Call for your appointment today 914-666-4665 | Mt. Kisco, New York
In the January 2018 issue of the British Medical Journal, the authors describe the case of a 61-year-old man who complained to his primary care physician and multiple emergency room personnel that he was having severe shooting pain over his scalp, neck and back.
“The degree of discomfort from his hair moving was so extreme he elected to shave his head to provide some relief,” writes Ebner. The man also presented with non-radiating back pain and bilateral dorsal arm paresthesias.
He reported having “three distinct large circular red lesions, one with a central clearing,” writes Ebner. However, his serologic and spinal tap results were normal.
The man had been exposed to ticks, “working outside optimizing the landscape for white tailed deer,” states Ebner. He had also been exposed to at least 30 ticks in 1 day, but did not recall a tick bite.
The initial doctors did not prescribe the treatment regime of at least 3 weeks of antibiotics, as recommended by both the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS).
Instead, the man was prescribed a single dose of doxycycline 200 mg. And physicians attempted to manage his symptoms with pain medications. “He had been up-titrated on gabapentin with minimal response and started on a narcotic for pain control,” the authors explain.
For the next 6 weeks, the man continued suffering with severe pain, worsening paresthesias, and right-sided cranial nerve VII palsy.
His repeat spinal tap was abnormal for lymphocytosis, elevation of protein, 6 oligoclonal bands, and a positive ELISA and IgG and IgM immunoblot. Physicians then diagnosed him with early Lyme neuroborreliosis and prescribed a 28-day course of intravenous ceftriaxone.
“After completion of antibiotic therapy, the patient reported feeling significantly improved,” explains Ebner. He did, however, continue to have some weakness on the right side of his face, along with intermittent back pain that was managed with gabapentin.
The 61-year-old man might have avoided 6 weeks of pain and suffering, narcotics, a repeat spinal tap, intravenous antibiotics, weakness of his face in the lower motor neuron pattern and back pain if he had been treated with at least 3 weeks of antibiotics, instead of a single dose of doxycycline.
Related Articles:
Single dose of prophylactic treatment of a tick bite only prevents a Lyme rash
Case report: persistent pain and fatigue after treatment for Lyme disease
At least 50% of patients with Lyme neuroborreliosis remain ill years after treatment
References:
- Ebner D, Smith K, DeSimone D, Sohail MR. Cranial neuropathy and severe pain due to early disseminated Borrelia burgdorferi infection. BMJ Case Rep. 2018;2018.
Related Posts
Way to go Dr. C! If anyone wants to see the current treatment protocols for a tick bite you can go to http://www.TreatTheBite.com There you’ll find a one page hand out to take with you to your doctors office- one for adults and one for children. Also there is a link to Dr. Cameron’s Lyme Treatment Guidelines there.
Nothing at all said in the online pubmed article abstract about the failed one dose of doxycycline treatment at first, and that is what most people will be seeing. Why is Mayo publishing in a British journal? Can’t find an American journal that will publish any failure report of an inadequate treatment? Will this man continue to have symptoms for which no further treatment will be provided, or will they go back to pain meds?
The man was treated successfully at 6 weeks. The authors offered insight into the consequences of treating Lyme disease with a single dose of doxycycline. The blog suggests that timely treatment might have avoided “The 61-year-old man might have avoided 6 weeks of pain and suffering, narcotics, a repeat spinal tap, intravenous antibiotics, weakness of his face in the lower motor neuron pattern and back pain if he had been treated with at least 3 weeks of antibiotics, instead of a single dose of doxycycline.”
It is not clear why the BMJ published the paper.
But the single dose of doxycycline isn’t meant to “treat lyme disease”, it’s meant to prevent lyme disease. It’s a prophylaxis. If he was already presenting symptoms, then a single dose should never have been used, not even by the CDC’s guidelines.
I agree.
I agree with Dr C!! Please don’t undertreat, or wait to treat. If you are unsure, just interview a few people that have had to live with chronic Lyme disease. Many people have told me their stories of how they were finally personally diagnosed with Lyme, Ehrlichia, or Rocky Mountain spotted fever, etc. I’m a veterinarian in the Franklin/Nashville area of middle TN. We blood test family dogs annually for antigen for Anaplasma, Lyme, and Ehrlichia. We have had almost 100 positives in just over 2 years. We are alarmed at these results and tell moms and dads to watch out for their kids and dogs regarding tick bites.
