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 | [[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 | ''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)=== | ===Early Disseminated Infection (Days to weeks)=== | ||
*Skin-mult annular lesions sparing palm/soles | *Skin-mult annular lesions sparing palm/soles | ||
*Nervous System-fluctuating meningoencephalitis, | *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: | *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 | *Cerebral vasculitis | ||
{{Differential Diagnosis Polyarthritis}} | |||
{{Tick borne illnesses DDX}} | {{Tick borne illnesses DDX}} | ||
== | ==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]] | *Adult: [[Doxycycline]] 200mg PO x1 | ||
*Child >8: | *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]]''' | **'''[[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]]''' | **'''[[Amoxicillin]]''' 500mg PO TID x 14-21 days | ||
***Preferred in pregnant, lactating, children | ***Preferred in pregnant, lactating, children <8 | ||
**[[Cefuroxime]] axetil | **[[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- | **[[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 | *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 | *Late Disease: If chronic neurologic/arthritic manifestations may be able to manage as outpatient | ||
* | *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
- 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
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)
- Skin-mult annular lesions sparing palm/soles
- 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
- Eye: Conjunctivitis, keratitis, retinal detachment, optic neuritis
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
- Enterovirus
- Hepatitis
- Mononucleosis
- Connective tissue disease
- Erythema Multiforme
- CAD
- Acute rheumatic fever
- Aseptic Meningitis
- HSV encephalitis
- Bell's Palsy
- Multiple Sclerosis
- Guillain-Barre
- Cerebral vasculitis
Polyarthritis
- Fibromyalgia
- Juvenile idiopathic arthritis
- Lyme disease
- Osteoarthritis
- Psoriatic arthritis
- Reactive poststreptococcal arthritis
- Rheumatoid arthritis
- Rheumatic fever
- Serum sickness
- Systemic lupus erythematosus
- Serum sickness–like reactions
- Viral arthritis
Tick Borne Illnesses
- Babesiosis
- Colorado tick fever
- Ehrlichiosis
- Heartland virus
- Lyme
- Murine typhus
- Rocky mountain spotted fever
- Southern tick-associated rash illness (STARI)
- Tick paralysis
- Tularemia
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
- Doxycycline 100mg PO BID x 14-21 days[3]
- 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 200-400mg/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
- Doxycycline 200-400mg/d divided into two doses q day x 10-28 days
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
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
- ↑ 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.
- ↑ Signs and Symptoms of Lyme Disease, CDC, page last reviewed: June 16, 2015.
- ↑ Shapiro, E. (2014) ‘Lyme disease’, New England Journal of Medicine, 371(7), pp. 683–684.