St Emlyn’s Lesson Plans

Tick bites and Lyme disease: a UK approach

Compare a recent tick bite, erythema migrans and symptoms that need specialist assessment.

Early-career Emergency Medicine / Higher Specialty Training · 45-minute session

For learners

Before: Allow about 18 minutes in total.

When we meet: We will discuss when Lyme disease can be diagnosed clinically, how to choose the appropriate treatment table and when to seek specialist advice.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Live NICE tables or current printouts, the three written case summaries below and a timer. Photographs are optional and must have appropriate permission and attribution.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.

Core preparation

NICE NG95: Lyme disease · About 15 minutes

Read NG95’s diagnostic recommendations and the treatment-table rows for erythema migrans in adults and children. Then find the rows for neurological and cardiac involvement so you can see where management differs.

https://www.nice.org.uk/guidance/ng95/chapter/Recommendations

Think about (allow 3 minutes): What would change your assessment from a recent tick bite to suspected Lyme disease?

Picture the scene

A walker arrives after removing a tick in the New Forest. An internet page recommends a single antibiotic dose. How would you explain the UK approach?

By the end of the session

Separate exposure without symptoms, erythema migrans and possible disseminated disease.
Use the NICE diagnostic pathway without unnecessary testing of characteristic erythema migrans.
Choose the correct age- and manifestation-specific treatment reference rather than importing another country’s regimen.

After the session

Check whether your department’s Lyme advice still contains an old screenshot, imported prophylaxis rule or unsupported age restriction.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 18 minutes in total.

Before learners arrive

Read NG95 and locate current BNF/BNFC access. Check local infectious-disease/microbiology and paediatric advice routes.
Be ready to explain why advice from a US website may differ from the UK pathway. Focus on how to choose guidance for the patient and exposure.

Equipment: Live NICE tables or current printouts, the three written case summaries below and a timer. Photographs are optional and must have appropriate permission and attribution.

Setup: Pairs identify the next decision, then nominate the source needed. Give more experienced learners the focal-symptom variation while others practise the uncomplicated-rash consultation.

If the preparation has not been completed

Replace the five-minute opening with three spoken case prompts: a tick removed today with a small itchy local reaction; an expanding rash two weeks later; and palpitations with dizziness after a recent rash. Pairs choose the next assessment or advice step and check the relevant NICE section. No separate cards are needed. In the 30-minute plan, use five minutes here and reduce the walker case from seven to five minutes.

Suggested session plan

0–5 min — The prophylaxis request. Invite a respectful explanation of the patient’s internet advice.
5–15 min — Exposure without disease. Separate prevention, diagnosis and safety-netting.
15–29 min — Clinical erythema migrans. Practise diagnosis and table-based prescribing checks without waiting for unnecessary tests.
29–40 min — Child and focal disease. Locate the correct source and rehearse escalation.
40–45 min — Close. Each learner states when the simple pathway stops being enough.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

The well walker

A 35-year-old removed a tick after a weekend walk. There is a small itchy red area at the bite site and no other symptoms. They request prophylaxis based on a US website.

Add this information as the discussion develops:

Ask learners to take an exposure and symptom history without assuming all tick bites transmit infection.
The patient asks whether a blood test today would rule out future disease.

Ask the group:

What distinguishes an immediate local reaction from erythema migrans?
What information can you give about observing the skin and seeking review?
How would you explain why geographical guidance differs without dismissing the patient’s research?

Discussion notes

Points to draw out:

Use the UK pathway: do not diagnose Lyme disease in someone with no symptoms solely because a tick bite occurred. An immediate local reaction is not the same as a later enlarging erythema migrans lesion.
Do not use US single-dose prophylaxis criteria as routine UK advice. Explain the signs that should prompt review and give practical tick-removal/prevention information. Early serology is not a certificate that illness cannot develop.

Common misconceptions:

Offering antibiotics because the patient is understandably anxious.
Assuming the person remembers every tick exposure.

For a more experienced group: Ask a senior group how recent travel changes the exposure assessment and where to seek region-specific advice.

An expanding rash

A 28-year-old has an enlarging red patch on the thigh over several days after countryside exposure. It is not particularly itchy or painful. They feel tired but have no focal neurological or cardiac symptoms.

Add this information as the discussion develops:

Ask what additional questions help distinguish uncomplicated disease from focal involvement.
The person may be pregnant and has a previous antibiotic allergy label.

Ask the group:

Does the rash need a classic target appearance?
Would you wait for a blood test before treatment?
Which table will you use, and which patient factors must be checked first?
How would you explain treatment, expected progress and when to return?

Discussion notes

Points to draw out:

Characteristic erythema migrans supports clinical diagnosis and treatment without laboratory confirmation. Lack of a remembered bite does not exclude it.
For adults with erythema migrans and/or non-focal symptoms, NICE recommends 21 days for first-choice doxycycline or the amoxicillin alternative; the second alternative azithromycin has a 17-day course. Check the exact drug, dose, duration and manifestation in the live table, taking pregnancy, allergy and contraindications into account.
Explain reassessment if symptoms worsen or do not improve; distinguish possible treatment reaction from allergy or progressive disease with clinical review.

Common misconceptions:

Waiting for serology despite a convincing clinical rash.
Choosing a regimen from a US podcast or an old screenshot without checking UK guidance.

For a more experienced group: Remove the rash and give non-specific symptoms with a plausible exposure. Work through the testing pathway and the effect of early sampling.

A child, or a patient with focal symptoms

A seven-year-old has a compatible expanding rash. In a second brief variation, an adult with a recent rash develops near-syncope and palpitations.

Add this information as the discussion develops:

Ask the group to locate the child table rather than recall an age cut-off from memory.
For the adult variation, ask what must happen before routine outpatient treatment is considered.

Ask the group:

Why is a blanket “no doxycycline under twelve” statement unreliable?
How does suspected cardiac or neurological involvement change urgency and specialist involvement?

Discussion notes

Points to draw out:

NICE has age- and manifestation-specific paediatric recommendations, including circumstances for off-label doxycycline. Check BNFC and seek appropriate specialist advice; do not calculate an improvised dose in this session.
Possible carditis, focal neurological disease or serious systemic illness needs timely assessment and specialist discussion. The simple erythema migrans pathway is insufficient.

Common misconceptions:

Treating all manifestations as the same oral antibiotic course.

For a more experienced group: Explore how to explain uncertainty to a family while seeking paediatric/infection advice.

Important clinical points

Do not use a US prophylaxis regimen as routine UK policy.
Use live prescribing tables and BNF/BNFC for age, pregnancy and focal manifestations.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

When is serology unnecessary?
Why can a very early negative test be unhelpful?
Which symptoms make this more than an uncomplicated-rash consultation?

Key teaching points:

A tick bite alone does not establish Lyme disease.
Use the treatment table that matches the person’s age and manifestations.
Erythema migrans can support clinical diagnosis without serology; still assess for other symptoms and complications.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Testing without erythema migrans and persistent symptoms after treatment can be difficult. Avoid promising a single test will settle every presentation; follow the current pathway and seek specialist advice where needed.

If the discussion drifts

Which presentation are we treating, and which source actually applies to this patient?

For a more experienced group

Examine how a study from another region might fail to transfer because of vector, background risk, case definition and treatment differences.

A 30-minute version

30-minute option: opening 3, walker 7, rash 12, child/focal variation 5, close 3. Omit the extended serology discussion.

Evidence and guidance

NICE NG95: Lyme disease — Diagnosis and age/manifestation-specific antibiotic tables; use with BNF/BNFC and local microbiology.https://www.nice.org.uk/guidance/ng95/chapter/Recommendations