McSweegan The Color of Infection

Lyme

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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Lyme

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 AfricanAmericans. 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 AfricanAmericans 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 warmblooded 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.

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