Emerging Lyme disease: A wake-up call for Nepal

Lyme disease is caused by a bacterium known as Borrellia burgdorferi and is transmitted by the bite of Ixodid tick. In its early stage, the disease usually starts with cold like symptoms

Many people, who particularly living in or visiting to sub urban/rural areas, frequently experience with tick bites problems in Nepal. Majority of these people usually do not develop or ignore early symptoms. Only those who develop late stage or complications seek treatment with various specialists such as cardiologists, rheumatologists or neurologists. Recently, a 32-year old patient visited our hospital with complaint of severe fatigue, pain, numbness and tingling sensation in arm with laboratory confirmed Lyme disease.

This is the first ever laboratory-confirmed case of Lyme disease in Nepal. Following this case, at least four other tick bite cases have visited our hospital over the last few months. This is a wake-up call for health care providers and policy makers in Nepal.

Lyme disease is caused by a bacterium known as Borrellia burgdorferi and is transmitted by the bite of Ixodid tick. In its early stage, the disease usually starts with cold like symptoms. If it goes untreated or unnoticed, it can spread to other parts of the body such as heart, muscle, bone, and nervous system, which refers to late stage of Lyme disease. Studies have shown that clinical presentations, however, are varied based on geographical locations, and perhaps based on species of the bacterium itself.

For instance, neurological problems in Lyme disease are common in Europe, while rheumatologic problems are more commonly seen in the North America. A limited number of cases of Lyme disease have been reported from India, where the majority of cases show rheumatologic problems in the Indian population. However, this published literature did not explain about neurological problems even after adequate treatment in Lyme patients, as seen in our Nepali patient, though more study is needed to identify differences in clinical nature between Indian and Nepali Lyme patients.

Erythema migrans, a “bull’s eye shaped” rash (a red ring with a clear center)”, is the hallmark of Lyme disease that is generally seen in early stage of Lyme disease. It begins 3 to 30 days (on average it appears about 7 days later) at the site of the tick bite. The rash gradually expands over the time and can appear in any parts of the body, but is rarely itchy and painful. It occurs in up to 80% of the infected patients.

However, approximately only 25% of the cases of Lyme disease showed this typical rash in the Indian patients. In our case, the patient developed rash at the site of the bite but did not remember its nature well. In fact, the vast majority of Lyme patients do not remember the initial rash or time of the tick bite due to various reasons. If the rash is identified at this early stage and initiated the treatment, complications can be prevented or avoided.

Lyme disease is one of the most reported vector-borne diseases worldwide. Centers for Disease Control and Prevention (CDC, USA) estimated that approximately 300,000 cases of Lyme disease occur each year, and many more might have been underreported in the US. In Europe, Lyme disease is commonly reported from Central and Northern region of Europe. So far, a very few number of Lyme disease cases are reported in the scientific literature in India.

Nevertheless, ticks that carry Lyme bacteria are widespread, particularly in Himalayan region of India, meaning Lyme disease might have been vastly underreported in India. In Nepal, although, dermatologists occasionally encounter patients with a “Bull’s eye-shaped” rash during their practices, they are unable to make a definitive diagnosis or reported to the scientific literature, even if they suspected Lyme disease due to lack of laboratory confirmation.

A current criterion for laboratory diagnosis of Lyme disease is not feasible, expensive and is not readily available in Nepal. This could be one of the main reasons for vast differences in the number of Lyme disease reported among developed and least developed countries.

Few people may have persistent symptoms such as fatigue, muscle or joint pain even after the treatment. It is known as Post-Treatment Lyme disease Syndrome (PTLDS). At this point, people tend to seek treatment from different specialty hospitals other than infectious disease hospital to overcome with PTLDS.

Our patients continued to have fatigue, muscle pain and neurological problem despite appropriate antibiotic therapy. Such symptoms will gradually decrease over the time. PLTDS has not yet been scientifically reported or documented in Asia before, thus our case is the first ever-reported PTLDS in-patient in Asia. In Nepal, most of the people who are being bitten by ticks either ignore the bite or go unnoticed because of non-itchy and painless bite and lack of adequate knowledge about its serious health consequences. Mass media reports or social networking can provide important information about the disease.

It is apparent that Lyme disease is emerging, and probably widespread but extremely overlooked tick-borne disease, particularly in rural areas of Nepal. Nearly half a dozen, who visited to our hospital after being bitten by ticks, had a history of travel to rural areas. If you are living in or recently visited to rural areas, and have a red ring like or “Bull’s-eye shaped” rash, then Let’s think, “Could it be a Lyme disease?”.

Pun is coordinator of the clinical research unit, Sukraraj Tropical & Infectious Disease Hospital