Beyond Lyme Disease: What You Need to Know About Tick-Borne Illnesses in New Hampshire

Ticks are becoming a growing health concern in New Hampshire and across New England. And Lyme disease isn't the only risk. What other tick-borne illnesses should you know about, and how can you protect yourself?

In this episode of On Call with Southern New Hampshire Health, infectious disease specialist Annie Mathew, MD, of Southern NH Health's Infectious Disease & Travel Medicine discusses Lyme disease, anaplasmosis, babesiosis, Powassan virus, and alpha-gal syndrome, a tick-related allergy to red meat. Learn about common symptoms, when to seek medical care, and practical ways to prevent tick bites and protect your family.

Listen now for expert advice on staying safe outdoors.

Complete Transcript: 

Host Keith Baldi: Welcome to On Call with Southern New Hampshire Health. I'm your host, Keith Baldi. On Call delivers the latest healthcare news and updates along with insights into the latest medical innovations and technologies. Southern New Hampshire Health is a nonprofit system serving the communities in Greater Nashua, New Hampshire, and northern Massachusetts. The health system includes a 188-bed hospital, one of Southern New Hampshire's most comprehensive teams of primary and specialty care providers, and five walk-in immediate care locations open seven days a week for urgent needs. Southern New Hampshire Health, expert care close to home.

Thanks for joining us for this episode of On Call with Southern New Hampshire Health. Today we're discussing a topic that anyone who loves the outdoors, or even goes outdoors for that matter, needs to learn about: tick-borne illness. We used to simply talk about dog and deer ticks here in the northeast and about Lyme disease, which got its name from a town in Connecticut. But now there are more types of ticks, more diseases to discuss, and more information for you to know. Here to help us understand the concerns is Dr. Annie Mathew, an infectious disease specialist with Southern New Hampshire Health. Dr. Mathew, thanks for joining us.

Dr. Annie Mathew: Thanks for having me.

Keith Baldi: So, Dr. Mathew, I do find your job in medicine as an infectious disease specialist to be such an interesting one. In some ways, I look at it as you're a medical detective, if you will, because it seems like there's so much for you to figure out in many cases before you can treat a patient. Is that a fair way to put it?

Dr. Annie Mathew: I think it's fair, but I would say just about every specialty in medicine has some detective work to do. I would say over the years I've noticed it's more of a collaborative type of effort from ID with all the other specialties. And I get a chance to meet and work with a lot of good people in a lot of different specialties.

Keith Baldi: That's great. I heard you speak not too long ago about different pharmaceuticals and different infections. And I was just enamored by the whole thing. It's very, obviously medicine is science-based, but just the way you spoke about it, you have to have so much, so much information in your head, it seems like.

Dr. Annie Mathew: Thankfully, when I don't, I can look it up.

Keith Baldi: That's great. So, how did you get into this specialty?

Dr. Annie Mathew: Yeah, so I grew up in Houston, Texas, the home of the Texas Medical Center, home of Dr. Michael DeBakey and Dr. Denton Cooley, who, if you're familiar with the history of medicine, they're pioneers. And they were kind of my heroes growing up. And all of a sudden in high school, I did a summer job at one of the hospitals, and I got a chance to meet Dr. DeBakey. And then later in residency, I got a chance to meet with Dr. Denton Cooley. So, those were life-changing experiences for sure. But I will tell you, I enjoyed working with the people in infectious diseases quite a bit in my training, and that kind of shifted me over into the specialty. You often see us as more of our serious side, but we have a lighter side as well. But that being said, it was really, and September, by the way, is Sepsis Awareness Month. So, we see a lot of patients who are septic. But infectious diseases allows us, through pharmacologic efforts and collaborative efforts with other specialties, to see people get better quickly. Just like sepsis happens quickly, getting better can happen quickly. And when you see it happen right before your eyes, it's life-changing. It's very sobering and very humbling, I would say. So those were kind of the things that brought me to infectious diseases in particular.

Keith Baldi: What an interesting story. And you're absolutely right. I mean, what you do is amazing. What all physicians and providers and everyone here in the health system does is amazing, but that's an interesting way to look at it. So, over the past 20 years, warmer temperatures and milder winters have meant that in some areas of the northeast, ticks are remaining active longer. Different types of ticks have traveled to our region. They're spreading more illness. What have you seen in your work?

