Lyme Disease: Erythema chronicum migrans


- 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: 
     - 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; 
            - references:
                    - 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
            - references:
                  - 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. 
     - carditis
     - 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; 
            - references:
                  - 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


- Labs:
    - culture:
            - B.Burgodorferi can be cultured on Barbour-Stoenner-Kelly medium, early in the disease, usually from erythema
                    migrans lesions;
    - 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; 
            - references:
                  - NEJM lab diagnosis table
                  - Prospective study of serologic tests for lyme disease


- 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;
    - traditionally we were taught that outside of the Northeast this disease is uncommon, but the disease may actually more common
               than reported;
    - references:
          - 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


- 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;
            - references:
                  - 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


References

Medical Progress: Lyme Disease.

Lyme arthritis in children. An orthopaedic perspective.

Lyme Disease

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