Lyme Disease Flashcards
What is treatment for Lyme Disease presenting as a characteristic rash?
For the initial rash(erythema chronica migrans) give
-for adults: doxycycline 100 mg BID x 10 days
-for pregnancy: amoxicillin 500 mg TID x 14-21 days
-for children: amoxicillin 250 mg TID x 14-21 days
or 50 mg/kg/day divided TID
Allergic patients: use 2nd or 3rd gen. Cephalosporins or macrolide
What is the Rx for patient with Bell’s Palsey as the only manifestation?
14-21 days of amoxicillin, doxy, macrolide or cephalosporin 2-3rd gen
What is the Rx for patient with First degree heartblock?
Any of the standard oral antibiotics prev. Mentioned
What is Rx for arthritis secondary to Lyme D.?
4 wks of oral antibiotics. May repeat x 1 if needed.
If it doesn’t resolve»_space;4 wks of ceftriaxone
What is Rx for 2nd or 3rd degree heart block?
Ceftriaxone 2 gm IV daily x 14 days
What is Rx for neurological involvement other than
BELLS PALSY?
IV cefuroxime 2 gm x 2 wks
How does Lyme disease present dermatologically?
What is the significance of multiple lesions of erythema chronicum migrans?
1) annular rash of erythema chronicum migrans: target lesion centrally with an expanding erythematous rash. Can also present as just an expanding rash without a bulls eye pattern. Can also present as just an
arciform and serpiginous wavy indurated erythematous area.
2) Lymphadenosis benigna cutis ( an erythematous nodule on nose, ear etc.){seen only in Europe}
** multiple lesions indicate disseminated disease» these patients have to be checked carefully for evidence of neurologic,cardiac ,joint or eye complications.»_space; they should have a spinal tap but in the absence of that they have to be treated for neuroborreliosis.
What are the neurologic complications of Lyme disease?
Cranial Neuropathy( usually Facial palsy), lymphocytic meningitis and radiculopathy . (Rarely: , encephalitis, myelitis and cerebral vasculitis.)
Early disseminated Lyme disease will present as a cranial neuropathy(usually facial Palsey.. occasionally ocular nerve palsy or trigeminal involvement) +/- lymphocytic meningitis +/- radiculopathy
These presentations will occur within several months of the infection.
What are the clinical manifestations of Lyme disease?
Early localized disease, occurring a few days to one month after the tick bite*
Erythema migrans - occurs in approximately 80 percent of patients
Associated symptoms and signs may include: fatigue, malaise, lethargy, mild headache, mild neck stiffness, myalgias, arthralgias, regional lymphadenopathy
Early disseminated disease•, occurring weeks to months after the tick biteΔ
Carditis - about 1 percent of patients reported to the CDC◊
Manifestations include AV nodal block, mild cardiomyopathy or myopericarditis
Neurologic disease - occurs in approximately 15 percent of untreated patients◊
Manifestations include lymphocytic meningitis, cranial neuropathy (most often facial, can be bilateral), peripheral neuropathy; rarely myelitis or encephalitis
Musculoskeletal involvement - occurs in approximately 60 percent of untreated patients◊
Manifestations include migratory arthralgias
Skin involvement - multiple erythema migrans lesionsΔ, borrelial lymphocytoma (in Europe)
Lymphadenopathy - regional or generalized
Eye involvement§ - conjunctivitis, iritis, choroiditis, vitritis, retinitis
Liver disease - liver function test abnormalities, hepatitis
Kidney disease - microhematuria, asymptomatic proteinuria
Late or chronic disease•, occurring months to years after the tick bite
Musculoskeletal symptoms - approximately 60 percent of untreated patients develop intermittent monoarticular or oligoarticular arthritis; approximately 10 percent of untreated patients develop persistent monoarthritis, usually affecting the knee
Neurologic disease - incidence has not been established
Peripheral neuropathy or encephalomyelitis
Cutaneous involvement - acrodermatitis chronica atrophicans, morphea/localized scleroderma-like lesions (both described only in Europe)
What are The three stages of Lyme disease?
Early localized disease> Early disseminated disease> Late Lyme disease.
