Lyme disease
Revision as of 17:04, 6 May 2022 by Masoodrm (talk | contribs) (→Early Disseminated Infection (Days to Weeks))
Background
- Caused by spirochete Borrelia burgdorferi
- Typically carried on Ixodes scapularis aka Deer tick
- The spirochete Borrelia mayonii has been a new strain implicated in cases in the midwest[1]
- Endemic to the northeastern US
- Peak time of infection is May to August
- 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 (7-14 Days)
- 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- Multiple annular lesions that spare the palm and 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 100 mg PO BID x 10 days [3]
- Acceptable for all pediatric patients when used for 21 days or less
- Also treats human granulocytic ehrlichiosis
- Amoxicillin 500 mg PO TID x 14 days [3]
- Preferred in pregnant, lactating
- Cefuroxime axetil 500 mg PO BID x 14 days [3]
- Macrolides- not first line
- Doxycycline 100 mg PO BID x 10 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
- Tick Borne Illnesses
- Bell's palsy
- Allen C. Steere, "Lyme disease" N Engl J Med 2001; 345:115-125. Accessed 13 Jan 2021.
- In-training exam review
External Links
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.
- ↑ 3.0 3.1 3.2 Clinical Practice Guidelines by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Lantos et al. Neurology Feb 2021, 96 (6) 262-273; DOI: 10.1212/WNL.0000000000011151