Meningitis, Lyme Disease, Babesiosis

Question 1

Types of Meningitis

Answer 1

Bacterial- immunocompromised (young, old) 80% offers in <24 months, alcohol abuse, neurosurgical patients.

Viral- aseptic, immunocompromised, college kids (summer and fall)

Fungal- Immunocompromised, aids, bird/pigeon droppings.

Other- Lyme or HSV meningitis.

Question 2

Meningitis Treatment and Diagnosis

Answer 2

Requires inpatient treatment.

Diagnosis- Lumbar puncture with culture and sensitivity.

Will need antibiotics until proven it is not bacterial.
Most patients will receive Vanco and Cefotaxime or Ceftriaxone.

Antipyretics, analgesia, antiemetics, seizure precautions if at risk.

May need antivirals depending on suspected cause.

May need to provide prophylaxis to contacts.

Question 3

Meningitis Exam Signs

Answer 3

Brudzinki- Positive when passive forward flexion of neck causes pain to involuntarily raise knees or hips in flexion.

Kernig- patient lying supine, flex hips and knees passively. Positive if leg extension causes pain.

Question 4

Lyme Disease

Answer 4

Most prevalent tickborne illness in NYS but Babesiosis and Anaplasmosis is spreading.

Reportable to health department.

EM Rash, can affect skin, joints, nervous system and heart.

Question 5

Lyme Stages: Early Localized

Answer 5

Early localized disease
- Erythema Migrans Rash
-With or without symptoms
-Fever, lethargy, regional lymphadenopathy, headache, myalgia, arthralgia.
-Few days to months after tick bite.
-Diagnosed clinically with typical rash
Serologic tests are insensitive in early infection

Question 6

Lyme Stages: Early Disseminated and Late Disseminated.

Answer 6

Associated with multiple EM lesions, usually days to weeks after infection.
Usually flu like symptoms- some have no symptoms of early disease.
May also have migratory arthritis and effusion in one or more joints, migratory pain in tendons, bursae, muscles and bones. May have a Bakers cyst. If untreated, arthritis may recur in the same or different joints.
Cardiac manifestations- conduction abnormalities (AV node block), myocarditis, pericarditis
Neurological manifestations- Bell’s palsy, meningitis, motor/sensory radiculoneuropathy, subtle cognitive difficulties, encephalitis, pseudotumor cerebri.
Other manifestations- conjunctivitis, keratitis, uveitis, mild hepatitis, splenomegaly.

Question 7

Lyme Lab Findings

Answer 7

Lab findings

• Elevated sed rate
• Mildly elevated LFTs
• Microscopic hematuria or proteinuria

Lyme Meningitis

• CSF shows lymphocytic pleocytosis (increased blood count), slightly elevated protein, normal glucose.
• Should add IGM/IGG antibodies to fluid analysis.

Question 8

Lyme Testing

Answer 8

Two-tier testing protocol

• ELISA or IFA (indirect fluorescent antibody) as a first step to evaluate for IGM & IGG antibodies- if positive move to western blot.
• Low specificity and may have false positives- may cross react with antibodies to other spirochetes, viral infections or autoimmune diseases.

Indicated in patients meeting all of the following criteria:

• Recent history of residing in or traveling to an area endemic for lyme
• risk factor for exposure to ticks
• symptoms consistent with early or late disseminated disease (meningitis, radiculopathy, mononeuritis, cranial nerve palsy, arthritis, carditis)

Testing not indicated in

• Patients with EM Rash- just treat for Lyme
• Screening of asymptomatic patients living in endemic areas
• Patients with nonspecific symptoms only such as fatigue, myalgia, arthralgia
• High risk of false positive results

Question 9

Western Blot

Answer 9

Performed after ELISA or IFA is negative.

If positive considered evidence of encounter with B. Burgdorferi.

Question 10

IGM antibody will appear positive with _______.

IGG antibody will appear positive _______ after EM Rash.

Answer 10

1) 1-2 weeks
2) 2-6 weeks

Only 20-40% of patients with EM are seropositive at the time of presentation.

Question 11

STARI

Answer 11

Southern tick-associated rash illness

EM like rash in patients following a bite from a lone start tick. May also be accompanied by flu-like symptoms.

No long term effects reported, no blood testing available.
Unknown if antibiotics are needed, but usually treated the same as Lyme.

Question 12

Lyme Prophylaxis

Answer 12

Controversial as EM occurs in up to 90% of patients and treatment at this stage results in resolution of the disease in at least 90% of patients.

