Tick-borne Disease in Children

Tolle Totum
Julia Greenspan, ND

Tick-borne disease is on the rise with children being most at risk for contracting multiple infections with just one tick bite. This article will focus on the common presentations of Lyme disease and associated co-infections through the different stages of childhood as well as the unique challenges of diagnosis and treatment. A clinical case presentation will illustrate an experience of chronic Lyme disease and manifestations of co-infections in a 12-year-old female that was not identified by 24 different physicians prior to presenting to this clinic. Naturopathic physicians are very well suited for the difficulties of tick-borne disease, with the ability to look at the whole patient and see the connection between seemingly unrelated symptoms.

Children are the most at-risk group for contracting Lyme disease and associated co-infections. They make easy targets, as they play outside, low to the ground, are in closer contact with family pets, and spend more time in the woods, which is just about everyone’s back yard here in New Hampshire.1 The good news is that if diagnosed and treated properly, kids tend to resolve the infection more completely and in a shorter amount of time compared to adults.2,3

The meaning of the word “properly” with regard to treating tick-borne disease is the cause of heated debate between physicians from both the allopathic and natural medicine specialties, the latter of whom might have distaste for the aggressive use of antibiotics. It becomes further complicated by the rate of emerging co-infections that are difficult to identify when diagnosis is purely based on positive lab results, which are hard to come by. The case presented in this article describes the story of Leah, a 12-year-old female who had seen 24 physicians prior to presenting to the clinic. I will not report much in the way of natural medicine applications, beyond simple recommendations. Probiotics are an absolute requirement when treating with antibiotics. Maintaining digestive stability and avoiding secondary infections are strongly correlated to the numbers of colony-forming units within the probiotic product used. The ideal dose is 100-400 billion live cells daily, away from the antibiotic dose. When patients have selected products off the shelf with lower counts, they typically require more medications to control Candida overgrowth or C. difficile infections. In general, the use of other natural supportive treatment is not always easy if the child is sensitive to tastes and textures, has not mastered the ability to swallow pills, or has parents who are unable to juggle the rigors of multiple treatment recommendations, a sometimes-non-cooperative child, and a difficult recovery. Teenagers may struggle with compliance due to adolescent rebellion or denial.

The best outcomes I have witnessed have been when antibiotics are used in conjunction with natural modalities including high-dose probiotics, immune-enhancing herbs, homeopathy, dietary changes, detoxification support, natural anti-inflammatories and other forms of energy medicine. Tick-borne infections are stealthy. Lyme disease (Borrelia burgdorferi infection) can change into different forms in the body, hide deep in tissue, and cause damage that can change the trajectory of a person’s life. It’s more important than ever to consider aggressive treatment when treating children. The goal of this article is to provide some insights and report observations based on one practitioner’s experience in a naturopathic practice where almost 100% of the patient population has some form of tick-borne illness.

A Case Report

Leah, a pleasant 12-year-old female presents to my clinic with her mother. They specifically want to be tested for tick-borne disease, based on a history of multiple tick bites since early childhood. Leah has never developed a characteristic erythema migrans rash. Her constellation of signs and symptoms are as follows: daily headaches, shortness of breath, debilitating fatigue, dizziness, tinnitus, neuropathies in her feet and pain in the bottom of them, widespread migrating joint pain without swelling, a feeling of bugs crawling on her skin, nausea with abdominal pain, repeated sore throats, brain fog, diarrhea, multiple fevers spiking as high as 105° F since the age of 2, night sweats, underweight but with a ferocious appetite, perioral cyanosis, and skin color changes to orange/blue, with a chicken-wire appearance that randomly appears in multiple sites. All symptoms cycle erratically with no pattern except for flu-like symptoms, which occur every 4 to 6 weeks. She is free of any other cardiovascular, neurologic, or gastrointestinal complication, based on evaluation of other specialists. Three other members of her family are being treated for chronic Lyme disease. Her mother had eliminated gluten and incorporated a whole foods diet prior to the first visit. Leah has a history of speech delays and learning disabilities in the area of reading comprehension. She is home-schooled and has been since the second grade because of health issues. All other physicians consulted prior to this visit have refused to treat her for tick-borne disease because of negative serology, using ELISA, for Lyme disease.