Early disease is characterized by the characteristic rash of Erythema Migrans. Usually occurs within one month of a tick bite. May or may not have constitutional symptoms( fatigue, arthralgia , myalgia, mild HA, mild stiff neck, ocas. fever…no uri sx)
Early Disseminated disease occurs several weeks to several months after a tick bite :multiple EM skin lesions(usually occur days to weeks after bite), fluctuating degrees of AV block, (pericarditis..rarely), cranial neuropathy and conjunctivitis***[Some patients will present with early disseminated disease with no history of a EM rash]
Late disease: occurs months to years after infection, ** and it may not be preceded with this signs or symptoms of early disease or early disseminated disease.: Presents as arthritis in one over a few joints.
It can also present as a subtle encephalopathy or polyneuropathy.
Outline of treatment for Lyme
Treatment of Lyme disease*
Drug Adult dosage Pediatric dosage
Erythema migrans (early disease)•
DoxycyclineΔ◊ 100 mg PO bid x 10 to 21 d ≥8 years: 2 mg/kg PO bid (maximum 100 mg per dose) x 10 to 21 d
or Amoxicillin 500 mg PO tid x 14 to 21 d 50 mg/kg/day divided tid PO (maximum 500 mg per dose) x 14 to 21 d
or Cefuroxime axetil 500 mg PO bid x 14 to 21 d 30 mg/kg/day divided bid PO (maximum 500 mg per dose) x 14 to 21 d
Neurologic disease
Isolated facial nerve palsy (early disseminated disease) DoxycyclineΔ§ 100 mg PO bid x 14 to 28 d ≥8 years: 2 mg/kg PO bid (maximum 100 mg per dose) x 14 to 28 d
More serious disease¥ (eg, meningitis, radiculopathy, encephalitis) (early or late disseminated disease) Ceftriaxone‡† 2 g IV once daily x 28 d (range 10 to 28 days) 50-75 mg/kg IV once daily (maximum 2 g per dose) x 28 d (range 10 to 28 days)
Carditis**
Mild (first-degree atrioventricular block with PR interval /=300 milliseconds)•• Ceftriaxone‡** 2 g once/day IV x 21 to 28 d 50-75 mg/kg once/day IV (maximum 2 g per dose) x 21 to 28 d
Arthritis¥
Arthritis without neurologic disease DoxycyclineΔ 100 mg PO bid x 28 d ≥8 years: 2 mg/kg PO bid (maximum 100 mg per dose) x 28 d
or AmoxicillinΔΔ 500 mg PO tid x 28 d 50 mg/kg/day divided tid PO (maximum 500 mg per dose) x 28 d
Arthritis with neurologic disease Ceftriaxone‡ 2 g IV once/day x 28 d 50-75 mg/kg once/day IV (maximum 2 g per dose) x 28 d
Recurrent arthritis (despite adequate prior oral therapy) Ceftriaxone‡ 2 g IV once/day x 14 to 28 d 50-75 mg/kg once/day IV (maximum 2 g per dose) x 14 to 28 d
or DoxycyclineΔ 100 mg PO bid x 28 d ≥8 years: 2 mg/kg PO bid (maximum 100 mg per dose) x 28 d
or AmoxicillinΔΔ 500 mg PO tid x 28 d 50 mg/kg/day divided tid PO (maximum 500 mg per dose) x 28 d
Acrodermatitis chronica atrophicans
DoxycyclineΔ 100 mg PO bid x 21 d ≥8 years: 2 mg/kg PO bid (maximum 100 mg per dose) x 21 d
or Amoxicillin 500 mg PO tid x 21 d 50 mg/kg/day divided tid PO (maximum 500 mg per dose) x 21 d
or Cefuroxime 500 mg PO bid x 21 d 30 mg/kg/day divided bid PO (maximum 500 mg per dose) x 21 d
bid: twice daily; tid: three times daily; PO: oral; IV: intravenous.
* Regardless of the clinical manifestation of Lyme disease, complete response to treatment may be delayed beyond the treatment duration. Relapse has occurred with all of these regimens; patients with objective signs of relapse may need a second course of treatment.
• Alternative but less effective therapy for patients unable to tolerate preferred regimens, azithromycin in adults: 500 mg once daily, in children: 10 mg/kg per day x 7-10 days or clarithromycin in adults: 500 mg twice daily, in children: 7.5 mg/kg twice per day x 14-21 days, or erythromycin in adults: 500 mg four times daily, in children: 12.5 mg/kg four times daily x 14-21 days.
Δ Should not be used for children younger than eight years old or for pregnant or lactating women.
