Overview & History
In 1975, a mysterious illness causing arthritis in children showed up in Lyme, Connecticut and adjacent communities. The new illness was found to be associated with tick bites. In 1981, a researcher named Dr. Willy Burgdorfer and colleagues isolated the microbial culprit, a corkscrew-like organism called Borrelia burgdorferi (named after Dr. Burgdorfer).
Dr. Burgdorfer noticed that symptoms of this new illness were very similar to a tick-borne condition long recognized in Europe called erythema migrans (EM), named for the associated rash migrating from the tick bite. Physicians in both North America and Europe have long recorded illness associated with a migrating rash surrounding tick bites (for over 100 years), but because they lacked effective treatment options, and because the illness was debilitating but not life-threatening, tick-borne illnesses never received much attention.
Not much has changed since then in the medical community. Because Lyme disease is difficult to define, difficult to treat, and rarely life-threatening, many doctors today turn a blind eye to it.
What has changed, however, is public awareness. People not only know about Lyme disease, but there is more public interest in it than ever before. Living with chronic debilitating illness is no longer acceptable and people want solutions. Because the medical establishment is not paying attention, people are turning to the Internet for information. And although the Internet can be a great source of information, there is also a lot of misinformation about what Lyme disease really is.
Lyme disease is not a panic-inducing epidemic like the Ebola virus. Borrelia burgdorferi, the microbe that causes Lyme disease, is a stealth microbe that insidiously makes people chronically miserable, often for a lifetime. It rarely kills directly. Its sole purpose is to complete a lifecycle stage within its host and then hop on board to the next tick that happens along. Within its natural host, the white footed mouse, it completes its lifecycle with seemingly little harm to the host.
How Lyme Disease Infections Work
Borrelia can adapt to a variety of natural hosts, and humans are one of the most common. When an invasion of borrelia enters the bloodstream through a tick bite, the immune system immediately recognizes it and responds aggressively. The microbe, however, has no desire to overwhelm the host with a catastrophic infection.
The ultimate stealth microbe, borrelia clears the blood stream quickly and uses its corkscrew shape to bore deeply into tissues. Collagen is the primary nutrient borrelia needs for survival, so the microbe has a preference for collagen-rich tissues such as joints, brain, muscle (heart muscle especially), eyes and skin. Most symptoms originate in these areas.
Stealth allows borrelia to blend in with all the other microbes in the body. If immune function is robust, the host-microbe relationship is balanced and borrelia causes no symptoms. If immune function is not up to par, however, tug-of-war ensues between the microbe and the immune system. Interestingly, the microbe actually uses this struggle to its advantage. It directly stimulates chemical messengers of the immune system called cytokines. Stimulation of cytokines causes inflammation, which breaks down tissues and releases collagen-rich nutrients to the microbe’s ultimate benefit. The ultimate opportunists, the microbes gravitate toward sites of established inflammation in the body, such as arthritic joints.
For the most part, the intensity of the immune reaction determines the intensity of a person’s symptoms—as opposed to the concentration of microbes present. In other words, most symptoms associated with Lyme disease are caused by the immune reaction and not the bacteria itself. This means that it doesn’t take a high concentration of microbes to feel very sick. Having low concentrations of microbes is one reason why Lyme disease is so difficult to properly diagnose.
This is a very different strategy than a microbe such as streptococcus pneumoniae, the microbe that commonly causes pneumonia. This aggressive microbe succeeds by overwhelming the host with infection. Because of its rapid growth rate, conventional antibiotic therapy is very effective for controlling this type of microbe. In contrast, Borrelia , which has a slow growth rate and does not depend on overwhelming the host, responds poorly to conventional antibiotic treatment.
In the first two weeks after a tick bite, antibiotic therapy can be helpful for clearing the microbes before they have an opportunity to clear the bloodstream and penetrate deeply into tissues. Antibiotic therapy will not, however, eliminate all of the microbes; it just helps to give the immune system the upper hand. After the microbes are disseminated into tissues, antibiotic therapy is less likely to eradicate the infection.
Beyond penetrating deep into tissues, borrelia also has the ability to shed the corkscrew shape and live inside cells (intracellular), well protected from antibiotic therapy. And if it gets hit really hard with multiple antibiotics, it can form a protective cyst and stay dormant until the antibiotics are long gone.
