Lyme disease: Difference between revisions

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== Background ==
==Background==
[[File:Lyme Disease Risk Map.gif|thumb|National Lyme disease risk map with 4 categories of risk.]]
[[File:Lyme Disease Risk Map.gif|thumb|National Lyme disease risk map with 4 categories of risk.]]
[[File:Ixodes scapularis.jpg|thumb|Ixodes tick]]
[[File:Ixodes scapularis.jpg|thumb|Ixodes tick]]
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*Endemic Areas: NE, E US Coasts  
*Endemic Areas: NE, E US Coasts  
*Caused by spirochete ''Borrelia burgdorferi''  
*Caused by spirochete ''Borrelia burgdorferi''  
*The spirochete ''Borrelia mayonii'' has been a new strain implicated in cases in the midwest<ref>Pritt BS, Mead PS, Johnson DKH, et al.Identification of a novel pathogenic Borrelia species causing Lyme borreliosis with unusually high spirochaetaemia: a descriptive study. Lancet Infectious Disease. Published Online: 05 February 2016. </ref>
*Peak in May to Aug  
*Peak in May to Aug  
*Stages: Early localized infection, early disseminated, and late disseminated
*Stages: Early localized infection, early disseminated, and late disseminated


== Clinical Features ==
==Clinical Features==
[[File:Erythema migrans - erythematous rash in Lyme disease - PHIL 9875.jpg|thumb|"Classic" bull's-eye rash (i.e. erythema migrans) found in 20%-30% of cases<ref name=CDC-Signs-Symptoms-April-2011>[http://www.cdc.gov/lyme/signs_symptoms/ Signs and Symptoms of Lyme Disease], CDC, page last reviewed: April 12, 2011.</ref>]]
[[File:Erythema migrans - erythematous rash in Lyme disease - PHIL 9875.jpg|thumb|"Classic" bull's-eye rash (i.e. erythema migrans) found in 70%-80% of cases<ref name=CDC-Signs-Symptoms-April-2011>[http://www.cdc.gov/lyme/signs_symptoms/ Signs and Symptoms of Lyme Disease], CDC, page last reviewed: June 16, 2015.</ref>]]
''3 Distinct Stages - Not all patients suffer all stages, and stages may overlap with remiss ions b/w stages''
''3 Distinct Stages - Not all patients suffer all stages, and stages may overlap with remissions between stages''
 
===Early Localized Infection (7-14d)===
*Erythema Chronicum Migrans: Occurs at site of tick bite, beginning with red macule that expands outward. Starts 3-30 days after bite and occurs in 70-80% of cases
*Erythema migrans rash more often without central clearing
*Fatigue, low grade [[fever]], migrating [[arthralgia]], lymphadenopathy, [[headache]], nausea/[[vomiting]], [[abdominal pain]]


===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)===
===Early Disseminated Infection (Days to weeks)===
*Skin-mult annular lesions sparing palm/soles
*Skin-mult annular lesions sparing palm/soles
*Nervous System-fluctuating meningoencephalitis, HA, N/V, CN palsies (ie 7th-can be bilateral) peripheral neuropathy, radiculopathy  
*Nervous System-fluctuating [[meningoencephalitis]], [[headache]], [[nausea/vomiting]], [[cranial nerve palsies]] (ie 7th-can be bilateral) peripheral neuropathy, radiculopathy  
*Cardiovascular: AV blocks, RBBB, dysrhythmias, LV dysfunction  
*Cardiovascular: [[AV blocks]], [[RBBB]], [[dysrhythmias]], LV dysfunction  
*Eye: Conjunctivitis, keratitis, retinal detachment, optic neuritis
*Eye: [[Conjunctivitis]], keratitis, [[retinal detachment]], [[optic neuritis]]