At the time of the initial visit, Leah was 64 inches tall and weighed 97 pounds; her BMI was 16.6, and her BP was 100/80 mm Hg. No temperature was recorded for that day due to battery failure with the thermometer. She appeared underweight, pale, with normal findings for neurological, cardiovascular, integument, and respiratory exams. There was no appearance of skin abnormalities; however, her mother presented photos of past events. Labs taken the day of her visit included a complete co-infection panel for Bartonella henselae, Babesia microti, Anaplasma phagocytophilum, and Ehrlichia chaffeensis. A western blot IgM/IgG for Lyme disease, and a CD-57 were also run. Lab results revealed a total WBC count of 3.9 (normal = 3.5-10.5), lymphocytes within normal limits, and a CD-57 NK count of 61. The reference range for CD-57 is 60-360, with the optimal range being 180-360. When the CD-57 value falls short of this goal before ending treatment, there is a strong possibility of recurrence, especially if the value is <100. For children under the age of 5 years old, the CD-57 test appears to be less reliable; thus, the criteria of being symptom-free for 8 weeks should be used as a primary determinant for concluding treatment. Leah’s western blot was positive, with IgM bands: 18, 23-25, 31, 41, 83-93. The Centers for Disease Control (CDC) only recognizes bands 23, 39, and 41. Some labs include bands that are not observed by the conventional testing run with the CDC approach. This information can be very helpful in determining patient exposure. Leah’s co-infection panel was negative. Treatment was started after all lab results were in. Leah was first started on minocycline: 50 mg, 1 tab BID po; azithromycin: 250 mg, 1 tab QD po; probiotics: at least 200 billion live cells daily and away from antibiotics; purified fish oil: 2000 mg of EPA/DHA daily; liver support: 2-3 caps daily of an herbal blend (Taraxacum officinale, dandelion; Silybum marianum, milk thistle; Camellia sinensis, green tea; Beta vulgaris, beet root; Raphanus sativus, black radish; and choline); and to continue with a gluten-free, whole foods diet.

Two-Month Follow-Up

During the first 2 weeks of treatment, Leah experienced an increase in fatigue and muscle pain. She had discomfort in her pelvis, unassociated with urination, and slight drooping of her eyelids, altering the shape of her face. She then lost the lateral aspect of both eyebrows, and lost hair on her head, which started growing back before the next follow-up. The episodic skin changes were more frequent and visualized in the office; the skin on her lower limbs had the appearance of chicken wire. She was still having sleep difficulty, pain, dizziness, neuropathies in her feet, debilitating fatigue, and night sweats. Headache was slightly reduced. Antibiotic therapy was continued, with some adjustments based upon symptoms associated with the clinical diagnoses of bartonellosis and babesiosis. Due to concern around overtreating with too many antibiotic medications at one time, she was started on sulfamethoxazole-trimethoprim: 400 mg-80 mg, 1 tab BID po; azithromycin: 500 mg, 1 tab QD po; and she discontinued minocycline. She was advised to continue with current supplements and dietary changes.

Three-Month Follow-Up

Leah reports improved cognition and reduction in overall pain. Hair has fully returned to her eyebrows. Her digestion is regular, she has healthy weight gain, and headaches have resolved. She was still having back pain, night sweats, shortness of breath and vertigo. Vitals: BP 98/60 mm Hg; temp 98.4° F; pulse 76 bpm; weight 100.6 pounds. All other physical exam parameters were within normal limits. Based on the persistence of babesiosis-like symptoms, changes were made to antibiotic therapy as follows: sulfamethoxazole-trimethoprim: 800 mg-160 mg, 1 tab BID po; azithromycin: 500 mg, 1 tab QD po; atovaquone: 750 mg/5 mL, BID po.