Dr. Annie Mathew: Yeah, so I'll backtrack a little bit and just talk a little bit about ticks in general. You know, I find the history of medicine very important, and ticks in particular, or I would say the white-tailed deer that carries these ticks in particular, Ixodes ticks, were pretty much decimated in the late 1800s and early 1900s. So tick-borne disease was not a particular issue. Fast forward to the late 1900s, you saw the volume of tick-borne illness start climbing and grow logarithmically since the mid-1990s. And the numbers that have really been eye-opening- the CDC has tracked have been numbers in the over 450,000 cases between 2004 and 2016. Another number: in 2004 and 2019, you have over 650,000 cases. So, in 2023, they charted over 90,000 cases of tick-borne illness. So, that's on average. Now we're seeing 90 to 100,000 cases per year of new tick-borne illness. So, with that, we are seeing definitely more tick-borne illnesses and things like that. And so that is just the background. So, all of us in New England, if we're looking for it, we see it. And so what has evolved over time, though, is you're seeing more reporting. More people are looking for it. So naturally the number of cases goes up. There is that component of, yes, global warming, warmer temperatures, that period of time the snow is not on the ground, the ticks are active. So even if you see a patch of green grass, imagine that the ticks are potentially there.

Keith Baldi: Sure. That kind of leads me into another question. You sort of answered it, but you know, when it comes to disease, I guess there's always a couple of different ways to look at it, right? Are we looking for it more and finding it more and diagnosing it more, or is it actually happening more? What do you think? I mean, is it a mixture here?

Dr. Annie Mathew: I think it's a mixture for sure, but it's definitely happening more because the volume of ticks has gone up, and the volume of these deer, the wildlife that are carrying these things, is going up. There's always that question from, kind of a global perspective, what's happening with wildlife in transition during periods of flooding and movement and transportation of wildlife overseas and things like that. So, that has that is also an ongoing lesson for us to kind of be aware as we're doing surveillance.

Keith Baldi: Sure. And as people spread out into suburbs and building, getting into habitats that you bump into animals, obviously, in different ways. And everyone loves to see the deer in their backyard, don't they? Because they're so beautiful.

Dr. Annie Mathew: But you know, they're bringing ticks with them, yes. And so that human interaction with wilder territories also brings increased cases. But we certainly are looking for it more.

Keith Baldi: Absolutely. As I mentioned at the start of our discussion, Lyme disease used to be the really big focus here in New England. I had a friend, I still have a friend I went to college with, and he had Lyme disease. He grew up in Connecticut as a child, so this was 40 years ago or so, and lost the use of his legs for a little while. That was, I think, at the time, they were thinking, what is this? What is this Lyme disease all about? How have you seen that illness develop over the years? Is it treatment-wise? Have you seen more diagnoses?

Dr. Annie Mathew: Yeah, so Lyme manifests in many different ways. The early onset or what we see initially, is often a rash. So that basically, so Lyme, once they're on the body, can get infected within 24 hours of being on a person's body in terms of Lyme disease. Once it's infected or once it's caused the infection, the transmission, it typically takes a couple of weeks for it to start manifesting. It can take up to six weeks to start manifesting and sometimes up to six months. So, there's an open window of when things can start showing up. So, you have the early situation where you have erythema migrans, but these days we see multiple variations of rashes, not just that target lesion that we're talking about. You can see any.

Keith Baldi: Right, that's what you were just describing, right? You used a term for it, but.

Dr. Annie Mathew: Erythema migrans, so basically a bull's-eye rash, yeah. So, if you look just for the bull's-eye rash, you may miss it. I was looking at one resource that showed over 6 different variations of rashes that have been associated with Lyme. So, different types of rashes can show up.

You see it, you treat it early. You can still use other agents other than doxycycline like amoxicillin or cefuroxime in those early periods. So fast forward, other things that it can manifest as: neuropathy, polyradiculopathy, meningoencephalitis; it can manifest even as carditis. So, we'll start out with each one.

Neurologic manifestations or cardiac manifestations are really things that we look at. And then it's the arthritises. So those kinds of manifestations are what we're seeing, where in particular, the treatment varies based on what we're seeing. You may have heard in cardiac disease, complete heart block. That is seen where Lyme disease is involved, and that requires immediate pacing, where someone has to stick a machine on to help pace the rhythm, right? Someone meaning cardiology in particular. So, you see where this is collaborative. It is definitely not just one specialty that's looking at this. So in particular, we get patients referred to us from orthopedics, from neurology, from cardiology, to rheumatology. These are the folks who often see it in addition to primary care. So these are manifestations where we want them on medication immediately, but we also want some type of confirmation. What makes it tricky is early on in the disease, sometimes you will see negative serology. So, you have to keep testing to be sure. And if it's kind of equivocal, sometimes you'll just keep looking for other reasons, of course, but still not hesitate to start them on treatment.