After the initial tug-of-war with the immune system’s first line of defense, secondary defenses take over and produce antibodies to destroy the microbes. The microbe has effective mechanisms of evasion against these defenses also, but a healthy immune system usually wins out eventually and the microbe is completely suppressed. By that time, however, if all goes according to nature’s plan, some members of the tribe will have escaped via a new tick bite and their mission of self-preservation will be accomplished; the life cycle is complete.
If you get caught off guard with a compromised immune system, however, the tug-of-war never ends. Chronic low grade infection becomes a normal state and the immune system never fully recovers. If unaddressed, chronic misery can set in for a lifetime.
The key to preventing Lyme disease from becoming chronic is having a strong immune system. People with a healthy immune system generally have minimal symptoms at initial infection and never develop chronic disease.
Did you know?
- Borrelia is the ultimate stealth microbe, and can adapt to many different natural hosts and is spread by a variety of ticks.
- Ticks require a blood meal during each of three stages (nymph, larva, adult). Borrelia can be transferred at any stage, but transfer during the larval stage is most common in humans because larval ticks are so tiny.
- New infections are most common in the spring and early summer.
- Symptoms are primarily caused by immune reaction (inflammatory cytokines) and not the bacteria itself. Borrelia has no genes coding for toxins that can harm the host.
- Borrelia does not rely on overwhelming the host with infection; significant illness can be caused by low concentrations of microbes.
- Lyme disease is often divided into three stages: early localized, early disseminated, and late disseminated, but the difference between the later two stages is often arbitrary.
- Separating Lyme disease into initial infection associated with acute tick bite and chronic Lyme disease may be more useful. The longer a person has had Lyme disease symptoms, generally the more difficult the recovery process.
- If Lyme disease becomes chronic, it can make you miserable for a lifetime and will cause you to age faster, but it is unlikely to kill you.
Lyme Disease Testing and Diagnosis
Finding borrelia (or any stealth microbe, for that matter) in the body is like trying to find a handful of criminals spread out in the city of New York. The microbes are masters at blending in with all the other microbes in the body. Separating low concentrations of borrelia apart from the 100 trillion other microbes in the body is a near herculean task.
Borrelia stays deep in tissues, has the ability to live inside cells (intracellular), has elaborate ways of tricking the immune system, changes its genetic signature readily, and doesn’t require high concentrations of microbes to cause illness.
These factors make developing an accurate test a real challenge, but there are still some tests that may help to confirm a diagnosis of Lyme disease.
Blood or Tissue Culture
The most definitive test for proving the presence of a microbe is growing it in the lab from a tissue or blood sample. However, because borrelia exists in such low concentrations in blood and tissues and is so difficult to grow under artificial conditions, cultures have marginal benefit for Lyme disease.
EIA Tests (ELISA and ELFA)
EIA tests look for the presence of antibodies produced by the host’s immune system against Borrelia. These are recommended as screening tests for Lyme disease.
The CDC (Centers for Disease Control) claims that everyone with Lyme disease will test positive, but in clinical practice, the test has had poor predictive value and most healthcare providers who treat Lyme disease find limited usefulness of these tests.
PCR tests specifically for Borrelia DNA in the host’s blood. However, because the microbe clears from the blood quickly, the value of PCR testing is limited. Only about half of individuals with Lyme disease will show a positive test, so the test is not very accurate. PCR tests should be limited to only very acute tick-bite exposure, but even then, a negative test does not rule out the possibility of a Borrelia infection.
Western Blot for Lyme
This test relies on production of antibodies by the host’s immune system for different parts (antigens) of the bacteria. Antibody production does not occur until the body’s secondary defense kicks in and is dependent on the host’s ability to mount an immune response. The Western Blot test may provide a more accurate diagnosis of Lyme disease than most of the other available tests.
Because Borrelia shares antigens with other bacteria, multiple positive antibodies (called bands) are required for a true positive test.
IgM antibodies show acute Lyme disease; CDC guidelines require 2 positive bands out of 3 (24, 39, 41). IgG antibodies are indicative of chronic disease; CDC guidelines require 5 positive bands out of 10 (18, 21, 28, 30, 39, 41, 45, 58, 66, 93).
Band 41 is specific for the flagella (tail) of spirochetes (corkscrew bacteria), but is not absolutely specific for borrelia. True positive tests are not that common. A company called IGeneX adds extra bands for more accurate testing, but the test is very expensive.
