Lyme Disease

Infectious diseases

Clinicals - History

Fact Explanation
Age Lyme disease is a multi system disease caused by the spirochete Borrelia burgdorferi which is transmitted by ticks to the humans . The deer ticks Ixodes scapularis & Ixodes pacificus are known to carry the bacterium and act as vectors for transmission. It takes about 3-30 days for the symptoms to appear after a tick bite , and three stages of infection are identified, namely early localized (stage 1), early disseminated (stage 2) and late stages (stage 3) .
The disease is most often found in the 5-9 years and 55-59 years age groups . Thus asking about the age can give a clue to the diagnosis.
Age
Lyme disease is a multi system disease caused by the spirochete Borrelia burgdorferi which is transmitted by ticks to the humans . The deer ticks Ixodes scapularis & Ixodes pacificus are known to carry the bacterium and act as vectors for transmission. It takes about 3-30 days for the symptoms to appear after a tick bite , and three stages of infection are identified, namely early localized (stage 1), early disseminated (stage 2) and late stages (stage 3) .
The disease is most often found in the 5-9 years and 55-59 years age groups . Thus asking about the age can give a clue to the diagnosis.
Occupation This is very important as mentioned above, the bacterium causing the lyme disease,
Borrelia burgdorferi, is most commonly transmitted by the deer ticks
Ixodes scapularis & Ixodes pacificus. Thus occupations that are likely to cause exposure to wild animals such as wild life officers /park rangers/ veterinary surgeons are at an increased risk of disease transmission .
Occupation
This is very important as mentioned above, the bacterium causing the lyme disease,
Borrelia burgdorferi, is most commonly transmitted by the deer ticks
Ixodes scapularis & Ixodes pacificus. Thus occupations that are likely to cause exposure to wild animals such as wild life officers /park rangers/ veterinary surgeons are at an increased risk of disease transmission .
Travel history Recent travel to country side/ wild life safari is important aspects of history as these findings can give a clue to the diagnosis. Travel history
Recent travel to country side/ wild life safari is important aspects of history as these findings can give a clue to the diagnosis.
Early localized stage :General ill symptoms The initial symptoms are fever, headache,malaise,chills, myalgia and fatigue similar to viral illness . Early localized stage :General ill symptoms
The initial symptoms are fever, headache,malaise,chills, myalgia and fatigue similar to viral illness .
Early localized stage : Skin rash Patients may complaint of a single erythematous lesion on the skin which is the erythema migrans rash. It is important to ask about skin rash in the history as 80% of patients present with erythema migrans rash at the initial stage . Early localized stage : Skin rash
Patients may complaint of a single erythematous lesion on the skin which is the erythema migrans rash. It is important to ask about skin rash in the history as 80% of patients present with erythema migrans rash at the initial stage .
Early localized stage : Joint pain Transient arthralgia with swelling of the joints can occur at the early localized stage . Early localized stage : Joint pain
Transient arthralgia with swelling of the joints can occur at the early localized stage .
Early disseminated stage : Skin rash The rash of erythema migrans may proceed into the early disseminated stage causing multiple lesions, as opposed to single lesion in the early localized stage . Early disseminated stage : Skin rash
The rash of erythema migrans may proceed into the early disseminated stage causing multiple lesions, as opposed to single lesion in the early localized stage .
Early disseminated stage : Joint pain Arthralgia is a common in the early disseminated stage .
Note: Joint symptoms are the most common extracutaneous manifestations of the early disseminated disease .
Early disseminated stage : Joint pain
Arthralgia is a common in the early disseminated stage .
Note: Joint symptoms are the most common extracutaneous manifestations of the early disseminated disease .
Early disseminated stage : Facial asymmetry of recent onset Patients may present with this symptom at the early disseminated stage when the facial nerve is affected resulting in palsy . Most often this is unilateral, and asking about the exposure to wild animals can give a clue to the cause of the palsy . Early disseminated stage : Facial asymmetry of recent onset
Patients may present with this symptom at the early disseminated stage when the facial nerve is affected resulting in palsy . Most often this is unilateral, and asking about the exposure to wild animals can give a clue to the cause of the palsy .
Early disseminated stage : Chest pain/ exertional dyspnea/ palpitations/syncope/fatigue These are all manifestations of cardiac involvement of the Lyme disease, causing Lyme carditis . Atrio-ventricular block causes palpitations and syncope . Other rare cardiac effects include bundle branch block, myopericarditis and heart failure . Lyme disease should be suspected in patients coming from endemic areas complaining of these symptoms, and the symptoms occur within 1 to 2 months after infection . Early disseminated stage : Chest pain/ exertional dyspnea/ palpitations/syncope/fatigue
These are all manifestations of cardiac involvement of the Lyme disease, causing Lyme carditis . Atrio-ventricular block causes palpitations and syncope . Other rare cardiac effects include bundle branch block, myopericarditis and heart failure . Lyme disease should be suspected in patients coming from endemic areas complaining of these symptoms, and the symptoms occur within 1 to 2 months after infection .
Late stage: Headache & neck stiffness This occurs in about 15% of untreated patients at the late stage as a consequence of neurological involvement of the disease causing meningitis . Late stage: Headache & neck stiffness
This occurs in about 15% of untreated patients at the late stage as a consequence of neurological involvement of the disease causing meningitis .
Late stage: Altered personality and difficulty in sleeping The patient or the family members may complaint of altered personality and insomnia, due to subacute encephalopathy or axonal polyneuropathy at the late stage of the disease . Late stage: Altered personality and difficulty in sleeping
The patient or the family members may complaint of altered personality and insomnia, due to subacute encephalopathy or axonal polyneuropathy at the late stage of the disease .
Late stage: Weakness of limbs & sensory impairment This can be present at the late stage in about 15% of untreated patients, as a result of motor/sensory radiculoneuropathy and myelitis . Late stage: Weakness of limbs & sensory impairment
This can be present at the late stage in about 15% of untreated patients, as a result of motor/sensory radiculoneuropathy and myelitis .
Late stage : arthritis Arthralgia in the early localized stage can progress into arthritis at the late stage in the untreated disease, with manifestation of clinical features about 6 months after the initial infection . This occurs in 60% of untreated patients and common sites of chronic arthritis are knee & hip joints . Late stage : arthritis
Arthralgia in the early localized stage can progress into arthritis at the late stage in the untreated disease, with manifestation of clinical features about 6 months after the initial infection . This occurs in 60% of untreated patients and common sites of chronic arthritis are knee & hip joints .
Post-Lyme disease syndrome: Fatigue / arthralgia / myalgia/ cognitive difficulties These symptoms may persist even after successful treatment of Lyme disease which is sometimes attributed to post-Lyme disease syndrome . This is thought to be caused by an auto-immune reaction triggered by the association of Lyme disease and human leukocyte antigen haplotypes . Post-Lyme disease syndrome: Fatigue / arthralgia / myalgia/ cognitive difficulties
These symptoms may persist even after successful treatment of Lyme disease which is sometimes attributed to post-Lyme disease syndrome . This is thought to be caused by an auto-immune reaction triggered by the association of Lyme disease and human leukocyte antigen haplotypes .

