Nurses must play detective to diagnose Lyme disease




Diagnosing tick-borne infections and the vast array of symptoms they cause often requires some detective work.

These investigative skills are among the best assets of healthcare professionals, many of whom will be faced with a new wave of infections this year.

“Ticks carry a lot of infections, not just Lyme disease,” said Ruth Kriz, MSN, APRN, a Washington, D.C.-based nurse practitioner who has studied the effects on tick-borne infections for 30 years.

According to a 2015 report from the Centers for Disease Control, 95% of confirmed Lyme disease cases were reported from only 14 states. The main geographic territory ranges from Maine to Virginia along the East Coast and the upper Midwest states of Wisconsin and Minnesota.

The migration patterns of many ticks is expanding, according to a long-term study published in 2015 by University of Indiana biology professor Keith Clay. That means clinicians outside those 14 states are likely to see an increase in patient concerns.

“Every year is a bad year,” CDC spokeswoman Kate Fowlie said.

What to listen for to detect Lyme disease

Taking a thorough patient history and using critical-thinking skills to consider infections other than Lyme disease are of the utmost importance for practitioners.

“Some negative [test results] could still be a maybe,” Kriz said. “The biggest red flag for me is when you have somebody who has multiple diagnoses. You need to start thinking in terms of, ‘Do they really have five things that went wrong in the past three years of their life that had a fairly rapid onset?’

Kriz has learned the skills healthcare professionals possess are invaluable when it comes to the often sneaky infections and the many symptoms that often mimic other health issues.

With Lyme disease, “not everyone gets the bull’s-eye rash” that is one marker of the disease, Kriz said. “Some estimates say less than half of people infected with Lyme actually get the bull’s-eye rash. If you don’t get it, it doesn’t prove that you don’t have Lyme.”

Patient history can help diagnose Lyme

The first time Kriz meets with a patient, she asks extensive questions during a 90-minute session.

She said the first interaction with a patient is the best time to explore the possibility of tick-borne disease diagnoses.

“If you’re taking a patient’s history and some complaints are coming out of the discussion, it might clue you in to ask further questions about pets, camping, hiking and travel to other regions of the country,” Kriz said.

Among the most common symptoms patients can experience are the following:
1. Headaches
2. Fever
3. Chills
4. Fatigue
5. Muscle/joint pain
6. Swollen lymph nodes
7. Stretch marks
8. Foot pain

Often, a patient will reveal, “I was fine before I went on this camping trip, and I’ve had one thing or another ever since,” Kriz said. “That’s the importance of taking a good history.”

Symptoms galore

The Bartonella infection, which includes Bartonella hesalae (cat scratch fever) and Bartonella quintana (Q fever), often leaves patients with what looks like stretch marks on the thighs, underarms, abdomen and back, according to Kriz. This also can cause foot pain, particularly in the morning.

Babesia is an organism that can lead to night sweats, joint pain, headaches and insomnia.

“A lot of these symptoms overlap,” she said. “Not everyone gets all these symptoms. I have many patients who present with fibromyalgia or chronic fatigue. They don’t present with joint pain at all.”

Two tiers of Lyme disease tests

The CDC has published a reference manual on tick-borne diseases for healthcare professionals.

Along with the 21-page manual, the CDC offers a two-tiered Lyme disease testing chart. For negative Lyme tests, the chart suggests consideration of an alternative tick-borne infection diagnosis.

Kriz has been working in the research and treatment of interstitial cystitis, a painful bladder condition, for 30 years and was an interstitial cystitis patient for 11 years. She has treated interstitial cystitis patients from 48 states and 24 countries.

According to the Interstitial Cystitis Network, a link between interstitial cystitis and Lyme is among the “rarer causes of bladder symptoms.”

Initial testing doesn’t always produce a guaranteed diagnosis with tick-borne diseases.

“Most practitioners haven’t had enough experience to do the proper testing and evaluate the test results to know what to do about them,” Kriz said. “You can’t depend on only one symptom to point you toward a specific organism.”


Courses Related to ‘Lyme Disease’

CE182-60: Lyme Disease: It’ll “Tick” You Off
 (1 contact hr)

Lyme disease is a systemic bacterial infection that can be transmitted through the bite of an infected tick and causes illness ranging in severity from mild and self-limiting to chronic and debilitating. It commonly attacks the skin and cartilage, but it may also target cardiovascular and neurological organs. Lyme disease is concentrated heavily in the Northeast and upper Midwest, but it has been reported in all states and the District of Columbia. Healthcare professionals may encounter patients infected with Lyme disease in almost any clinical setting, as well as in patients’ homes. Updated clinical knowledge about this disease will enable healthcare practitioners to confidently provide the best care possible to this patient population.

CE182-60: Treating and Preventing Communicable Diseases
 (7.9 contact hr)

One of the primary responsibilities of all nurses is the prevention of infection in the healthcare environment. This course provides the key concepts of the epidemiology and transmission of disease for nurses in all specialties and clinical settings. It discusses how infections are spread and how to protect yourself, your patients, and others from contracting communicable diseases. The course covers a variety of infectious disease topics and issues of current interest: tuberculosis, hepatitis C, multidrug-resistant organisms, foodborne illness, meningitis, scabies, lice, Lyme disease, sexually transmitted infections, viral hepatitis (including hepatitis C) and travel medicine. Each disease is discussed in detail, including the etiology, diagnosis, treatment options, and prevention strategies and nursing interventions.

CE182-60: Infectious Microbes and Disease
 (1.4 contact hr)

Each year, Streptococcus pneumoniae — a bacterium — is a significant cause of morbidity and mortality in the U.S. despite the availability of a vaccine. Until 2000, at least 40% of the 60,000 cases of invasive S. pneumoniae infection were resistant to at least one drug. The Center for Disease Control and Prevention’s 2012 Active Bacterial Core Surveillance Report estimated that 3,300 cases of invasive pneumococcal infections caused by S. pneumonia were fatal. Pathogenic bacteria share the instinct to survive with their unwilling hosts. When faced with an antimicrobial attack, they rapidly assemble defensive resources. Although bacteria carry only a single chromosome, evolution has provided them with mechanisms that allow them to survive even aggressive antimicrobial treatment. Surviving bacteria are often resistant; these survivors reproduce and, by natural selection, become the dominant organism in the host. This course provides information about infections, antibiotic resistance, colonization and breaking the chain of disease.


About the author
Robert G. Hess Jr., PhD, RN, FAAN

Robert G. Hess Jr., PhD, RN, FAAN 

Robert G. Hess Jr., PhD, RN, FAAN, is OnCourse Learning's executive vice president and chief clinical executive. He also is founder and CEO of the Forum for Shared Governance (www.SharedGovernance.org). As an editor for Nurse.com/Nursing Spectrum, Hess penned editorials on career topics. As a presenter at professional conferences, Hess often addresses participants on how to find the right job and steps for building a successful career. Join his Facebook followers at Robert G Hess Jr.

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