The newest technology for testing for acute borrelia infection is the Ceres Nanotrap (Ceres Nanosciences). This test, performed on a urine sample, captures the outer surface protein from the borrelia bacteria. The company claims high specificity for the borrelia bacteria and high sensitivity for picking up acute infection. At this time, the test is not indicated for diagnosing chronic Lyme disease.
Note: Lab tests may help to confirm a Lyme disease diagnosis, but they often produce inaccurate results. In fact, more than half of people with symptoms associated with Lyme disease will not meet qualifications for a positive lab test for Borrelia burgdorferi.
Acute (Early-Stage) Lyme Disease
Symptoms of Acute Lyme Disease
One of the most well-known symptoms of Lyme disease is the classic “bull’s eye” rash (erythema migrans) that appears several days, or sometimes weeks, after getting a tick bite. For the bull’s eye rash, redness extends outward from the tick bite with an outer more prominent red ring.
Although the bull’s eye rash has long been considered definitive proof of Lyme disease, and considered more accurate than lab tests, even the rash may not be absolute. Only 1/3 of people with Lyme disease will get the rash, and only 10% of reported bull’s eye rashes are associated with the presence of borrelia in the blood (there are other types of microbes that can also cause the rash).
Other symptoms of acute Lyme disease include:
- Fatigue or tiredness
- Neck stiffness
- Muscle aches
- Low grade fever
- *High fever and swollen lymph nodes generally indicate a co-infection
Having a history of tick bites, along with the bull’s eye rash and other Lyme disease symptoms, is the most reliable way to diagnose infection with borrelia—if it looks like a duck and walks like a duck, it probably is a duck. However, even this type of diagnosis is far from being absolute.
Antibiotic Treatment for Acute Lyme Disease
During the first two weeks after a tick bite, there is an opportunity to reduce the concentration of microbes within the host using conventional antibiotics before the microbes disseminate deeper into tissues.
Healthcare professionals routinely recommend doxycycline 100mg taken twice daily for 2-3 weeks. Metronidazole 500mg taken twice daily can be added to cover for a wider range of possible coinfections. Some providers prescribe clindamycin as an oral antibiotic treatment, which has a high association with overgrowth of Clostridium difficile in the gut (causing bloody diarrhea). Clindamycin should only be used topically or intravenously.
Antibiotic therapy will not eliminate all of the microbes; it just helps to give the immune system the upper hand. After the microbes have disseminated into tissues, antibiotic therapy is less likely to eradicate the infection.
Aside from antibiotics, a healthy immune system is essential for preventing chronic disease. At least half of people with an infected tick bite will develop fatigue and migrating arthritis within weeks to months after completing antibiotic therapy. Repeat antibiotics generally provide transient benefit or no benefit at all.
Chronic (Late-Stage) Lyme Disease
Chronic Lyme disease is rarely fatal, but it can make you miserable for a lifetime. Typically, people with chronic Lyme disease look normal on the outside. Routine screening labs at the doctor’s office often come back as normal, which can be extremely frustrating for patients because they are often discounted as not being ill.
Inside, however, deep in tissues, a chronic war is going on between a hidden microbe (or microbes) and the person’s immune system. This results in a wide spectrum of seemingly unrelated symptoms.
Symptoms of Chronic Lyme Disease
When Lyme disease becomes late-stage or chronic, a different set of symptoms may emerge from the initial onset of the infection. These symptoms may include:
- Tooth pain
- Chronic infection
- Chronic fatigue
- Chronic pain
- Migrating arthritis or joint pain
- Muscle pain
- Chronic flu-like symptoms
- Neck stiffness and creaking
- Bell’s palsy (paralysis or weakness in the facial muscles of one side)
- Brain fog or loss of cognitive function
- Heightened sensitivity and agitation to noise and sound
- Ringing in ears
- Sleep disorders or trouble sleeping
- Visual changes or blurry vision
- “Floaters” in vision and eye discomfort
- Dizziness and instability
- Muscle twitching
- Paresthesias (burning or tingling in feet and hands)
- Tremors (head and hands)
- Chest pain
- Irregular heart beats
- Shortness of breath or difficulty catching breath
- Unstable bladder
- Gastrointestinal (GI) or digestive dysfunction
Most anyone who is infected with Borrelia burgdorferi ends up having microbes buried deep in tissues. The severity of a person’s symptoms is highly dependent on the person’s genetic makeup and strength of immune system. Many people do not have obvious symptoms or symptoms that are outwardly debilitating.