Clinicals - Examination

Fact Explanation
Early localized stage: General examination: Skin rash Erythematous, oval to circular, with a median diameter of 16 cm, appearing as a single lesion is the classical erythema migrans rash seen in the Lyme disease. The common sites are the back, groin, popliteal fossa, abdomen & axilla . More than one lesion may be seen in about 10-20% of patients . Early localized stage: General examination: Skin rash
Erythematous, oval to circular, with a median diameter of 16 cm, appearing as a single lesion is the classical erythema migrans rash seen in the Lyme disease. The common sites are the back, groin, popliteal fossa, abdomen & axilla . More than one lesion may be seen in about 10-20% of patients .
Early disseminated stage: General examination: Skin rash Tha rash of erythema migrans is seen at multiple sites at the early disseminated stage . Early disseminated stage: General examination: Skin rash
Tha rash of erythema migrans is seen at multiple sites at the early disseminated stage .
Early disseminated stage: Cardio-vascular examination This is important in patients complaining of cardiac symptoms, to look for signs of heart failure, which is a rare complication . Early disseminated stage: Cardio-vascular examination
This is important in patients complaining of cardiac symptoms, to look for signs of heart failure, which is a rare complication .
Late stage: General examination: Neck stiffness/ meningism/positive kernig’s sign These signs are present when the patient is having meningitis, which can occur in about 15% of untreated patients at the late stage of the disease . Late stage: General examination: Neck stiffness/ meningism/positive kernig’s sign
These signs are present when the patient is having meningitis, which can occur in about 15% of untreated patients at the late stage of the disease .
Late stage: Neurological examination: Altered mental status and cognitive impairment This can be present rarely when subacute encephalopathy or axonal polyneuropathy is present at the late stage. Altered mental status can also occur due to meningitis, which is another neurological manifestation . Late stage: Neurological examination: Altered mental status and cognitive impairment
This can be present rarely when subacute encephalopathy or axonal polyneuropathy is present at the late stage. Altered mental status can also occur due to meningitis, which is another neurological manifestation .
Late stage: Neurological examination: Cranial nerve palsies This is also a sequel of neurological manifestations at the late stage of the disease. Thus in every patient presenting at the late stage, cranial nerve examination should be carried out . Facial nerve is commonly affected and mostly unilateral . Late stage: Neurological examination: Cranial nerve palsies
This is also a sequel of neurological manifestations at the late stage of the disease. Thus in every patient presenting at the late stage, cranial nerve examination should be carried out . Facial nerve is commonly affected and mostly unilateral .
Late stage: Neurological examination: Motor & sensory deficit Motor/sensory impairment can be present at the late stage due to radiculoneuropathy and myelitis . Late stage: Neurological examination: Motor & sensory deficit
Motor/sensory impairment can be present at the late stage due to radiculoneuropathy and myelitis .