Only doxycycline is recommended and repeated courses of antibiotics are not recommended for frequent tick bites.

Amoxicillin has been studied, not shown to be effective.

Prophylaxis will not prevent the development of other tick-borne illnesses.

Question 13

Prophylaxis of Lyme Criteria

Answer 13

All of the following should be met:
-Attached tick is identified as an adult of nymph I. Scapularis tick
-Tick is estimated to have been attached for >36 hours by degree of engorgement or time of exposure
-Prophylaxis is begun within 72 hours of tick removal
-Doxy in not contraindicated
_pregnant, breastfeeding, 8 x one time dose.

Question 14

Antibiotic Treatment of Early Lyme

Answer 14

Doxycycline 100mg orally BID in adults
2mg/kig BID children >8 for 10-21 days

Amoxicillin 500mg TID in adults
50mg/kg/day TID for children (max 500mg/dose) for 14-21 days

Cefuroxime axetil 500mg BID
30mg/kg/day TID for children 14-21 days

Question 15

Treatment for Isolated Facial Nerve Palsy

Answer 15

Doxy 100mg BID x 14-21 days

Question 16

Treatment for More Serious Neurological Disease

Answer 16

Ceftriaxone 2g IV Daily x21 days

Question 17

Treatment for Arthritis with/without Neurological Disease and recurrent arthritis despite previous oral therapy

Answer 17

With: Ceftriaxone 2g IV daily x 28 days

Without: Doxy 100mg BID x 28 days or Amocivillin 500mg TID x 28 days

Recurrent: Ceftriaxone 2g IV daily x 14-28 days or doxy 100mg BID x28 days or Amocivill 500mg TID x 28 days

Question 18

Treatment of Mild Cardiac Disease r/t Lyme Disease

Answer 18

Doxy 100 mg BID x 14-21 days or amoxicillin 500mg TID x 14-21 days or cefuroxime axetil 500mg BID x 14-21 days.

More serious disease- ceftriaxone 2g daily x 21-28 days.

Question 19

Post Treatment & Chronic Lyme

Answer 19

Microbiological treatment failure does occur, but it is rare.

Poor absorption or noncompliance with treatment is usually suspected

Reasons for this

• Initial diagnosis incorrect
• May be coinfected with another tickborne illness
• Possible that Lyme is curedm but patient has another disorder (fibromyalgia)
• Knee synovitis may persist for months after abx therapy
• With neuro involvement permanent damage may have occurred

No recommended treatment plan

Question 20

Reinfection with Lyme

Answer 20

May occur
Often identified as development of a new EM rash in a patient previously treated.
No established criteria for diagnosis of reinfection based on serological testing, so diagnosis of reinfections can be difficult without an EM rash.

Question 21

Babesiosis

Answer 21

Most frequently found in the northeast and upper midwest US
Can occur as the result of blood transfusions anywhere
Caused by a parasite which infects RBCs
Transmitted by Ixodes scapularis ticks
Infections can be asymptomatic to life threatening
Risk factors for infection include asplenia, advanced age, immunocompromised
Not all infected patients are symptomatic or febrile
Severe cases associated with marked thrombocytopenia, DIC, hemodynamic instability, hepatic compromised, AMS, and death

Inclubation period 1-9 weeks.

Question 22

Babesiosis Symptoms

Answer 22

Fever, chills, sweats, malaise, faituge, GI symptoms, dark urine. Manifestations of severe disease may occur as fever resolves. These symptoms include diarrhea, nausea, vomiting.

Severe disease usually occurs in older/immunocompromised patients and associated with a parasitemia >4%.

Question 23

Babesiosis Complications

Answer 23

ARDS, DIC, CHF, Renal failure, Coma.

May include peristent or relapsing disease.

Question 24

Babesiosis Laboratory Findings

Answer 24

Hemolytic anemia

• Low H/H
• Thrombocytopenia
• Elevated BUN/CR
• Mildly elevated LFTs
• Elevated retic count

May be seen on a peripheral blood smear
May have positive Babesia PCR
May test positive on antibody testing but does not distinguish between acute and previous infection

Question 25

Babesiosis Treatment

Answer 25

Atovaquone 750mg BID plus azithromycin 500-100mg x1 dose then 250-1000mg daily x 7-10 days (Higher dose for immunocompromised patients)

Clindamycin 300-600mg IV every 6 hours or 600mg orally every 8 hours pulse Quinine 600mg orally every 6-8 hours x 7-10 days
Usually for severely ill patients

ID consult recommended

No treatment for patients without symptoms. However, consider treatment for patients with parasitemia >3 months.