Leah continues to be monitored. Her prognosis is good, with an expected recovery time of 6 months to a year while continuing with some form of therapy.

Discuss Treatment With Parents and Children

Patients and their parents should be informed about what to expect with treatment, including the Jarisch-Herxheimer reaction commonly experienced with the treatment of spirochetes, most noted with syphilis.4 In Lyme disease, a “Herx reaction” is typically an amplification of symptoms experienced since the onset of the disease, and seen more with chronic Lyme disease than with acute infections with a new bite. This conversation is important to have directly with the child in order to reduce fears and help parents prepare for their own discomfort of watching their child be uncomfortable. Symptoms will vary in intensity, but it is better if they are prepared for the difficulties. Not being prepared could cause serious panic. The child should always be the focus of the discussion, with a direct conversation in a way that they can understand, based on maturity.

Common Presentations in Children Under Age 10

If a child has a chronic tick-borne disease, it can be difficult to get an accurate depiction of the symptoms, especially if they are used to having physical discomfort or if they are not old enough to have the words to explain how they feel. In the office, words like “whooshes” in the ear, “sprinkles” in the legs, “boo-boos” or “dogs barking” in their feet become important descriptors for those 5 years of age and under. The closer the patient is to pre-adolescence, the more complete the history becomes.

Bell’s palsy,5 erythema migrans,6 and arthralgias are cited in the literature as the most frequent presentation of pediatric Lyme disease. Bell’s palsy has been seen in this clinic maybe 5 times out of the hundreds of children treated. Most patients never remember being bitten by a tick, and most parents do not remember seeing one on their child. Parents report presenting to the pediatrician’s office with concerning symptoms following a tick bite, but without the cardinal symptoms, and being refused treatment. If treated, they are typically given a short course of antibiotics; sometimes only one tablet is prescribed.7,8 If the same symptoms return a few weeks later, families are told it could not be related to the tick bite because the child was already treated and/or lab work did not provide any evidence of infection. However, the clinical history and presentation clearly demonstrates a different story.

Symptoms most often reported by parents and patients during the first office visit are fatigue, lower extremity joint pain, abdominal pain, and headaches. These symptoms will come and go, which is confusing for parents trying to not react to every complaint, for fear of being seen as paranoid. Young children may become clingy, anxious, exhibit extreme emotional reactions out of proportion to the situation, have a return of nighttime enuresis, become more antisocial, or fall behind on meeting their milestones, as reading and writing becomes more expected of them. They will frequently put themselves to bed with exhaustion, only to wake throughout the night, unable to fall back to sleep. Most parents who tell their pediatricians about their concerns are asked if there is stress in the home, are referred out for evaluation for attention deficit disorder or the dreaded catch-all— “growing pains.” Children under the age of 10 have presented with past diagnoses of fibromyalgia. There is no reason that a child of this age should be experiencing this level of pain and fatigue without a more specific diagnosis than this.

Tick-borne Disease in Adolescents

There is never a good time to be sick, but there are unique challenges in being chronically ill as a teenager. Teenagers are more resistant to taking the prescribed medications or following treatment guidelines. They usually feel isolated, embarrassed and unable to share their emotions with peers, due to lack of empathy. They may turn to the use of illicit drugs to palliate symptoms, reject school, have frequent absences, and suffer from a deeper sense of anger/depression if they have missed out on important social events. Prior to an accurate diagnosis, they may have been labeled as lazy or having ADHD, which can lead to an internalization of this belief system even when they now know their symptoms are due to an infection.

