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Current Trends Update: Lyme Disease and Cases Occurring during
Pregnancy -- United States
Lyme disease is a tickborne illness caused by a spirochete,
Borrelia burgdorferi. The number of cases reported to CDC has
increased over the past 2 years so that Lyme disease is now the
most
commonly reported tickborne illness in the United States. Although
it
is reportable in only a few states, informal national surveillance
was
initiated by CDC in 1980 and has been compiled annually since 1982.
In 1980, 1982, and 1983, 226, 491, and 599 cases, respectively,
were
reported in the United States. In 1984, a provisional total of
1,498
cases was reported (Table 2). For Lyme disease patients for whom
1983
and 1984 surveillance data are available, ages ranged from 1 year
to
81 years (median 34 years). Fifty-four percent of cases occurred
among
males. Eighty percent of cases occurred during the 4-month period
May-August, with the peak incidence in July.
Since 1980, reported cases of Lyme disease have occurred in an
increasing number of states. Lyme disease was acquired in 11
states
in 1980 and 1982, 18 states in 1983, and 21 states in 1984.
Increasing numbers of cases have occurred in three states outside
previously recognized endemic areas: Arkansas, North Carolina, and
Texas. Isolated, serologically confirmed cases have been acquired
in
Florida, Georgia, Indiana, Michigan, New Hampshire, Virginia, and
Tennessee. However, in all reporting years, over 90% of all cases
were acquired in only seven states: Connecticut, Massachusetts,
Minnesota, New Jersey, New York, Rhode Island, and Wisconsin. In
addition to the states listed in Table 1, isolated, clinically
suspected but unconfirmed cases of Lyme disease have been reported
from Kentucky, Maine, Missouri, Montana, Ohio, and Vermont.
The possible association between Lyme disease during pregnancy
and
adverse outcome has recently received attention. Transplacental
transmission of B. burgdorferi has been documented in a pregnant
woman
with Lyme disease who did not receive antimicrobial therapy. She
delivered an infant with a congenital heart defect (1). The
relationship between the intrauterine infection and congenital
heart
defect has not been established. In an effort to assess the risk
of
Lyme disease during pregnancy, the state and territorial
epidemiologists and CDC have established a registry to enroll cases
of
Lyme disease in pregnant women before the outcome of pregnancy is
known. Of the 19 pregnancies evaluated to date, none resulted in a
child with a congenital heart defect. However, other adverse
outcomes
were found, including intrauterine fetal demise in the second
trimester, prematurity, and developmental delay with cortical
blindness. None of the adverse outcomes have been documented to be
caused by Lyme disease. Outcomes of 14 of the pregnancies were
completely normal. The risk of adverse outcome for pregnancies
complicated by Lyme disease is not currently known.
Reported by State and Territorial Epidemiologists; Respiratory and
Special Pathogens Epidemiology Br, Div of Bacterial Diseases,
Center
for Infectious Diseases, CDC. Editorial Note
Editorial Note: Lyme disease, first described in 1977 (2), is
characterized by a distinctive skin lesion, erythema chronicum
migrans
(ECM), which starts as a red macule at the site of a tick bite and
expands to become an annular erythema with central clearing. Some
patients develop systemic manifestations, including neurologic,
cardiac, and arthritic abnormalities weeks to months after the skin
lesion. B. burgdorferi has been isolated from cerebrospinal fluid
(3)
and visualized in synovia of patients with Lyme disease (4),
suggesting the spirochetes can persist in various sites in the body
and may be responsible for the systemic manifestations.
Because antimicrobial therapy decreases the morbidity from Lyme
disease, it is important that cases be recognized and patients
treated. In endemic areas, Lyme disease can be diagnosed if the
typical ECM skin lesion is present. Serologic tests have been
developed to measure antibody against B. burgdorferi (5,6). These
tests, when positive, can help support the clinical suspicion of
Lyme
disease in atypical cases, such as those without ECM or those
occurring outside recognized endemic areas. However, serologic
tests
are often negative, particularly early in Lyme disease. Therefore,
a
negative result does not exclude the diagnosis early in the course
of
the illness (7). Antimicrobial therapy with oral tetracycline is
recommended for patients with early manifestations of Lyme disease;
penicillin and erythromycin are also effective (8). Children and
pregnant women should be treated with penicillin. Some of the
neurologic abnormalities, as well as established arthritis, have
been
found to respond to high dose intravenous penicillin (9,10).