Keith Baldi: So that's a wide range of symptoms, right? And potential systems, right? What do you tell patients who think they might have Lyme disease, or what are the symptoms that might bring you into the doctor? I guess it sounds like it could be a lot of things, right? So definitely, if you see that rash, definitely if you take a tick off of yourself, is that something?

Dr. Annie Mathew: Yeah, so if you take a tick off of yourself, and you knew it wasn't on you 5 hours ago, your risk may be small. But say it's been a whole day since you did a skin check and all of a sudden you're like, whoa, I was outdoors yesterday morning with my dog and now it is, 11 o'clock in the late morning and here's a tick, I find it and it's engorged. That would be a significant risk of potentially developing Lyme disease. So that's when you go to your doctor, and you say, I'm concerned about Lyme disease.

Other instances, of course, are fever, unexplained rash, joint pains that have been ongoing. If you're having a cardiac evaluation and they're seeing things that are unusual or new numbness, new neurologic symptoms that are unexplained by something else. And that's an important part of it. Is it unexplained by something else? So we'll talk; I'm sure we'll delve into that a little bit more.

Keith Baldi: Right. That's it. Yeah. I guess if something is off, you always want to really look into it. You always want to contact your provider, right?

Dr. Annie Mathew: And I would say these days, there's so much information on the internet. There is a tendency for all of us, even medical professionals, to try to self-diagnose. It's okay to have another set of eyes look at you. And the benefit of that is it's a very objective look. And so that kind of gives you some guidance, and you could kind of discuss testing and things like that as opposed to saying, " This is exactly what I have. I'm certain because I read it.”

Keith Baldi: Right. Well, and now you can even get tests, I think, for Lyme disease in like, a pharmacy; you can take them at home. Right. It's just when you have a medical professional for a reason, right? I mean, you see these things, you see how they develop, the difference between A&B just by usually looking at it.

Dr. Annie Mathew: And things may change over time, but the only thing worse than no data is bad data. So, we want to be selective with how we get our data when we have questions about our healthcare in general, but very much so where tick-borne illnesses are involved.

Keith Baldi: Absolutely. So, beyond Lyme, there are other concerns now, right? What tick-borne illnesses are showing up here in New Hampshire that you've seen or that could be here?

Dr. Annie Mathew: Yeah, so we'd say early spring, late fall, anaplasmosis is seen, babesiosis, which is a parasitic infection. Ehrlichiosis, a little more common in the Midwest and southern United States, but we do see it. And then Powassan, which is newer, which is a virus. Powassan is particularly infectious and has particularly high mortality. It just needs to be on the skin for about 15 minutes, sometimes for it to be infectious. And 1/4 of the cases with Powassan, we see meningoencephalitis with it, meaning that meningitis type of symptom, the neurologic symptoms that we were talking about. So, some of these can be very aggressive. Thankfully, we don't see that much Powassan.

The typical ones we see are Lyme, Anaplasma, and Babesia. And those show up with various manifestations. You'll see liver enzyme abnormalities; platelet counts may be disrupted, and white blood cell counts may be off. You may see high fevers or intermediate fevers, extreme fatigue. So there are a lot of different symptoms that will show up with these other tick-borne illnesses as well.

Keith Baldi: And that makes it difficult, I guess, because it goes from, in a lot of ways, for people to be aware of these goes from, oh, what symptoms might I have to, I have to prevent these ticks from getting on me in the 1st place. Because, like you're saying, I would always know, and I have children; when we were outside checking them over, we found ticks on ourselves over the years and, got them out quickly. And so there wasn't as much concern, of course, because Lyme was the one and it was like, okay, it takes a little while. We were just outside. We saw it, but if it's 15 minutes for some of this, like really then it's not even a case in some, instances of I want to check when I get home to I want to prevent them from getting on me in the 1st place because if you're going for a three hour hike and they're on you and they bite you half an hour into your hike then you could be infected you're saying with in short order.

Dr. Annie Mathew: In this virus in particular, yes. And so prevention is definitely key. I will say that our testing has ramped up. You had asked how things have evolved in the last 20 years. Testing has ramped up. Now, all the hospitals have tick-borne panels with the electronic medical record. You just click, and you're able to pull these up. And what we found is the PCR testing for some of these in particular is more reliable than, say, those antibody tests. So those are available. And we test folks pretty readily. Some of these at certain hospitals are sent out. So, they take a few days to come back. But again, if your suspicion is high that that's what's going on, sometimes you get people on treatment and then you pull back treatment if it's negative.