Mild arthritis and fatigue, commonly associated with the aging process, in many cases may actually be related to stealth microbes. Because concentrations of microbes are so low, finding out for sure is nearly impossible.
In symptomatic chronic Lyme disease, the immune system and the microbes reach a standoff. The degree of symptoms very much depends on the status of the person’s immune function. If the balance is tipped more in the favor of the immune system, symptoms are less. If the balance is tipped more in favor of the microbe, symptoms will be greater. The tip of the balance is very much influenced by the person’s genetic makeup and health habits. Lyme disease is different for every individual.
Disease progresses, not because the microbe is winning, but because the chronic tug-of-war accelerates the aging process. Tissues break down faster and the individual becomes more susceptible to other chronic diseases. People who have had chronic Lyme disease for a long time have more difficulty overcoming it because there is more accumulated damage that must be reversed.
Coinfections with other microbes or infections with other strains of borrelia can also complicate the picture of chronic Lyme disease.
Lyme Disease Coinfections & Related Conditions
Borrelia burgdorferi is not the only type of borrelia. In Europe two other species of borrelia, Borrelia afzelii and Borrelia garinii, are more common than Borrelia burgdorferi as a cause of Lyme disease. Tick-borne illnesses have been recognized in Europe for much longer than in North America. B. afzelii is more apt to cause skin problems and B. garinii is more often associated with neurological symptoms.
Worldwide, there are at least 12 different species of borrelia that cause illnesses similar to Lyme disease. Because of mobility of people, different species are circulating around the world. This contributes to another layer of difficulty in diagnosis.
Sometimes Lyme disease isn’t borrelia at all. Borrelia burgdorferi has a preference for only certain types of ticks. In the Northeast, where Lyme disease is most common, borrelia is spread by the black-legged deer tick. This tick is less common in the South (but becoming more common), where the lone star tick (white spot on the back) predominates.
The lone star tick is not thought to carry borrelia, but reports of Lyme disease have become quite common in the South. As it turns out, the lone star tick is associated with a lyme-like illness named STARI (Southern Tick-Associated Rash Illness). It can be associated with a bull’s eye rash and all the symptoms of Lyme disease, but tests for borrelia are always negative. As of yet, the causative microbe is unknown, but you can bet it shares similar stealth characteristics to borrelia.
Borrelia rarely travels alone. Ticks and other biting insects (mosquitoes, fleas, lice, chiggers, biting flies, scabies) carry a wide range of potentially opportunistic microbes. The addition of coinfections complicates and compounds the picture of Lyme disease. A handful of potential coinfecting microbes are now well known, but new ones are being discovered every day.
The list of the known microbes considered Lyme disease coinfections includes bartonella, mycoplasma, babesia, ehrlichia, and anaplasma.
Symptom profiles for coinfections are similar to borrelia and related mostly to stimulation of cytokine cascades, not high concentrations of microbes. They all have stealth characteristics and have the ability to infect and thrive inside cells. They are masters of evading the immune system and can be even harder to diagnose than borrelia. And though they each have slightly different strategies, their motive is the same: scavenge enough resources and nutrients from an adaptable host to survive.
Common characteristics of Lyme disease coinfections:
- They are parasites (must have a host to survive)
- They are all well adapted to a human host, but can still cause illness if immune function is not robust
- Initial infection causes flu-like symptoms with fever
- They all have stealth characteristics (but vary in tactics)
- Human infections are common, but often subclinical (not sick enough to seek medical attention and resolve spontaneously)
- In general, they have very low potential to be fatal or life-threatening (just like borrelia, they can make you miserable for a lifetime, but are unlikely to kill you)
- Chronic symptomatic illness only occurs if immune function is compromised
- Being infected with multiple microbes at once increases the likelihood of Chronic Immune Dysfunction and chronic illness
Having an infection with multiple microbes may be more common than not. Coinfection with multiple microbes increases the intensity of symptoms and immune compromise. Each different microbe can initiate a different set of cytokines, thus causing highly variable symptoms between patients. Tick-borne coinfections can occur without infection with borrelia.
