Lyme disease: Difference between revisions
| Line 67: | Line 67: | ||
===Early Disemminated=== | ===Early Disemminated=== | ||
*'''Doxycycline''' (see above dosing) | *'''[[Doxycycline]]''' (see above dosing) | ||
*'''Amoxicillin''' (See above dosing) | *'''[[Amoxicillin]]''' (See above dosing) | ||
===Lyme Meningitis=== | ===Lyme Meningitis=== | ||
*'''[[Ceftriaxone]]''' 2g IVq12h x 14-28 days | *'''[[Ceftriaxone]]''' 2g IVq12h x 14-28 days | ||
**Doxycycline 200-400 mg/d divided into two doses q day x 10-28 days | **[[Doxycycline]] 200-400 mg/d divided into two doses q day x 10-28 days | ||
**Penicillin G, Cefotaxime | **[[Penicillin G]], [[Cefotaxime]] | ||
===Cardiac Disease=== | ===Cardiac Disease=== | ||
*Mild (1st degree AV with PR <0.3 sec) | *Mild (1st degree AV with PR <0.3 sec) | ||
**Doxycycline/Amoxicillin PO | **[[Doxycycline]]/[[Amoxicillin]] PO | ||
*Severe (HIgh-degree AV block) | *Severe (HIgh-degree AV block) | ||
**[[Ceftriaxone]]/Pen G IV | **[[Ceftriaxone]]/[[Pen G]] IV | ||
===[[Arthritis]]=== | ===[[Arthritis]]=== | ||
*Doxycycline, Amoxicillin PO, as effective as parenteral | *[[Doxycycline]], [[Amoxicillin]] PO, as effective as parenteral | ||
*[[Ceftriaxone]]/Pen G IV | *[[Ceftriaxone]]/[[Pen G]] IV | ||
== Prophylaxis == | == Prophylaxis == | ||
Revision as of 20:18, 26 March 2014
Background
- Tick Borne - Ixodes black-legged ticks
- Endemic Areas: NE, E US Coasts
- Caused by spirochete Borrelia burgdorferi
- Peak in May to Aug
- Stages: Early localized infection, early disseminated, and late disseminated
Clinical Features
3 Distinct Stages - Not all patients suffer all stages, and stages may overlap with remiss ions b/w stages
- Early Localized Infection (7-14d)
- Erythema Chronicum Migrans: At bite site beginning w/ red macule that expands outward. Occurs 60-80% of cases
- Fatigue, low grade fever, migrating arthralgia, lymphadenopathy, headache, N/V, abd pain
- Early Disseminated Infection (Days to weeks)
- Skin-mult annular lesions sparing palm/soles
- Nervous System-fluctuating meningoencephalitis, HA, N/V, CN palsies (ie 7th-can be bilateral) peripheral neuropathy, radiculopathy
- Cardiovascular: AV blocks, RBBB, dysrhythmias, LV dysfunction
- Eye: Conjunctivitis, keratitis, retinal detachment, optic neuritis
- Late Disseminated Infection (Months to Years)
- Arthritis: Monarticular/oligoarticular asymmetric arthritis (large joints-commonly knee)
- Brief episodes separated with complete remission
- Migratory pattern may occur
- Nervous System: Subtle encephalopathy, fatigue, polyneuropathy
- Arthritis: Monarticular/oligoarticular asymmetric arthritis (large joints-commonly knee)
Diagnosis
- ELISA if positive obtain confirmatory Western blot
- PCR
- Cultures, serologies
- LP with lymphocytic pleocytosis, elevated protein, normal glucose, + spirochete antibody, paired serum/CSF serologic tests,PCR
- Arthrocentesis, serologic testing of fluid
DDx
- Enterovirus
- Hepatitis
- Mononucleosis
- Connective tissue disease
- Erythema Multiforme
- CAD
- Acute rheumatic fever
- Aseptic Meningitis
- HSV encephalitis
- Bell's Palsy
- Multiple Sclerosis
- Guillain-Barre
- Cerebral Vascultitis
- Juvenile rheumatoid arthritis
Treatment
No risk when duration of attachment <24 hrs
Early Localized Infection
- Treat before serologic testing if endemic area if + erythema migrans rash
- Doxycycline 100 mg PO BID x 14-21 days
- Also treats human granulocytic ehrlichiosis
- Amoxicillin 500 mg PO TID x 14-21 days
- Preferred in pregnant, lactating, children <8
- Cefuroxime axetil 500 mg PO BID x 14-21 days
- Macrolides-not first line
- Doxycycline 100 mg PO BID x 14-21 days
- Jarisch-Herxheimer like reaction can occur in first 24 hrs of treatment (fevers, chills, myalgia, tachycardia)
Early Disemminated
- Doxycycline (see above dosing)
- Amoxicillin (See above dosing)
Lyme Meningitis
- Ceftriaxone 2g IVq12h x 14-28 days
- Doxycycline 200-400 mg/d divided into two doses q day x 10-28 days
- Penicillin G, Cefotaxime
Cardiac Disease
- Mild (1st degree AV with PR <0.3 sec)
- Severe (HIgh-degree AV block)
- Ceftriaxone/Pen G IV
Arthritis
- Doxycycline, Amoxicillin PO, as effective as parenteral
- Ceftriaxone/Pen G IV
Prophylaxis
- Adult: Doxycycline 200 mg PO x1
- Child >8: 4 mg/kg up to 200 mg PO x1
- Give if all of the following are met:
- Tick is adult/nymphal I. scapularis
- Tick was attached >36 hours based on degree of engorgement or exposure time
- Prophylaxis can be given within 72 hrs after time tick was removed
- Local rate of infection in ticks >20%
- Doxycycline is not contraindicated
- Old vaccine has little to no efficacy after 1 year
Disposition
- Outpatient
- Early Disease
- Late Disease: If chronic neurologic/arthritic manifestations may be able to manage as outpt
- F/u with PMD, rheum, ID
- Admission
- Lyme carditis-cardiac monitoring
- Prominent neurologic symptoms for IV Abx and further care
See Also
Source
Harwood and Nuss