, para-influenza, CSF india ink
prep, malaria screen, measles, mycoplasma, Q fever, rabies, RMSF, RSV,
rotovirus, rubella, toxoplasmosis, typhus, varicella, Lyme disease
serologies and VDRL were negative.  EBV antibodies were present. HSV IFA was
positive and rose following administration of IVIG.  IgG for ehrlichia was
positive at 1:256 by the Centers for Disease Control.  Intravenous
immunoglobulins were given for putative Rasmussen's Syndrome, steroids for
"vasculitis", and intravenous acyclovir for the possiblity of herpes
encephalitis.  Intravenous nafcillin was given for coagulase negative
staphylococcal bacteremia.  CT scans and MRIs of the brain, initially
normal, demonstrated evolution of cerebral atrophy and periventricular white
matter disease.  June 1996 the patient demonstrated arthritis involving
hands, wrists, ankles, knees, and hips, was experiencing frequent seizures
and was unable to walk, speak, respond to verbal commands, or feed herself.
Paired Lyme ELISAs in CSF and serum 7/96 were negative, but Lyme IgG
immunoblot in serum disclosed the presence of 30, 41, 66, & 93 kiloDalton
bands as well as 60 kDa band.  CSF cell count, glucose protein, and IgG were
normal.  CSF, {*filter*}, and urine Lyme PCRs were negative as was culture for
borrelia in BSK-H .  Myelin basic protein and oligoclonal bands were absent.
Osp A antigen capture assay in CSF and Lyme-specific immune complexes in CSF
and serum were negative.  Treatment with intravenous ceftriaxone initially
resulted in worsened seizure activity and treatment was changed to
cefotaxime.  Arthritis resolved within one month of starting antibiotics.  A
short course of doxycycline  was given to cover the possibility of
co-infection with ehrlichia.  During six months of treatment with
intravenous cephalosporins seizures, which had remained poorly tractable
despite intensive {*filter*}anticonvulsant therapy, diminished and became readily
controllable with lower dosage of anticonvulsants.  The patient became able
to walk, vocalize in simple sentences, feed herself, and use a swing set but
remained severely neurologically impaired with significant brain injury
evident on brain MRI and CT scan.  Antibiotic therapy was stopped 12/3/96.
Seizures reoccurred within one week of cessation of antibiotics and became
increasingly difficult to manage despite continuation of anticonvulsant
therapy.  While in a tertiary care hospital her condition deteriorated and
she died 1/30/97. An autopsy was performed.

**********************************************************************
CORRESPONDENCE

LYME DISEASE

TO THE EDITOR:  Dr. Steere briefly addresses the important question of
prophylactic antibiotic therapy for deer-tick bites in his superb review of
Lyme disease (Aug. 31 issue) (1).  Others have offered the opinion that only
attachments by engorged deer ticks warrant treatment (2).

Although it is believed that Borrelia burgdorferi is transmitted mainly in
the later stages of tick feeding (3-5), the earlier transmission of small
numbers of the organism has not been ruled out.  Riberio et al. (3) were
unable to procure sufficient saliva for examination before three days of
attachment, after which spirochetes were seen.  We do not know the minimal
inoculum of B. burgdorferi sufficient to establish infection in animals or
humans.  Under circumstances favorable to the bacterium, the transmission of
a single spirochete could theoretically result in Lyme disease.  Infection
with a small inoculum of a slowly reproducing organism may be difficult to
detect experimentally and is likely to be clinically latent (6).  Very
extended periods of careful follow-up may be required to ensure that no
transmission has occurred.  The well-accepted practice of treating pregnant
women preventively with antibiotics after unequivocal deer-tick bites
highlights the inconsistency of failing to do so in other patients who have
been bitten by deer ticks.

Treating Lyme disease at the earliest possible time, before the spirochete
has become widely disseminated and has reached parenchymal or intracellular
sites, is of great advantage.  Once these sites have been reached, treatment
becomes much more difficult, since organisms in these locations may be less
affected by antibiotics (7).

Although physicians may feel righteous in selectively prescribing
antibiotics only when disease is manifest or overwhelmingly likely (such as
after the removal of engorged deer ticks), withholding them after less
protracted deer-tick attachments subjects their patients to a sort of
Russian roulette.  The risk of transmission of Lyme disease after the early
removal of attached deer ticks appears to be small (5), but we cannot say
that it is zero.  Patients should be informed of the small risk of acquiring
infection in these circumstances and offered the option of preventative
treatment if that is what they prefer.