Additionally, suppression of immune function by these microbes can allow reactivation of dormant viruses. There are eight known herpes-type viruses that can infect humans. A common feature all of these viruses share is the ability to lie dormant in nerve tissue and reemerge later when immune system function is compromised.
The three most common viruses are Epstein-Barr virus (EBV), the cause of mononucleosis, Cytomegalovirus (CMV), a common viral infection that can cause heart failure and Human herpesvirus type 6 (HHV-6), a virus very commonly found in active form in chronic fatigue patients. The list also includes Herpes simplex type 1 (fever blisters), Herpes simplex type 2 (genital ulcers), and Varicella zoster virus (chickenpox and shingles).
Because stealth microbes (borrelia and coinfections) are so difficult to diagnose, sometimes it must be assumed that they are there. You cannot rely on lab tests alone; symptoms are often a better guide than lab testing.
Not surprisingly, chronic Lyme disease shares many symptoms with other fatigue-like conditions including fibromyalgia and autoimmune diseases. Lyme disease is also commonly associated with multiple sclerosis, Parkinson’s, rheumatoid arthritis, dementia, and ALS.
The possibility that all of these conditions are associated with stealth microbes is extremely high. Which disease happens is dependent on the combination of microbes, the status of the patient’s immune system, and the patient’s genetic makeup.
When you understand Lyme disease, you begin to understand the underlying nature of all chronic disease processes.
The exceptions include ehrlichia/anaplasma, (ehrlichiosis/anaplasmosis), babesia (babeiosis), and rickettsia (Rocky Mountain Spotted Fever). These tick-borne microbes are more virulent than borrelia and can potentially cause severe acute life-threatening illness. Infection with one of these microbes should be suspected whenever high fever with drenching sweats are associated with recent tick bite. Acute antibiotic therapy should be administered immediately.
The Current Approach to Chronic Lyme
The experts at the Center for Disease Control and Prevention (CDC) do not actually recognize the term, “chronic Lyme disease”. Instead, they classify persistent Lyme-like symptoms occurring beyond six months as “Post-Treatment Lyme Disease Syndrome (PTLDS)”. The authors of the text state that this only occurs in a very small percentage of people and generally resolves spontaneously. Extended antibiotic therapy is not recommended.
Experts at the opposite end of the spectrum who do recognize chronic Lyme disease recommend extended therapy (6-9 months) with potent antibiotics.
People suffering from chronic Lyme disease end up getting caught in the middle.
Even though most of the world accepts that chronic Lyme disease exists, at present, there is no evidence that prolonged antibiotic therapy offers long-term benefit. Some people do improve while on antibiotic therapy (many people get worse), but typically relapse when antibiotics are stopped.
This isn’t surprising; if you study the true nature of borrelia, aggressive and prolonged antibiotic therapy just doesn’t make any sense.
Antibiotics depend on rapidly growing microbes in high concentrations. Borrelia and other opportunists grow very slowly, occur in very low concentrations in the body, and penetrate into tissues where antibiotics do not reach. Used long term (months), antibiotics kill friendly flora and allow more aggressive opportunists to become antibiotic resistant and thrive. The end result is further disruption of immune function and ultimately worsening of the host’s illness.
The more you see chronic Lyme disease as an infection with specific microbes that must be completely eradicated to win the war, the less likely you are to ultimately prevail.
A Different Perspective
This war is won slowly and incrementally. It is not a battle with specific microbes as much as is it an imbalance within the entire microbiome of the body (which is shifted toward opportunistic pathogens).
The underlying cause is disruption of immune function caused by the microbes, but also other factors such as poor diet, toxins, and chronic stress.
As such, the solution is breaking the vicious cycle of Chronic Immune Dysfunction and creating a healing environment within the body. This is done by taking pressure off the healing systems of the body by reducing stress factors.
Herbal therapy is ideal for restoring wellness because herbs empower the body to get well. Comprehensive herbal therapy enhances immune function, reduces inflammatory cytokines, and supports healing of tissues. Herbs do not function like antibiotics. Herbs suppress opportunistic pathogens, but without destroying non-harmful flora. This rebalances the microbiome and restores wellness to the body.
When the approach shifts from “treating an illness” to supporting wellness and the ability to function normally, specific diagnoses and whether or not specific microbes are present does not matter as much.
