The Curbsiders Internal Medicine Podcast

Episode #516: Lyme Disease Primer featuring Dr. Sophie Woolston
Date: March 2, 2026

Episode Overview

This episode offers an expert-guided, practical approach to the evaluation, diagnosis, prevention, and treatment of Lyme disease. Drawing on Dr. Sophie Woolston’s experience as an infectious disease specialist in Maine, the hosts and Dr. Woolston discuss Lyme disease epidemiology, clinical manifestations, testing pitfalls, evidence-based management, and effective patient counseling. The conversation is peppered with clinical pearls, memorable analogies, and practical takeaways for primary care and hospital-based clinicians.

Key Discussion Points & Insights

1. What Is Lyme Disease?

• Definition: Tick-borne infection caused primarily by Borrelia burgdorferi (09:18, Dr. Woolston).
• Clinical syndrome: Manifests with a range of symptoms and can be effectively treated.

2. Epidemiology & Geography

• Endemic Regions: Originally concentrated in southern New England, now expanding north, south, and west; increasingly found in Minnesota, Wisconsin, Great Lakes, and Mid-Atlantic regions (10:16, Dr. Woolston).
• Trend: The geographic range and incidence are expanding.

3. Seasonality of Lyme Disease

• Typical Season: Mid-to-late spring, summer, and even into late fall, depending on climate (11:43, Dr. Woolston).
• Caveat: Lyme can occur in any month above freezing; vigilance is required year-round in endemic areas.

“When temperatures are above freezing, ticks can be alive… It certainly needs to be something that we're worried about.”
— Dr. Sophie Woolston [13:15]

4. History Taking for Suspected Lyme

• Exposure Details: Ask about patient and pet outdoor activities, close household contacts, and tick exposures—personal and environmental (13:15).
• Clinical Suspicion: Keep Lyme on the differential in patients presenting with fever, rashes, joint pain, and no clear localizing source, especially in endemic areas (14:00-14:46).

5. Clinical Stages and Presentations

• Early Localized Lyme: Erythema migrans (EM) rash (“bullseye”), fevers, myalgias, malaise. The EM rash is pathognomonic when classic—diagnosis is clinical (18:52, Dr. Woolston).

  • Quote:

  “If you see [an EM rash], you’ve made the diagnosis. … When it's classic, I'm happy, I'm good, I actually don't need anything else to make a diagnosis.”
  — Dr. Sophie Woolston [19:19]

• Early Disseminated Lyme: Weeks to months after bite; includes carditis (often AV block), cranial and peripheral neuropathies, migratory arthralgias.

• Late Lyme Disease: Months later; classic presentation is mono/oligoarticular arthritis—often the knee, with prominent swelling but not severe pain.

  • Quote:

  “The most classic thing that I see is that patients … are complaining that generally one joint, generally the knee, is swollen and red and achy, but it rarely is significantly painful.”
  — Dr. Sophie Woolston [22:39]

• Incidence of Progression: 15–25% progress to disseminated or late Lyme if untreated; some may self-resolve (24:02–24:20).

6. Diagnostic Testing: Challenges & Approach

• Serologic Tests: Not reliable in early disease—IgM may be negative at this stage. Antibody persistence can render results ambiguous for years (26:22–29:31).

  • Key point: Prior exposure = positive antibodies, not necessarily active infection.
  • Lyme serologies (IgM and IgG) can remain positive or revert; interpretation is context- and stage-dependent (28:49–29:31).

• Testing Strategy:

  • Early localized disease (EM rash): Clinical diagnosis—do NOT delay or depend on serology (26:22, 35:15).
  • Vague/systemic presentations: Consider broader tick panels—especially if fever without rash (30:21–31:03).
  • “Tick panels” may test for Lyme, anaplasmosis, and babesiosis—these other pathogens can be detected by PCR; Lyme cannot (31:03).

“Testing for Lyme can often… is antibody testing, so it’s often showing an exposure present or past to Lyme… the IgM aspect… can actually stay positive for years after an initial exposure.”
— Dr. Sophie Woolston [27:51]

• Interpreting Western Blot:
  • IgM positive if ≥2/3 bands
  • IgG positive with ≥5/10 bands
    (33:12–33:39)

7. Treatment of Lyme Disease

• First-Line:
  • Doxycycline (100mg BID for 10 days in early disease) is effective, affordable, and well-tolerated (35:54–36:07).
  • Alternatives for doxycycline allergy/pregnancy/sun intolerance: Amoxicillin; cefuroxime as less frequently used (36:22).
• Late Disease/Arthritis: Longer course (up to four weeks)
• Early Disseminated (e.g., carditis): Start with IV ceftriaxone, transition to oral doxycycline (57:47–58:20).
• Coinfections: Treat based on symptoms; Babesia requires separate therapy.