Kenneth B. Liegner, M.D.
8 Barnard Rd.
Armonk, NY 10504

TO THE EDITOR:  Dr. Liegner, like many physicians, favors the practice of
treating all tick bites prophylactically with antibiotic therapy.  I believe
that this decision should be a clinical judgment based on the type of tick,
its degree of engorgement, and the patient's level of anxiety.  With an
anxious patient, it may be best to treat in any case.  With one who is not,
watchful waiting may be justified.

Allen C. Steere, M.D.
New England Medical Center
Boston, MA 02181

Reprinted from the New England Journal of Medicine
322:474-475 (February 15), 1990

**************************************************************
PREVENTION OF LYME DISEASE AFTER TICK BITES

TO THE EDITOR:  The article by Magid et al. takes a largely
dollars-and-cents approach to deciding whether or not to treat deer-tick
bites prophylactically, and comes down on the side of treating in certain
circumstances. Not factored into that decision analysis are the toll of
human suffering associated with Lyme disease, the lives of some that are
truly ruined (1,2), and the fact that medical science may be incapable of
curing entrenched Lyme disease in some patients (3,4).  One is then faced
with the option of either administering long-term treatment for a chronic
infection or allowing patients to deteriorate clinically over time,
untreated.  The Tuskegee experience has amply demonstrated the untoward
effects of one type of untreated spirochetal infection (5).  These
considerations, which may incline the physician more toward prophylactic
treatment than watchful waiting, are hard to quantitate in a decision
analysis (6).  a?|

Kenneth B. Liegner, M. D.
8 Barnard Rd.
Armonk, NY  10504

Reprinted from the New England Journal of Medicine
328:136-139(January) 14, 1993

*********************************************************************
ANTIMICROBIAL PROPHYLAXIS AFTER TICK BITES

TO THE EDITOR:  We believe Shapiro et al. (Dec. 17, issue) (1) had
inadequate evidence to support their recommendation for nontreatment of
deer-tick bites.  The population samples were much too small for a
meaningful comparison of the risks of serious late sequelae with the risks
and benefits of prophylactic antibiotic therapya?|

John Genter, M.D., Nancy Berman, Ph.D.
Harbor-UCLA Medical Center
Torrance, CA 90501

Roberta E. Madison, Dr. P.H.
California State University
Northridge, CA 91330

a?|What will happen when the first patient with an intentionally untreated
tick bite is found to have the Guillain-Barre syndrome, chronic progressive
encephalomyelitis, myocarditis, or chronic arthritis? Will this Journal
article be cited as a m{*filter*}or legal defense?a?|

David A. Drachman, M.D.
University of Massachusetts Medical School
Worcester, MA 01655

|Avoidable infection may occur in some patients not treated for known
deer-tick bites.  In some bitten persons, classic disease will develop
early. Ideally, such illness will be correctly diagnosed and adequately
treated.  Even this is not certain, however, for the mile influenza-like
illness and other nonspecific symptoms that may follow deer-tick bites and
may indicate true infection may not be correctly recognized by either the
patient or the physician. In other cases, infection is subclinical.  The
outcome will depend on the interaction of spirochete and host factors, on
whether or not the correct diagnosis is made at a later time, and on whether
effective treatment is given.

Cases of meningomyeloencephalitis are becoming commonplace in the New York
counties of Westchester, Putnam, Dutchess, Orange, and Rockland as the
epidemic of Lyme disease enters its second decade.  Patients with this
condition may be misdiagnosed as having multiple sclerosis (1,2) and treated
inappropriately with corticosteroids or cytotoxic agents.   The application
of even intensive antibiotic therapy at this stage may not halt the
neurologic injurya?|.

