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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

diff dx

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:

Prevention


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:
  • 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

References