- Discussion:
- deer tick (Ixodes) borne spirochetal infection leading to widespread symptoms;
- in U.S. Lyme disease is most prevalent in areas with heavy deer population (North East);
- life cycle includes larval, nymph, and adult (with the nymphal stage transmitting bacteria);
- infection is due to Borrelia burgdorferi spirochetes;
- contains several outer surface proteins that allow organism to survive in different host environments;
- tick takes up to 24 hours to attach and then takes 48 hours or longer for Borrelia burgdorferi to proliferate within tick and then spread back into host;
- in Europe
it is caused by
B. afzelii, B. garinii, B. burgdorferi, and
occasionally by other species of borrelia;
- less than 1% of tick bites result in Lyme disease;
- Clinical Features:
- erythema chronicum migrans:
- will occur in 80% of patients with Lyme disease;
- rash occurs one week to one month after tick bite in 50-70% of patients;
- look for expanding red papule or macule, most often greater than 5 cm in diameter;
- most common in the inguina, axilla, behind the knee;
- partial or complete central clearing may develop which accounts for the bullseye appearnance;
- rash often fades spontaneously after 4 weeks;
- constitutional symptoms
- flu like symptoms: fatigue, headache, myalgias, and arthralgias;
- neurologic symptoms
- neurologic symptoms may occur early or late;
- look for headache, neck stiffness, facial palsy, encephalitis;
- may see subacute encephalopathy, axonal polyneuropathy, and leukoencephalitis;
- may see pure motor neuron disease which may be confused with
amyotrophic lateral sclerosis
- references:
-
Immunologic reactivity against Borrelia burgdorferi in patients with motor neuron disease.
-
Lyme disease and the peripheral nervous system.
- carditis
- acute or chronic arthritis
- 10% of patients will have chronic arthritis;
- with chronic arthritis, consider PCR testing of joint fluid inorder to rule out a persistent low grade infection;
- respiratory and GI complaints are notably absent;
-
diff dx:
-
adult arthritis
-
childhood arthritis
- Labs:
- culture:
- B.Burgodorferi can be cultured on Barbour-Stoenner-Kelly medium, early in the disease, usually from erythema migrans lesions;
- PCR: may allow orgaism identification from joint fluid (and if necessary from spinal fluid);
- antibody response (serum lyme titer) helps make the diagnosis;
- ELISA is sensitive but not specific, where as the Western blot is specific;
- in the first several weeks, there is an IgM response (which is persistent), followed by and IgG response after one month;
- ref:
NEJM lab diagnosis table
- Prevention:
- vaccines have be developed which mimic the B burgdorferi outer-surface lipoprotein A (OspA);
- w/ repeated dosing, efficacy of over 90% has been reported;
- be aware, however, that outside of the Northeast this disease is uncommon;
- Treatment:
- oral antibiotic treatment is sufficient for mild symptoms but IV antibiotics (
ceftriaxone) is required with neurologic symptoms, carditis, or resistant arthritis;
-
doxycycline 100 mg PO bid for 2-3 weeks;
- avoid use in children younger than 8 years;
-
tetracycline
-
penicillins:
-
penicillin v (1st choice in child & pregnancy)
-
amoxicillin 500 mg PO tid;
-
erythromycin
- A. atrophicans:
-
penicillin g (20 million units/day for 10 days;
- alternatively, consider ceftriaxone 1gm IV q12hr for 14 days;
- relapses should be retreated;
- stage ii: neurologic or cardiac, stage iii: arthritis;
- for the later three rx with ceftriaxone or
penicillin g (hd);
-
length of treatment:
- proper length of treatment remains controversial, but it is clear that treatment needs to be continued far beyond the resolution of the acute symptoms;
Medical Progress: Lyme Disease.
Review: Diagnosis of Lyme Disease Based on Dermatologic Manifestations.
Chronic arthritis of the knee in Lyme disease. Review of the literature and report of two cases treated by synovectomy.
Lyme arthritis in children. An orthopaedic perspective.
Immunization against Lyme disease - an important first step. Steigbigel RT, Benach JL. NEJM 1998;339(4):263-264.
A vaccine consisting of recombinant Borrelia burgdorferi outer-surface protein A to prevent Lyme disease. Sigal LH et al. NEJM 1998;339(4):216-222.
Vaccination against Lyme disease with recombinant Borrelia burgdorferi outer-surface lipoprotein A with adjuvant. AC et al. NEJM 1998;339(4):209-215.
Lyme Disease. Allen Steere MD. NEJM. Vol 345. No 2. Jul 12. 2001.
Lyme Arthritis Presenting as Acute Septic Arthritis in Children.
Peripheral neuropathies after arthropod stings not due to Lyme disease. A report of five cases and review of the literature.
A Critical Appraisal of "Chronic Lyme Disease"