Kenneth B. Liegner, M.D.
8 Barnard Rd.
Armonk, NY 10504

a?|Liegner ignores the fact that no one in our study had serologic evidence
of
asymptomatic infection, although all were tested three months or more after
the bite.  He also ignores the fact that persons who have latent infection
with Treponema pallidum have generally had signs and symptoms of primary or
secondary syphilis that was never treated.  In Connecticut,
meningoencephalitis due to Lyme disease is not "commonplace".  We would be
surprised if it is in an adjacent county in New Yorka?|

Eugene Shapiro, M.D., Anne T. Berg, Ph.D.
Yale University School of Medicine
New Haven, CT 06510

Michael A. Gerber, M.D., Henry M. Feder, Jr., M.D.
University of Connecticut Health Center
Farmington, CT 06032

Reprinted from the New England Journal of Medicine
328:1418-1420 (May 13), 1993

--------------------------------------------------------------------------
------

Subject: Re: B. burgdorferi can be transmitted by direct contact
Newsgroups: sci.med.diseases.lyme
View: Complete Thread (4 articles) | Original Format
Date: 2000/02/01

Marie cannot post to the newsgroup--this is her message

Probably by excretes either by {*filter*}or mucous membrane transmission

There are a few other papers showing transmission by direct contact ...

87154125 Am J Trop Med Hyg 1987 Mar; 36(2): 402-7
{*filter*}infection of Peromyscus maniculatus with Borrelia burgdorferi and
subsequent transmission by Ixodes dammini.
Burgess EC, Patrican LA
We determined if deer mice (Peromyscus maniculatus) could be infected by
Borrelia burgdorferi and develop sufficient spirochetemia to infect larval
Ixodes dammini. Ten P. maniculatus were infected orally with 0.05 ml phosphate
buffered saline containing approximately 400 B. burgdorferi. On days 21 or 28
after infection (AI) larval I. dammini were fed on the deer mice. Each of the
P. maniculatus developed antibodies (up to 7 log2) to B. burgdorferi and B.
burgdorferi was isolated from the {*filter*} of 1 deer mouse on day 51 AI. Nymphs
resulting from these larvae were then allowed to feed on 10 uninfected P.
maniculatus. All 10 of these tick-infected P. maniculatus developed antibodies
(up to 7 log2) to B. burgdorferi, and B. burgdorferi was isolated from the
{*filter*} of 1 of the 10 P. maniculatus 15 days after tick feeding and from the
pooled organs of another of the tick-infected P. maniculatus. Six of the orally
infected P. maniculatus developed clinical signs including ruffled hair coat,
inappetence, reluctance to move, and lameness in the rear legs. All P.
maniculatus tissues were grossly and histologically normal on necropsy. These
findings show that P. maniculatus are susceptible to {*filter*}infection and develop
sufficient spirochetemias to infect I. dammini larvae. Experimental {*filter*}
inoculation of P. maniculatus with B. burgdorferi resulted in sufficient
spirochetemia to infect larval I. dammini capable of transmitting B.
burgdorferi to uninfected P. maniculatus

96414111 Eur J Epidemiol 1996 Feb; 12(1): 9-11
Unusual features in the epidemiology of Lyme borreliosis. Angelov L In this
study two cases of Lyme borreliosis are presented. First, the author describes
how he contracted Lyme borreliosis 24 hours after he visited an endemic area.
The second case described is that of a woman who developed Lyme borreliosis
symptoms, when intestinal content of an infected tick came into contact with
her conjunctiva. In both cases the diagnosis is based on clinical picture and
positive serological tests. The first case shows the probability of contracting
Lyme borreliosis when the duration of the tick's attachment to the skin is less
than 24 hours. The second case, described demonstrates transmission of B.
burgdorferi by contact.  

In this paper author refers to cases with direct transmission are mentioned:
1. 1989 Prag conference - a lab worker dropped a tick on a firelamp, the tick
bursted and its intestinal content hit his eye, he developed conjunctivitis and
positive serology
2. Sweden. EM developed in a scratch wound, contaminated with manure, that
contained Bb.
and describes this
1994 a 41y Woman. Had removed numerous ticks from dog, some of the ticks were
crushed and bursted into her eye. Developed conjunctivitis, later arthralgia
ans subfebrilia, positive Lyme serology.

and the authors own story ... he discusses the possibility of contracting Lyme
< 24 hours exposition

________________________

According to Durland Fish-".....86% OF PERSONS WITH
LYME DISEASE ARE UNAWARE OF THE CAUSATIVE TICK BITE.  Clearly,  exposure to
ticks is a more important determinant of risk than are specific incidents
of tick bite."(source:The American Journal of Medicine based on the
symposium held Dec. 7-8, 1994.  The supplement was in the April 24, 1995
Volume 98 (suppl 4A) of The American Journal of Medicine)
_________________________________