McSweegan Lyme

The Color of Infection

Just before bedtime one night, my wife called me into our son’s room. “Look at these red

splotches on his legs,” she said. The splotches were flat, ring-shaped rashes scattered around his

skinny legs. One look and I said, “Oh, he’s got Lyme disease. He’s presenting with multiple

erthyma migrans.” After fourteen years of marriage, my wife is used to such pronouncements.

He did have Lyme disease. The next day we took him to the doctor where he was

paraded before the rest of the office staff as a classic example of early-stage Lyme disease with

multiple erythema migrans (EM) rashes. The doctor gave him a prescription for amoxicillin, a

common antibiotic, and sent him home.

Lyme disease is caused by the bacterium, Borrelia burgdorferi, which people get from the

bite of the annoyingly tiny deer tick. We almost never notice these pesky hitchhikers so they

usually get away with a little of our blood in exchange for some unwanted bacteria.

As the bacteria multiple and spread under the skin, a red rash—often described as a

“bull’s eye”—begins to form. It has a warm, dark center surrounded by a diffuse red ring. Those

were the EM rashes I saw on my son’s legs.

Seventy to eighty percent of people infected with the Lyme bacterium develop this

telltale rash. The EM rash is a great aid to doctors trying to diagnosis a patient who is

complaining of fever, headache, fatigue, and muscles aches.

The EM showed up very nicely on my son’s Anglo Saxon legs. But what if he had been

African-American? Would I have seen the rash?

Researchers at the University of Maryland School of Medicine in Baltimore tried to

answer that question a couple of years ago.

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Maryland has a lot of deer and all of those deer carry deer ticks. Some of those ticks,

carrying Lyme bacteria, can latch on to suburbanites. According to Dr. Alan Fix in the School’s

Department of Epidemiology and Preventive Medicine, people living on the upper Eastern Shore

and the counties northeast of Baltimore have especially high rates of Lyme disease. (In 2003

Maryland had 656 cases.)

According to national data collected by the federal Centers for Disease Control and

Prevention (CDC), Lyme disease is more common among Whites than among African-

Americans.

Lyme disease can be thought of as a disease of location; more Whites live in suburban or

rural areas where they are more likely to encounter ticks.

But the upper Eastern Shore is rural and 13 percent of its population is African-American.

Here Whites and African-Americans contract Lyme disease at about the same rates because they

live in the same environment and therefore have the same risk of exposure to deer ticks.

However, Dr. Fix and his colleagues found that whites are more likely to develop a

noticeable EM rash and African-Americans are more likely to develop arthritis from untreated,

late-stage Lyme disease.

What does this mean? Well, it probably means the telltale EM rash is not being

recognized on many dark-skinned African-American residents and they are subsequently

developing complications caused by delays in diagnosis and treatment. One of the most

common complications from Lyme disease is arthritis.

The University of Maryland researchers suggested other possible explanations for

differences in Lyme disease cases and outcomes, including a lack of awareness among African-

Americans about what an EM rash means, and less access to medical care. There may also be

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some bias among physicians who believe Lyme disease is rare among minorities or who fail to

report all cases to the CDC and state health departments.

Whatever the reasons, the work of Fix and his colleagues suggests more education about

Lyme disease is needed among African-Americans and the physicians who serve them. But that

may not be happening.

Last year, the Department of Health and Mental Hygiene announced that cases of Lyme

disease were increasing in Maryland. Unfortunately, the Department’s press office does not

seem to have any Lyme disease brochures for the public. Meanwhile, the Maryland Arthritis

Project is trying to reduce the statewide burden of arthritis, but there appears to be no effort to

link Lyme disease prevention with arthritis reduction and better public education.

Nationally, Whites may continue to bare the burden of this backyard pest, but it is clear

that certain Maryland zip codes carry an equal opportunity risk of infection.

Writing in the American Journal of Epidemiology, Dr. Fix referred to skin color as a

“superficial marker of phenotypic variation.” That’s a great way to say our differences are only

skin-deep.

Certainly, deer ticks and Lyme bacteria have no interest in the color of their warm-

blooded hosts. We shouldn’t either except as a means of reducing the overall burden of

infectious diseases in the United States.

For more information on Lyme disease, visit www.cdc.gov/ncidod/dvbid/lyme.