Keith Baldi: Sure. There's one. So, this one is one of the reasons that I wanted to have you here to discuss ticks, something called alpha-gal syndrome, which I don't think still a lot of people know about this because I've talked to people about just doing this podcast and they're like, I don't know what you're talking about. And in my mind, it's kind of a wacky thing. So, this is my take at the most basic level. You know, someone gets bitten by a tick, and they can't eat steak anymore. So, I simplified it, but…

Dr. Annie Mathew: Yeah, so it's in particular mammalian meat. So pork, lamb, and beef in particular are what's been evaluated for this. But alpha-gal is basically what the tick carries. And basically, when a person gets injected, or you get a tick bite, that gets inserted into your bloodstream. And you start creating IgE to this, or it's circulating in your system. And so your body is already averse to this at this point, right? Now you've created antibodies to this. So, the minute you consume this, now your body can't take it. You're now allergic to it because the meat also has the alpha-gal in it. So, when you recognize this again, you're like, okay, my body can't take this. And you start having nausea, vomiting, diarrhea, allergic type of reactions, itchiness, scaly patches on the skin, or worse, anaphylaxis, which for people in the allergy world know that's very dangerous because that's when throat swelling happens, they can't breathe, things like that, things that require an EpiPen. So, testing can actually be done for serum IGE levels, but it's typically the onset happens about 2 to 8 hours after eating a meat meal. And so this is a newly recognized thing overall, but it's definitely present, and it's something that, you know, came out of left field.

Keith Baldi: Right, I would think, and that goes back to my detective comment at the very beginning. I would think that's difficult to figure out because, as a doctor, you're, doctors all over are collaborating and saying, what is going on here? Why are people having this? You've eaten pork for the past 40 years of your life, and now all of a sudden you had a couple of meals, and you're super sick.

Dr. Annie Mathew: Yeah, and this is the collaboration with allergy immunology. Because disease in itself, you have something that may be straightforward in infection, but then you have the more complex, far-reaching ones like these that, the gift that keeps giving, so to speak, in a negative way. So this is where we just have a heightened awareness of it. We don't want to be alarmist, but we certainly want to just be aware. And if you have questions, reach out.

Keith Baldi: Sure. So the tick gets on you. The tick has this specific thing in it. It goes into your skin, under your skin, injects it in there. And then you develop this allergy to it. It's just suffering. So, because I want to be able to eat a steak once in a while. Cardiology- that's a different podcast to talk to a cardiologist about how much red meat you eat or your PCP, right?

I always like to end the podcast with a message to people of how they can protect themselves, how they can, what they should know about here because we've gone over a lot of the symptoms and things you should look out for and making sure that you get an actual medical diagnosis, like you said, rather than looking on the internet, which is always good advice. So, what would you say to the average person? Everyone wants to go outside still and have fun. They walk their dog, they go hiking, whatever it may be. What should people be aware of and do?

Dr. Annie Mathew: So, in general, you see people going out and spraying their yard, trying to get rid of ticks and things like that. But now nationwide, Congress has actually stepped in and put together a work group to try to prevent vector-borne diseases. So, this has become more of a public health concern. And you'll see universities working on vector-borne diseases. We have a tick-free council in New Hampshire, which goes around doing a lot of education. And they're doing surveillance all the time of how many ticks are showing up in the area, in particular in New Hampshire. But they also collaborate with Massachusetts and the other New England states. So, Tick Free New Hampshire is active.

But on a personal level, what can we do? Long sleeves, long pants, light colored clothing; you can see the ticks on those. Or permethrin on your clothes, those things tend to try to deter the ticks and get rid of them. So those are the basic things.

And then of course, bathing. If you bathe, the ticks can't really hang on. They're off. So just be aware of that and do frequent tick checks if you're out in the woods, checking your kids. Also check certain areas like armpits, groins, hairlines. Those are the areas where sometimes ticks will hide. So those are things that we want to be aware of. And then, those in particular, if you see something, I think the most important thing to keep in mind, or just as important as knowing when it is a tick-borne illness, is knowing when it's not a tick-borne illness. And for that, it just takes that evaluation.

Keith Baldi: Fantastic. Thank you so much. Before we go, I just want to mention that Southern New Hampshire Health has a great way to make sure you can find the best primary care provider available. You can call 1-880-EASY. That's 1-880-3279. You'll be matched with someone who best fits your needs. Dr. Annie Mathew, an infectious disease specialist at Southern New Hampshire Health. Thank you so much for joining us.

Dr. Annie Mathew: Thanks for having me.

Keith Baldi: You've been listening to On Call from Southern New Hampshire Health. For more information about the health system or to learn more about some of the topics featured in this podcast, visit us on social media and on our website, snhhealth.org.