On January 10, 2018 my husband was given doxycycline 100 mg twice a day for 10 days by his primary health provider. He had been deer hunting in North Eastern North Carolina and found a blacklegged deer tick on his right side under his armpit.
He also had a bullseye rash. I took a picture to show him. I removed the tick, but couldn’t remove the head. After doing a bit of research, he decided to see his doctor and get antibiotics. She told him she didn’t think it was lyme because it was the wrong time of the year but since it looked infected she prescribed the antibiotic. No lyme test was done. No follow up was done even when he went back because his blood pressure was elevated. On May 9th, four months later, he died suddenly of “unknown causes”. The death certificate states the cause of death acute myocardial infarction. An autopsy was not done. Months later I remembered the tick bite. After researching lyme disease, I believe my husband had lyme carditis. My husband may be alive today if his doctor had been more conscientious and better educated.
You may never know. Acute myocardial infarctions are common. Tick can bite during warms spells in the North. Ticks are also active in the South in the winter.
I am so so sorry.!!! This is ridiculous dr. Need to stop thinking everything is done by the book for everyone. They should run all test they can and give meds for a longer time
There is such a lack of information or belief by doctors that Lyme actually exists in Missouri, I could use your dosage duration advice or recommendation if you have time. The short: Starting at 7 weeks post bite, is 100 mg of Doxy for 10 days sufficient?
The long: I was bitten by a tick 7 weeks ago and had no initial rash, zero symptoms, etc. I went and got tested at 3 weeks post bite because my niece was also bitten a week later and had the rash and they prescribed antibiotics. My test came back negative at 4 weeks so I moved on. 5 weeks post bite I had minor chills, bad headache, stiff neck and lower back pain for 4 days but wrote it off as the flu as symptoms subsided, sans the headaches. I was outdoors again this past weekend and came back with bug bites (no ticks that I saw) and started to see two (2) circular rashes around my mosquito bites in an area that was not my initial tick bite location. In addition, headaches were getting worse and was feeling minor joint pain and dizziness. I went to urgent care and was prescribed 100 mg of Doxy for 10 days at 7 weeks post bite. I am now 3 days in and am even more dizzy and the joints feel swollen (assuming this is herxing). Do you believe the 100 mg for 10 days is sufficient time for a 7 week lingering Lyme infection to be eradicated? Thank you very much in advance!
I often do not find 10 days of antibiotics enough.
No
I was prescribed 2 doses of 100 mg a day for 21 days, would it be ok to take both doses at once, as in 200mg instead doing 100 mg twice a day.
NO
I have had chronic Lyme disease for14 years because my doctor failed to diagnose it. 5 years later I found out another way. I was given 6 weeks of doxycycline.Now 9 years later I was feeling fatigued and more forgetful and achy. A new doctor for me prescribed 2 weeks of Doxycycline. Is that enough?
I typically treat my patients longer. I have them return for follow-up to determine if I should extend treatment or change treatment. Call my office in Mt. Kisco at 914 666 4665 if you need help.
Hi Dr C, I am glad to find your page. I would be interested to know your opinion on how many weeks of doxycycline you think that I should receive. I got bitten back in the middle of August, but I am only getting treated now for Lyme disease. Do you think 3 weeks treatment of 100mg twice per day is enough?
I have Lyme disease patients in my practice that are well. Some are not so well. I prefer 4 weeks to start with a visit at 4 weeks to reassess response to treatment. I find 4 to 6 week to start most helpful for my patients as long as I have followup.
Hi Dr. Cameron, I just found your page and this article searching for the single dose doxycycline issue. We go hiking often, usually on trails. My husband found a tick on him last week, on Nov 12. He removed it as the tick wasn’t completely attached, the head was still on it. He was able to get a phone appointment with his primary care physician for Nov 16. Doctor said, since it was a recent bite, the SINGLE DOSE doxycycline (2 tablets, 100mg each taken together) should be enough. He took the tablets the same night with dinner. Would that be enough to prevent Lyme? What he should be aware of in the coming days? Weeks? Should he ask for an actual treatment of several weeks? (We’re in Ontario, Canada, the medical system is always pretty rationed here).