===Late Disseminated Infection (Months to Years)===
===Late Disseminated Infection (Months to Years)===
*Arthritis: Monarticular/oligoarticular asymmetric arthritis (large joints-commonly knee)  
*Arthritis: Monarticularule outligoarticular asymmetric arthritis (large joints-commonly knee)  
**Brief episodes separated with complete remission  
**Brief episodes separated with complete remission  
**Migratory pattern may occur  
**Migratory pattern may occur  
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==Differential Diagnosis==
==Differential Diagnosis==
*Enterovirus  
*[[Enterovirus]]
*[[Hepatitis]]
*[[Hepatitis]]
*[[Mononucleosis]]
*[[Mononucleosis]]
*Connective tissue disease  
*[[Connective tissue disease]]
*Erythema Multiforme  
*[[Erythema Multiforme]]
*CAD  
*CAD  
*Acute rheumatic fever  
*[[Acute rheumatic fever]]
*Aseptic [[Meningitis]]
*Aseptic [[Meningitis]]
*[[HSV]] encephalitis  
*[[HSV]] encephalitis  
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*[[Multiple Sclerosis]]  
*[[Multiple Sclerosis]]  
*[[Guillain-Barre]]
*[[Guillain-Barre]]
*Cerebral Vascultitis
*Cerebral vasculitis
*Juvenile rheumatoid arthritis
 
{{Differential Diagnosis Polyarthritis}}


{{Tick borne illnesses DDX}}
{{Tick borne illnesses DDX}}


== Diagnosis ==
==Evaluation==


*ELISA if positive obtain confirmatory Western blot  
*ELISA if positive obtain confirmatory Western blot  
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*Cultures, serologies  
*Cultures, serologies  
*LP with lymphocytic pleocytosis, elevated protein, normal glucose, + spirochete antibody, paired serum/CSF serologic tests,PCR  
*LP with lymphocytic pleocytosis, elevated protein, normal glucose, + spirochete antibody, paired serum/CSF serologic tests,PCR  
**Must be performed in patients with neuro findings (facial nerve palsy, meningoencephalitis, etc)
**CNS Lyme disease will be treated with ceftriaxone
*Arthrocentesis, serologic testing of fluid
*Arthrocentesis, serologic testing of fluid


== Management ==
==Management==
''No risk when duration of attachment <24 hrs''
''No risk when duration of attachment <24 hrs''


=== Prophylaxis ===
===Prophylaxis===
*Adult: [[Doxycycline]] 200 mg PO x1  
*Adult: [[Doxycycline]] 200mg PO x1  
*Child >8: 4 mg/kg up to 200 mg PO x1  
*Child >8: 4mg/kg up to 200mg PO x1  
*Give if all of the following are met:  
*Give if all of the following are met:  
**Tick is adult/nymphal ''I. scapularis''  
**Tick is adult/nymphal ''I. scapularis''  
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*Treat before serologic testing if endemic area if + erythema migrans rash  
*Treat before serologic testing if endemic area if + erythema migrans rash  
**'''[[Doxycycline]]''' 100 mg PO BID x 14-21 days  
**'''[[Doxycycline]]''' 100mg PO BID x 14-21 days<ref>Shapiro, E. (2014) ‘Lyme disease’, New England Journal of Medicine, 371(7), pp. 683–684.</ref>
***Also treats human granulocytic ehrlichiosis
***Also treats human granulocytic ehrlichiosis
**'''[[Amoxicillin]]''' 500 mg PO TID x 14-21 days  
**'''[[Amoxicillin]]''' 500mg PO TID x 14-21 days  
***Preferred in pregnant, lactating, children &lt;8
***Preferred in pregnant, lactating, children <8
**[[Cefuroxime]] axetil 500 mg PO BID x 14-21 days  
**[[Cefuroxime]] axetil 500mg PO BID x 14-21 days  
**[[Macrolides]]-not first line
**[[Macrolides]]-not first line
*Jarisch-Herxheimer like reaction can occur in first 24 hrs of treatment (fevers, chills, myalgia, tachycardia)
*Jarisch-Herxheimer like reaction can occur in first 24 hrs of treatment (fevers, chills, myalgia, tachycardia)
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*'''[[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]] 200-400mg/d divided into two doses q day x 10-28 days  
***Preferred for facial palsy or Lyme meningitis (lack of efficacy studies other medications)
**[[Penicillin G]], [[Cefotaxime]]
**[[Penicillin G]], [[Cefotaxime]]


===Cardiac Disease===  
===Cardiac Disease===


*Mild (1st degree AV with PR &lt;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)  
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*[[Ceftriaxone]]/[[Pen G]] IV
*[[Ceftriaxone]]/[[Pen G]] IV