◊ Doxycycline also has activity against Anaplasma phagocytophilum and Bartonella henselae (which causes cat scratch disease) but not against Babesia microti.
§ Amoxicillin or cefuroxime are alternatives in patients with contraindications to doxycycline.
¥ In late disease, the response to treatment may be delayed for several weeks or months.
‡ Or cefotaxime 2 g IV q 8 hours x 14-28 days for adults and 150-200 mg/kg/day in 3 divided doses (maximum 6 g per day) for children or penicillin G 18 to 24 million U per day divided into doses given every 4 hours in adults and 200,000 to 400,000 U/kg per day divided every 4 hours (maximum 18-24 million U per day) in children.
† In nonpregnant adult patients intolerant of beta-lactam antibiotics, doxycycline 200 to 400 mg per day orally or intravenously in two divided doses. In children ≥8 years of age, doxycycline 4 to 8 mg/kg per day in two divided doses to a maximum daily dosage of 200 to 400 mg.
** A parenteral antibiotic regimen is recommended for initiation of treatment for hospitalized patients. IV antibiotics should be continued until high-grade AV block has resolved and the PR interval has become less than 300 milliseconds. The patient may then be switched to oral therapy to complete a 21 to 28 day course.
•• A temporary pacemaker may be necessary.
ΔΔ Cefuroxime may be used as an alternative in patients with contraindications to doxycycline and amoxicillin, although it has not been assessed in clinical studies for this indication.
Adapted with permission from: Wormser GP, Dattwyler RJ, Shapiro ED, et al. The Clinical Assessment, Treatment, and Prevention of Lyme disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.
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What are some important points about the diagnostic test for Lyme disease?
-Serologic testing not indicated for EM rash only: takes 2 to 4 weeks to Mount a serological response.
-if not certain that the rash is secondary to EM>ELISA. If (-) can repeat
In 2-4 wks. Meanwhile treat.
-* do not test asymptomatic individuals. About 5% of the normal population will test positive on ELISA into various factors such as: cross-reactivity with other rickettsial diseases, autoimmune disorders,
other infections such as endocarditis, sarcoidosis ** these are false positive reactions
- testing should not be done For patients with non-specific symptoms only (eg, fatigue, myalgias/arthralgias). The use of serologic testing in populations with a low pre-test probability of Lyme disease results in a greater likelihood of false positive test results than true positive test results.
-Patients will often remain positive on ELISA for life after being treated.
Thus testing for antibodies after treatment is not recommended for evidence of successful treatment.
-For patients who have had symptoms for 1 to 2 months don’t do IgM
just do IgG ELISA and Western Blot(because if these patients have a positive IgM and negative IgG testing then the IgM is likely a false positive)
What is 2 Tiered Testing?
1st Do EIA/ELISA, IF (+) >>2nd Do confirmatory WesternBlot If ELISA(+) but WB(-) > not Lyme
> What is Borrelia mayonii?
> Where has this illness been reported to date?
> What are the symptoms of this illness?
> A recently discovered spirochete bacteria that
can cause an illness similar to Lyme disease.
> Reported in at least 2 counties in northwestern Wisconsin with likely patient exposure sites in north central Minnesota and western Wisconsin. Currently available evidence suggests that B. mayonii is limited to the upper midwestern U.S; Carried Blacklegged deer tick.
B. mayonii causes fever, headache, rash, and neck pain in the early stages of infection, and arthritis in later stages of infection like the illness caused by B. burgdorferi. However, B. mayonii also causes NAUSEA, VOMITING, DIFFUSE RASHES (INSTEAD OF THE SINGLE “BULL’S-EYE” RASH), AND A HIGHER CONCENTRATION OF BACTERIA IN THE BLOOD.
Is there ever a real indication for doing an IgM Lyme Test?
From a real case(Although Migratory Arthralgia may be a symptom of early disseminated ) Doing the serology was a reasonable choice, but the IgM should have been skipped because there are so many false (+) IgM’s. Patients with early disseminated Lyme will invariably have a (+) IgG test. 5% of healthy people will have a false (+) Lyme IgM. So in reality there’s little reason to order an IgM: It can take several weeks to turn (+), so when deciding if a rash is EM it’s not much help. Just treat the EM based on appearance. Only order an IgG **OR order the new VlsE C6 peptide ELISA (or C6 test) . This is a test for a specific an IgG that may turn (+) within 1-2 weeks of contracting Lyme Disease in some patients.