Thank you in advance!!!
I am not in favor of a single 200 mg dose of doxycycline.Others disagree. The study supporting a single dose of doxycycline was tiny ( 8 rashes in the treatment group versus 1 rash in the placebo group). The study did not look at whether a single dose were effective for other Lyme disease manifestations.
I have removed multiple deer ticks from myself and my dogs this season. I came down with a fever, chills, severe joint aching and I couldn’t move my right arm. I touched my back beneath my shoulder and it was hot and sensitive. When looking in the mirror I saw the lymes rash 4×4 inches wide. I went straight to the doc and was prescribed 3 weeks doxycycline 100 mgs 2x a day. I haven’t received my blood test results yet. Doc said if blood comes back negative for lymes to stop medication? I feel like I may be in early stage where the infection may not be detected so I’ve decided to continue with antibiotics whether positive or not. Make sense????
Makes sense to me. I often find the test to be negative early in the disease. Moreover, the antibiotics may be helpful for Lyme disease but can interfere with the test. I also encourage a followup treatment before the treatment is finished to determine if i have a good outcome.
Thank you Dr. C. I am a physician who has worked in Virginia, Mississippi, California, Indiana and Arkansas. When I first worked in Virginia around 10 years ago now, I ordered a Lyme test on a patient in the ER and the medical director laughed at me saying they didn’t have much of it there and he never ordered it. I said well, I was from Arkansas and we had it there, and the symptoms seemed consistent. Well, the test came back positive and he came and talked to me. He became proactive about changing the practice in the State and now not only do they recognize it exists, but require ER doctors to inform people about it and give them information about the lack of sensitivity of the testing. I always prescribe 3 weeks for presumed lyme with 1/2 that time with amoxicillin and 1/2 w/doxy if children. In Mississippi, I saw multiple patients with it, but again, huge denial among the Internal medicine, and even family practice population. Here in Arkansas, it depends where you work, but it can be difficult to get treatment, understanding, information and testing anywhere in the US (may be why it was published in the BMJ). I believe the hunting industry, which is huge, somehow has a role in this. Nonetheless, I have a telebusiness, now, and am happy to help if anyone is in those states, and needs care. Text or call 479 926 8000 for more information. Thank you Dr. C. I follow you closely, appreciate that you investigate and write with the patient as the first priority. Your effort and knowledge is greatly appreciated.
Dr. Cameron, thanks for being so vigilant in treating this often misunderstood illness. I just returned from western NC yesterday and discovered a female black legged tick feasting on my calve just under my sock. It was likely not attached for more than 36 hours but wasn’t sure to be honest. Despite knowing what to do, I panicked and pulled it off. I did get the head but not sure about the mouth (pinchers). I have sent off the tick to be tested but my doctor (friend) prescribed the single dose of 200mg doxycycline as a prophylaxis (assuming the tick was positive). Would you advise taking it now (about 24 hours post removal) or waiting for the pathology on the tick to start a more aggressive treatment. First tick bite and I’m a bit of a medical worrier. Thanks for all that you do!
A single dose of doxycycline is effective at preventing a tick bite but not other manifestations. I typically watch or treat for 3 to 4 weeks with follow-up
Thank you! Would it be better for me to wait for the pathology on the tick to start treatment or take the 200mg doxycycline now and wait to hear back to decide what to do next?
I advise my patients to take the doxycycline at the time of the bite they are comfortable with a single bite.
I’m a bit confused and pretty concerned. Should I take 200mg of doxycycline Hyclate up to 72hrs after bite (that would be late tonight) under these conditions? —I had what looks exactly like a nymph or larve black legged tick (deer) (poppy seed size) bite that I removed fairly easily from my back. It did not look look engorged and got the whole thing out intact. Bite site is itchy and small pink raised bump. I had been mowing and believe was only on there for 8 or so hours or less. I sent it off for testing today. I am confused bc further testing may not be accurate if I take it, yet really want to prevent anything if possible. I am in Norwalk, CT. Thank you so much!!!
