Lyme Disease: Erythema chronicum migrans
- 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:
- acute severe joint pain:
- ref: Primary Lyme Arthritis of the Pediatric Hip
- 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 appearance;
- rash often fades spontaneously after 4 weeks;
- Review: Diagnosis of Lyme Disease Based on Dermatologic Manifestations.
- Images in Clinical Medicine: Disseminated Lyme Disease
- 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
- Immunologic reactivity against Borrelia burgdorferi in patients with motor neuron disease.
- Lyme disease and the peripheral nervous system.
- Peripheral neuropathies after arthropod stings not due to Lyme disease: a report of five cases and review of the literature.
- acute or chronic arthritis
- 10% of patients will have chronic arthritis;
- with chronic arthritis, consider PCR testing of joint fluid in order to rule out a persistent low grade infection;
- Chronic arthritis of the knee in Lyme disease. Review of the literature and report of two cases treated by synovectomy.
- Lyme Arthritis Presenting as Acute Septic Arthritis in Children.
- respiratory and GI complaints are notably absent;
- diff dx:
- adult arthritis
- childhood arthritis
- sepic knee
- references: Predictive Factors for Differentiating Between Septic Arthritis and Lyme Disease of the Knee in Children
- B.Burgodorferi can be cultured on Barbour-Stoenner-Kelly medium, early in the disease, usually from erythema
- PCR: may allow organism 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 an IgG response after one month;
- NEJM lab diagnosis table
- Prospective study of serologic tests for lyme disease
- vaccines have be developed which mimic the B burgdorferi outer-surface lipoprotein A (OspA);
- w/ repeated dosing, efficacy of over 90% has been reported;
- traditionally we were taught that outside of the Northeast this disease is uncommon, but the disease may actually more common
- A vaccine consisting of recombinant Borrelia burgdorferi outer-surface protein A to prevent Lyme disease. Recombinant Outer-Surface Protein A Lyme Disease Vaccine Study Consortium.
- Vaccination against Lyme disease with recombinant Borrelia burgdorferi outer-surface lipoprotein A with adjuvant. Lyme Disease Vaccine Study Group.
- Immunization against Lyme disease - an important first step.
- 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;
- penicillin v (1st choice in child & pregnancy)
- amoxicillin 500 mg PO tid;
- 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;
- Safety of intravenous antibiotic therapy in patients referred for treatment of neurologic Lyme disease
- Counterpoint: long-term antibiotic therapy improves persistent symptoms associated with lyme disease
- Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease
Medical Progress: Lyme Disease.
Lyme arthritis in children. An orthopaedic perspective.
A critical appraisal of "chronic Lyme disease".
Borrelia Being Bashful
Lyme Arthritis in Children Presenting with Joint Effusions
Commentary on an article by Matthew D. Milewski, MD, et al.: "Lyme Arthritis in Children Presenting with Joint Effusions".
Effective treatment of Lyme disease-related arthritis may depend on proper diagnosis
Original Text by Clifford R. Wheeless, III, MD.
Last updated by Data Trace Staff on Tuesday, December 6, 2016 6:27 am