Investigations - Diagnosis

Fact Explanation
Full blood count (FBC) FBC may show elavated white cell count with neutrophilic leukocytosis due to bacterial infection.
Note: a normal FBC does not exclude the diagnosis of Lyme disease as some patients may have normal results in the FBC .
Full blood count (FBC)
FBC may show elavated white cell count with neutrophilic leukocytosis due to bacterial infection.
Note: a normal FBC does not exclude the diagnosis of Lyme disease as some patients may have normal results in the FBC .
Erythrocyte sedimentation rate (ESR) ESR may be elevated in some infected patients and therefore is a useful test to be done initially. Erythrocyte sedimentation rate (ESR)
ESR may be elevated in some infected patients and therefore is a useful test to be done initially.
Culture of the organism Culture is done on skin biopsy of patients with single lesions of erythema migrans and on the serum of patients with multiple lesions. The disadvantages are that it cannot be used among those without erythema migrans and not routinely available . Culture of the organism
Culture is done on skin biopsy of patients with single lesions of erythema migrans and on the serum of patients with multiple lesions. The disadvantages are that it cannot be used among those without erythema migrans and not routinely available .
Serological tests This is the preferred diagnostic test . Testing by enzyme linked immune sorbent assay (ELIZA) followed by western blot to confirm the initial results is recommended . Serological tests
This is the preferred diagnostic test . Testing by enzyme linked immune sorbent assay (ELIZA) followed by western blot to confirm the initial results is recommended .
C6 peptide assay This is a IgG ELIZA test that has shown a promising result in confirmin the diagnosis but need further evaluation . C6 peptide assay
This is a IgG ELIZA test that has shown a promising result in confirmin the diagnosis but need further evaluation .
Polymerase chain reaction (PCR) PCR in the synovial fluid and cerebro spinal fluid (CSF) in patients with chronic arthritis and neurological Lyme disease respectively is recommended in patients with late Lyme arthritis . Polymerase chain reaction (PCR)
PCR in the synovial fluid and cerebro spinal fluid (CSF) in patients with chronic arthritis and neurological Lyme disease respectively is recommended in patients with late Lyme arthritis .
Intrathecal antibody testing in the CSF sample This is the investigation of choice to diagnose neurological Lyme disease . Intrathecal antibody testing in the CSF sample
This is the investigation of choice to diagnose neurological Lyme disease .
Testing for the antigen in urine This is usually not recommended as it has high false-positive rate . Testing for the antigen in urine
This is usually not recommended as it has high false-positive rate .
Brain imaging (CT/ MRI) and analysis of cerebro-spinal fluid These can be useful at the late stage when neurological symptoms are present or to exclude other neurological differential diagnoses such as bacterial meningitis. Brain imaging (CT/ MRI) and analysis of cerebro-spinal fluid
These can be useful at the late stage when neurological symptoms are present or to exclude other neurological differential diagnoses such as bacterial meningitis.

Investigations - Management

Fact Explanation
Recommendation for follow-up Follow-up of the chronic disease and evaluating the response to treatment with repeated serological testing is not currently recommended as persistently elevated antibody levels may be present in both cured and chronically ill patients . Recommendation for follow-up
Follow-up of the chronic disease and evaluating the response to treatment with repeated serological testing is not currently recommended as persistently elevated antibody levels may be present in both cured and chronically ill patients .