Diagnosis of Lyme Disease and Co-infections

In many cases, more than one infection is contracted from the Ixodes scapularis (deer tick), due to the ticks’ feeding behavior at different stages of their maturity. They feed from mice, deer, cats, birds, horses, dogs, and many other animals living low to the ground. Ticks are typically referred to as nature’s dirty needle. They eventually dump multiple bacteria and viruses all at once directly into the blood supply of the victim. Tick-borne disease includes multiple strains of Borrelia, Bartonella, Babesia, Ehrlichia/Anaplasma, and Mycoplasma.

Depending on the age of the child, it can be very difficult to get the full history. Most patients will not think that most of their symptoms are related, especially if they have been sick most of their lives. Each of these infections has its own nuances, in terms of clinical presentation, physical findings, and serology. Antibody  testing is often unreliable, with a lot of false negatives. When the clinical presentations of the different tick-borne diseases are recognized and treated, there can be significant reduction of symptoms.

A Change in the Paradigm

In a recent article in Current Opinion in Pediatrics, June, 2013, emerging tick-borne infections were reviewed and a statement issued that those who are practicing in tick-infested areas should treat when there is suspicion of infection based on clinical presentation.9 As simple as it sounds, it is a breakthrough for patients who have faced the absolute certainty of a doctor who is refusing to treat because they have negative serology in their hands. When reaching out to a patient’s pediatrician or insurance company, it will help to be armed with literature to support the position to treat. It is also worth noting that while all other tick-borne infections are addressed in this article, it is very rare to have a co-infection present without antibodies reflecting exposure to Lyme Borrelia as well. There still is a great deal of avoidance around the topic of chronic Lyme disease.

Several parents tell the same stories as Leahﾕs family: multiple visits to specialists and therapists to figure out whatﾕs wrong with their child. Diagnoses are made, such as fibromyalgia, chronic fatigue, anxiety, allergies, and other behavioral problems. Medications are prescribed to palliate pain, control behavior or mood. Parents who insist on talking about the possibility of chronic tick-borne disease feel judged, and some are accused of Munchausen by proxy. Naturopathic physicians can significantly help this population with our open minds, willingness to use multiple modalities, the ability to see the connections between multiple symptoms by listening to the whole story and, most important, the deeply instilled tenet of treating the cause.  

Table. Symptom summary of common clinical presentations of tick-borne infections

Lyme Disease (Borrelia infection)	Bartonella infection	Babesia infection
Migrating joint pain Joint swelling Abdominal pain Fatigue Symptoms reoccurring every 4-6 weeks Relapsing flu-like symptoms Enuresis after being dry in young children Nightmares Tinnitus Sore throats Frequent upper respiratory infections	Obsessive-compulsive behaviors Anger turning inward Self-mutilation Suicidal ideation Parethesias Pain in the soles of feet in AM Striae rash on trunk and extremities Tics or tremors Onset of new seizure disorder Floaters or vision changes Chest pain and/or rib pain Isolated enlarged lymph nodes	Night sweats Chills Muscle weakness Debilitating fatigue and brain fog Fevers Bone pain in the extremities Vertigo Persistent headaches Shortness of breath Anxiety Abdominal pain with nausea

 
Julia Greenspan, ND graduated for National College of (Naturopathic) Natural Medicine in 2006. She currently practices in Amherst, New Hampshire and founded Greenhouse Naturopathic Medicine in 2007. Dr Greenspan’s primary focus is working with tick-borne illnesses in people of all ages. She is also a Lyme disease survivor/advocate, which has given her a very unique perspective.  She is a member of ILADS and follows many of their treatment guidelines.  She currently serves as the chair of the Naturopathic Board of Examiners for the State of New Hampshire. She has been voted one the top doctors by  reader polls in 2011, 2012, and 2013. She has been featured as an expert on tick-borne disease on NECN, WMUR, local talk radio, and local newspapers, including the Cabinet and Union Leader.

1. Jones CR, Harris SJ.  Pediatric Lyme Disease: Diagnosis and Treatment. Lyme Times; Summer, 2005:5-11.   http://www.lymedisease.org/lyme_times/issues/lyme_times_issues_children.html. Accessed May 1, 2013.
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