Previously, Lyme disease was recognized in three endemic areas:
the coastal areas of the northeast (Connecticut, Delaware,
Maryland,
Massachusetts, New York, New Jersey, Pennsylvania, Rhode Island),
the
midwest (Minnesota, Wisconsin), and the west (California, Nevada,
Oregon, Utah). Although these areas are within the range of the
known
tick vectors, I. dammini and I. pacificus, some areas where Lyme
disease has occurred are not. However, B. burgdorferi has been
found
in Amblyomma americanum (11) and Dermacentor variabilis; these and
other ticks may be vectors in some areas.
It is not known to what extent the increase in numbers and
widening geographic distribution of cases reflect increased
recognition or reporting rather than increased incidence of the
disease or spread of the vectors and/or spirochete. Increased
reporting is probably responsible for part of the greater than 500%
increase in reported cases in Connecticut in 1984, because an
active
surveillance system was initiated in the state that year.
Underreporting is suspected in some states, such as Massachusetts,
where officials think far greater numbers of cases are occurring
than
are reported. CDC encourages reporting of cases of Lyme disease to
state and local health departments so the geographic distribution
and
temporal trends can be better defined.
Since transplacental transmission of B. burgdorferi has been
documented, it will be important to determine whether maternal
infection with B. burgdorferi is associated with an increased risk
of
adverse pregnancy outcome. Cases of Lyme disease during pregnancy
should be reported to state health departments and CDC (telephone
(404) 329-3687) before delivery so the types and approximate
frequency
of any adverse outcome can be determined and appropriate diagnostic
tests obtained.
References
Schlesinger PA, Duray PH, Burke BA, et al. Maternal-fetal
transmission of the Lyme disease spirochete, Borrelia
burgdorferi. Ann Intern Med 1985 (in press).
Steere AC, Malawista SE, Syndman DR, et al. Lyme arthritis: an
epidemic of oligoarticular arthritis in children and adults in
three Connecticut communities. Arthritis Rheum 1977;20:7-17.
Steere AC, Grodzicki RL, Kornblatt AN, et al. The spirochetal
etiology of Lyme disease. N Engl J Med 1983;308:733-40.
Johnston YE, Duray PH, Steere AC. Lyme arthritis: spirochetes
found in synovial microangiopathic lesions. Am J Pathol
1985;118:26-34.
Craft JE, Grodzicki RL, Steere AC. Antibody response in Lyme
disease: evaluation of diagnostic tests. J Infect Dis
1984;149:789-95.
Russell H, Sampson JS, Schmid GP, Wilkinson HW, Plikaytis B.
Enzyme-linked immunosorbent assay and indirect
immunofluorescence
assay for Lyme disease. J Infect Dis 1984;149:465-70.
Shrestha M, Grodzicki RL, Steere AC. Diagnosing early Lyme
disease. Am J Med 1985;78:235-40.
Steere AC, Hutchinson GJ, Rahn DW, et al. Treatment of the
early
manifestations of Lyme disease. Ann Intern Med 1983;99:22-6.
Steere AC, Green J, Schoen RT, et al. Successful parenteral
penicillin therapy of established Lyme arthritis. New Engl J
Med
1985;312:869-74.
Steere AC, Pachner AR, Malawista SE. Neurologic abnormalities
of
Lyme disease: successful treatment with high-dose intravenous
penicillin. Ann Intern Med 1983;99:767-72.
Schulze TL, Bowen GS, Bosler EM, et al. Amblyomma americanum;
a
potential vector of Lyme disease in New Jersey. Science
1984;224:601-3.
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