I find prompt removal helpful. I discuss the uncertainty with my patients when making a decision. I am not comfortable with a single 200 mg of doxycycline. You can read my concerns in my Inside Lyme Science blog https://danielcameronmd.com/importance-second-opinion-prophylactic-treatment-tick-bite/
Hi Dr. C!
I was bit by a tick, never saw the actual tick but shortly thereafter developed the bulls eye rash. I also had high fever (105) and chills and thought it was COVID. At the ER, the infectious disease doctor told me that I had classic Lyme, as I had the rash and it was estimated that I was bit about a week ago. IgM test confirmed it.
I was immediately started on 100mg of Doxy twice a day for 4 weeks. I was asymptotic on day 3 of Doxy.
Do you have confidence in the 30 day 100mg x 2 times a day regimen?
I ask because I have a work colleague who is challenging me to step up to the 8 week of Doxy 200mg x twice a day regimen, which is what he was prescribed for his bite a few years back.
Thank you
George
I have Lyme disease patients who have remained well after 4 weeks of doxycycline. I advise my patients to return at 4 weeks before completing treatment to evaluate how they are responding to treatment and to evaluate for other tick borne co-infections. Researchers have not typically evaluated than 4 weeks of treatment. I have treated longer than a month on a case by case basis with success.
Hello Dr. I have recently travelled back from Romania and was bitten by a tick the third day there. I went to go get tested two weeks after bitten and my tests came back negative, however I was determined to go back to testing as I started developing a rash around that area. One month after bitten I had positive result come back and went to go get treatment. The area I was in was very unaware of the risks that some ticks may carry. This made it difficult to get a doctor to prescribe me some doxycline but I was able to finally get some after a month and a half and began taking 100 mg / day. I had a total of 20 pills given however after all my research I saw the suggested 200 mg / day instead. I am on day 9 – should I begin taking 2/day now and is there anything else I should be aware of? Planning on getting a check up this week but I would greatly appreciate your opinion. Thanks
I typically prescribe 100 mg of doxycycline twice a day for a month for my patients with followup to determine response to treatment. I have had to change therapy or treat for a co-infection in some patients. Finally, I also assess them for other illnesses unrelated to a tick.
Dr. Cameron! I was diagnosed with lyme 2 years ago and was treated with 2 separate times with doxy. It took awhile but I eventually got better.. Fast forward to now. I live in a rural community where ticks are everywhere. I haven’t seen a tick on me, atleast not attached. I did have one crawling on my shirt. But I have had a few strange bites I noticed on my neck and leg.I started feeling ill a few weeks ago and was sure lyme got me again. I was tested for lyme and I just received my results on the portal. Which were negative. I had one postive band IGG 41 ( I believe that is a old infection), And One postive band IGM 23. Doesn’t that signal a new infection? My doctor hasn’t called me yet about the result but I highly doubt she will treat me due to the negative results. I do have a older prescription of doxy ( not expired), from January that I was given for another condition, but I never needed to take them, once my bloodwork came back negative. I really feel I should, just to be safe.
The proposed single 200 mg dose of doxycycline only works if prescribed within72 hours of a known tick bite. I am not convinced a single dose prevents manifestations of Lyme disease other than a rash. A single dose of doxycycline has not been shown to be effective if you are already ill. I don’t find that single band helpful. I do encourage my patients to have an evaluation by a doctor experienced in treating Lyme disease if their doctor cannot find an answer.
Dr. Dont want to believe anything that they cant see. If he said he was around ticks and now he has lymes symptoms. Why not give him full course of antibiotics. Dr. Let people suffer because they are afraid of bacteria become immune to antibiotics. But people should suffer. A-specially because someone thinks they know it all. I have been dealing with lymes for over 1 1/2yrs now all because dr. Refuse to look at my symptoms and rely on test to much. Before all these fancy test dr. Relied on what they new or seen. All my test were negative For a hole year. I suffered and still am. Because I wouldn’t be listened to. Now all my test are positive for lymes. And no antibiotics work because they waited to long. So i live everyday miserable with brain fog and major headaches DAILY, EVERY DAY. So if u think u may be sick dont stop until u feel ok with the assessment. Its your body and life. Not the dr. They go home happy with pocket full of money.