Why Prolonged Antibiotic Use May Not Be Ideal for Chronic Lyme Disease
- Borrelia and other stealth microbes typically have slow growth rates and respond less well to conventional antibiotics than more virulent microbes.
- Borrelia exists in low concentrations deep in tissues where antibiotics do not penetrate well.
- Borrelia’s corkscrew shape allows it to quickly bore deeply into cartilage and tissues. Borrelia can also form dormant cysts that is completely resistant to antibiotics; the harder you hit it, the more resistant it becomes.
- Lyme disease co-infections have the ability to hide and thrive inside cells, thus gaining protection from antibiotics.
- Antibiotic resistance occurs at a high rate with these types of stealth microbes. Long term use of antibiotics destroys the normal flora (friendly bacteria) in the gut and skin. This contributes to Chronic Immune Dysfunction. You cannot get well without a healthy immune system.
- Possibly the most compelling suggestion that antibiotic therapy has significant limitations is this: if antibiotics really worked, people would not be searching for other solutions. But people are scouring the Internet by the thousands everyday for alternatives to conventional antibiotic therapy.
Work With Your Physician
The recommendations listed on this page are not intended to replace an in-person consultation with your physician, and you should discuss all treatment options (including natural treatments) with your physician before you begin. If a bull’s-eye rash (indicative of Lyme disease) is present, schedule an appointment with a physician immediately.
Physicians on the Vital Plan medical board use both conventional medications and herbal therapy in their practice: they recommend medications to treat symptoms acutely and herbal therapy to foster wellness long term. See how Dr. Rawls, founder of Vital Plan, overcame Lyme disease >>
Fortunately, herbal therapy has very low potential for toxicity and is generally not shown to have any interference with conventional medications, so our physicians often use the two in conjunction (please discuss any decisions regarding medications with your physician).
The most important part of recovery is a long-term commitment. It may take many months to begin experiencing a change in health, but if you stay committed, better health is in reach.
*Statements on this page have not been evaluated by the FDA and are not intended to diagnose, treat, cure, or prevent any disease. For medical concerns, please consult a qualified healthcare provider.
1. Image sources: http://www.cdc.gov/lyme/signs_symptoms/; https://microbewiki.kenyon.edu/index.php
2. William Rawls, MD. Suffered Long Enough. Dog Ear Publishing, 2014.
3. Stephen Harrod Buhner, Healing Lyme, Natural Healing and Prevention of Lyme Borreliosis and Its Coinfections, Raven Press, Silver City, N.M., Copyright 2005.
4. The Healing Power of Rainforest Herbs, by Leslie Taylor, ND, SquareOne Publishers, 2005, sarsaparilla and cited references.
5. Stephen Harrod Buhner, Herbal Antivirals, Storey Publishing, Copyright 2013 AND Stephen Harrod Buhner, Healing Lyme Disease Coinfections, Healing Arts Press, Copyright 2013.
6. Kerry Bone and Simon Mills, Principles and Practice of Phytotherapy, Churchill Livingstone Elsevier, 2013.
7. PDR for Nutritional Supplements, Thomson Reuters, 2008.
9. http://www.allisure.com/AllisureSMPC.pdf technical studies documenting antimicrobial activity of Allisure.
10. Centers for Disease Control and Prevention website: www.cdc.gov
11. National Geographic 11/2011
12. National Institute of Allergy and Infectious Diseases website. http://www.niaid.nih.gov/topics/lymedisease/understanding/pages/intro.aspx
13. P Parola and D Raoult, Ticks and Tickborne Bacterial Diseases in Humans: An Emerging Infectious Threat, Clinical Infectious Diseases, Vol. 32, Issue 6, 2001, p. 897-928
14. A G Barbour and S F Hayes, Biology of Borrelia Species, Microbiol Rev. Dec. 1986, 50(4) p. 381-400
15. A Steer, J Coburn, and L Glickstein, The Emergence of Lyme Disease, J Clin Invest, April 2004, 113(8), p. 1093-1101
16. S Buhner, Healing Lyme Disease Coinfections, Healing Arts Press, 2013
17. S Buhner, Natural Treatment for Lyme Coinfections, Healing Arts Press, 2015
18. K Singleton MD, The Lyme Disease Solution, Brown Books, Dallas, Texas, 2008
19. R Horowitz, Why Can’t I Get Better?, St. Martin’s Press, 2013
20. Wikipedia offers an excellent summary article about Lyme disease