== Disposition ==
==Disposition==
===Outpatient===
===Outpatient===
*Early Disease  
*Early Disease  
*Late Disease: If chronic neurologic/arthritic manifestations may be able to manage as outpt
*Late Disease: If chronic neurologic/arthritic manifestations may be able to manage as outpatient
*F/u with PMD, rheum, ID <br>  
*Follow up with primary care, rheum, ID <br>


===Admission===
===Admission===
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==See Also==
==See Also==
*[[Tick Borne Illnesses]]
*[[Tick Borne Illnesses]]
*[[Bell's palsy]]


== References ==
==References==
<references/>
<references/>


[[Category:ID]]
[[Category:ID]]

Revision as of 18:59, 21 October 2018

Background

National Lyme disease risk map with 4 categories of risk.
Ixodes tick
  • Tick Borne - Ixodes black-legged ticks
  • Endemic Areas: NE, E US Coasts
  • Caused by spirochete Borrelia burgdorferi
  • The spirochete Borrelia mayonii has been a new strain implicated in cases in the midwest[1]
  • Peak in May to Aug
  • Stages: Early localized infection, early disseminated, and late disseminated

Clinical Features

"Classic" bull's-eye rash (i.e. erythema migrans) found in 70%-80% of cases[2]

3 Distinct Stages - Not all patients suffer all stages, and stages may overlap with remissions between stages

Early Localized Infection (7-14d)

  • Erythema Chronicum Migrans: Occurs at site of tick bite, beginning with red macule that expands outward. Starts 3-30 days after bite and occurs in 70-80% of cases
  • Erythema migrans rash more often without central clearing
  • Fatigue, low grade fever, migrating arthralgia, lymphadenopathy, headache, nausea/vomiting, abdominal pain

Early Disseminated Infection (Days to weeks)

Late Disseminated Infection (Months to Years)

  • Arthritis: Monarticularule outligoarticular asymmetric arthritis (large joints-commonly knee)
    • Brief episodes separated with complete remission
    • Migratory pattern may occur
  • Nervous System: Subtle encephalopathy, fatigue, polyneuropathy

Differential Diagnosis

Polyarthritis

Algorithm for Polyarticular arthralgia

Tick Borne Illnesses

Evaluation

  • 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
    • Must be performed in patients with neuro findings (facial nerve palsy, meningoencephalitis, etc)
    • CNS Lyme disease will be treated with ceftriaxone
  • Arthrocentesis, serologic testing of fluid

Management

No risk when duration of attachment <24 hrs

Prophylaxis

  • Adult: Doxycycline 200mg PO x1
  • Child >8: 4mg/kg up to 200mg 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

Early Localized Infection

  • Treat before serologic testing if endemic area if + erythema migrans rash
    • Doxycycline 100mg PO BID x 14-21 days[3]
      • Also treats human granulocytic ehrlichiosis
    • Amoxicillin 500mg PO TID x 14-21 days
      • Preferred in pregnant, lactating, children <8
    • Cefuroxime axetil 500mg PO BID x 14-21 days
    • Macrolides-not first line
  • Jarisch-Herxheimer like reaction can occur in first 24 hrs of treatment (fevers, chills, myalgia, tachycardia)

Early Disemminated

Lyme Meningitis

Cardiac Disease

Arthritis

Disposition

Outpatient

  • Early Disease
  • Late Disease: If chronic neurologic/arthritic manifestations may be able to manage as outpatient
  • Follow up with primary care, rheum, ID

Admission

  • Lyme carditis-cardiac monitoring
  • Prominent neurologic symptoms for IV antibiotics and further care

See Also

References

  1. Pritt BS, Mead PS, Johnson DKH, et al.Identification of a novel pathogenic Borrelia species causing Lyme borreliosis with unusually high spirochaetaemia: a descriptive study. Lancet Infectious Disease. Published Online: 05 February 2016.
  2. Signs and Symptoms of Lyme Disease, CDC, page last reviewed: June 16, 2015.
  3. Shapiro, E. (2014) ‘Lyme disease’, New England Journal of Medicine, 371(7), pp. 683–684.