8. Post-Treatment Lyme Disease Syndrome (“Chronic Lyme”)

• Definition: Fatigue, pain, neurocognitive symptoms after treatment; affects 5-10% (62:52).

• Evidence: Trials of long-term antibiotics do not improve outcomes and carry risk for harm (67:46).

  • Quote:

  “More antibiotics does not seem to change the outcomes… often the most typical finding… is actually just a higher risk of adverse events.”
  — Dr. Sophie Woolston [67:46]

• Counseling: Validate symptoms, explain testing limits, and avoid unnecessary and potentially dangerous therapies. Focus on supportive, holistic approaches to wellness (diet, movement, sleep, stress reduction) (62:52–73:16).

9. Prevention: Counseling for Patients

• Best Advice:
  • Cover skin: Wear long pants/socks, hats, long sleeves (37:14).
  • Use insect repellents: DEET (thick application); permethrin-treated clothing.
  • Regular tick checks after exposure; shower/bathe soon after time outdoors (39:53).
  • Environmental management: Remove brush near residential areas.

"The best advice that I can have is having a protective layer against your skin... You've got to wear pants and tuck them into your socks, which doesn't matter what it looks like."
— Dr. Sophie Woolston [37:14]

10. Tick Removal

• Use tweezers, grab as close to the mouthparts as possible, pull with steady pressure until mouthparts release (45:22–46:29).
• Avoid open flames, petroleum jelly, or twisting.

11. Post-Exposure Prophylaxis

• Indication: Tick attached >36 hours, within 72 hours of removal, in high-risk area—give doxycycline 200mg once (54:18).
• Liberal use is reasonable due to safety profile, especially in high-risk, high-exposure patients (55:27–56:06).

12. Lyme Disease Vaccine

• Current Status: Human Lyme vaccine is in phase 3 trials; previous vaccine was removed due to public concern, not scientific safety issues (50:12).
• Encouraging news: Newer vaccine candidates are on the horizon and appear safe and immunogenic (50:12–53:44).

13. Patient Counseling on Testing & Alternative Therapies

• Warn about the pitfalls of unvalidated laboratory tests and caution against supplement-based Lyme clinics and invasive treatments unsupported by evidence (73:16–74:59).
• Quote:

“If somebody makes a test and they're telling you you need to get that test done and they're benefiting from you getting that test done… they have an inherent conflict of interest…”
— Dr. Paul Nelson Williams [73:16]

14. Psychosocial Approach

• Validate patients’ suffering, address misinformation, foster trust to avoid alienation (75:08–75:37).

Notable Quotes & Memorable Moments

• “If you see [an EM rash], you’ve made the diagnosis.”
  — Dr. Sophie Woolston [19:19]
• “When temperatures are above freezing, ticks can be alive.”
  — Dr. Sophie Woolston [13:15]
• “More antibiotics does not seem to change the outcomes… often the most typical finding… is a higher risk of adverse events.”
  — Dr. Sophie Woolston [67:46]
• On tick removal: “The most important thing, of course, with tick removal is that you focus on trying to remove the mouth part… several strong tugs and relax, and then tug again.”
  — Dr. Sophie Woolston [45:22]
• “The best way to approach Lyme disease is to prevent so remember those pants tucked into your socks.”
  — Dr. Sophie Woolston [76:12]
• “…there are easy to take treatments that are extremely safe and effective, but the best way to approach Lyme disease is to prevent.” [76:12]

Timestamps for Key Segments

• Lyme Definition and Microbiology – 09:18
• Epidemiology & Seasonality – 10:16, 11:43
• History Taking for Lyme Exposure – 13:15
• Clinical Stages of Lyme Disease – 18:52
• Diagnostic Testing: When and How – 26:22, 28:49, 30:21, 33:12
• Treatment Overview – 35:54, 36:22, 57:47
• Prevention Tactics – 37:14, 39:53
• Tick Removal – 45:22
• Post-Exposure Prophylaxis – 54:18, 55:27
• Vaccine Discussion – 50:12–53:44
• Post-Treatment Lyme Disease Syndrome – 62:52, 67:46, 73:16

Take-Home Points (76:12)

• Lyme disease is common, expanding, and can cause diverse symptoms.
• Early recognition and treatment are highly effective with low resistance.
• Diagnosis is clinical in most cases—especially if EM rash is present—serology can be misleading.
• Prevention is paramount: barrier clothing, repellents, tick checks.
• Prolonged antibiotics do not help “chronic Lyme” and can harm; focus on supportive approaches.
• New vaccines on the horizon may offer future protection.
• Above all: partner with, validate, and educate patients.

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