Management - Supportive

Fact Explanation
Assess the risk of transmission The duration of the deer tick on the human and whether it is engorged are the factors that determine the risk of transmission. The tick should be attached for at least 36 hours for transmission of Borrelia burgdorferi to occur as it takes about that time to reach the tick’s salivary glands from the gut . This knowledge influences on treatment decisions as removal of the tick within 24 hours of attachment can prevent transmission . Assess the risk of transmission
The duration of the deer tick on the human and whether it is engorged are the factors that determine the risk of transmission. The tick should be attached for at least 36 hours for transmission of Borrelia burgdorferi to occur as it takes about that time to reach the tick’s salivary glands from the gut . This knowledge influences on treatment decisions as removal of the tick within 24 hours of attachment can prevent transmission .
Take measures for prevention of the disease Health education regarding prevention is an important aspect in the management, particularly in those living in endemic areas. Advice to avoid grassy/ wooded areas that are rich in deer population is very important as it it the the most effective preventive measure .
Also, advice to wear light colored clothing and frequent check-ups to easily detect ticks and bathing following outdoor activities are useful measures of prevention. Use of tick repellents also can be effective, as well as environmental modifications including mowing of grass, deer exclusion fencing and cleaning the leaf litters.
Fine-tipped forceps are recommended to remove the attached ticks .
Take measures for prevention of the disease
Health education regarding prevention is an important aspect in the management, particularly in those living in endemic areas. Advice to avoid grassy/ wooded areas that are rich in deer population is very important as it it the the most effective preventive measure .
Also, advice to wear light colored clothing and frequent check-ups to easily detect ticks and bathing following outdoor activities are useful measures of prevention. Use of tick repellents also can be effective, as well as environmental modifications including mowing of grass, deer exclusion fencing and cleaning the leaf litters.
Fine-tipped forceps are recommended to remove the attached ticks .

Management - Specific

Fact Explanation
Antibiotic treatment : Doxycyclin Oral doxycycline is the preferred drug of choice for early localized & disseminated disease with erythema migrans. It can also be used for cardiac disease and for arthritis at the late stage . Doxycycline is a tetracycline that has broad spectrum activity. It exerts its bacteriostatic effect by inhibiting protein synthesis of bacteria . It has added benefit as well, as it acts against other tick-borne illnesses such as human granulocytic anaplasmosis, that can co-exist with the Lyme disease in 10% of patients .
the recommended dosage is 100mg twice daily for adults for 10 to 21 days for early localized stage, 10 to 21 days for early disseminated days and 28 days for late stage .
Important: Doxycycline is contraindicated in breast feeding and pregnant women and chldren less than 8 years .
Antibiotic treatment : Doxycyclin
Oral doxycycline is the preferred drug of choice for early localized & disseminated disease with erythema migrans. It can also be used for cardiac disease and for arthritis at the late stage . Doxycycline is a tetracycline that has broad spectrum activity. It exerts its bacteriostatic effect by inhibiting protein synthesis of bacteria . It has added benefit as well, as it acts against other tick-borne illnesses such as human granulocytic anaplasmosis, that can co-exist with the Lyme disease in 10% of patients .
the recommended dosage is 100mg twice daily for adults for 10 to 21 days for early localized stage, 10 to 21 days for early disseminated days and 28 days for late stage .
Important: Doxycycline is contraindicated in breast feeding and pregnant women and chldren less than 8 years .
Antibiotic treatment : Amoxycillin Can be given 500mg three times daily for 14 to 21 days in early localized stage and for 28 days in the late stage . Antibiotic treatment : Amoxycillin
Can be given 500mg three times daily for 14 to 21 days in early localized stage and for 28 days in the late stage .
Antibiotic treatment : Macrolides Azithromycin, erythromycin and clarythromycin can be used. The recommended dosages are for azithromycin: 500mg daily for 7 to 10 days; erythromycin: 500mg for 14 to 21 days; clarithromycin; 500mg twice daily for 14 to 21 days in early localized stage and for 28 days in arthritis .
Note: as macrolides are less effective than other drugs, they should be reserved for those who are intolerant to doxycycline/amoxycillin and cefuroxime acetil .
Antibiotic treatment : Macrolides
Azithromycin, erythromycin and clarythromycin can be used. The recommended dosages are for azithromycin: 500mg daily for 7 to 10 days; erythromycin: 500mg for 14 to 21 days; clarithromycin; 500mg twice daily for 14 to 21 days in early localized stage and for 28 days in arthritis .
Note: as macrolides are less effective than other drugs, they should be reserved for those who are intolerant to doxycycline/amoxycillin and cefuroxime acetil .
Antibiotic treatment : cephalosporins Intravenous cefotaxime & cephtriaxine are used for cardiac and neurologic Lyme disease and refractory Lyme arthritis . The recommended dosing for cefotaxime is 2g 8 hourly while for cephtriaxone is 2g daily for 14 to 28 days .
important: As cephtraixone is not superior to oral antibiotics and has more adverse effects, it is not recommended to use in early Lyme disease unless the patient is having cardiac or neurologic symptoms .

Note: prolonged antibiotic therapy for chronic Lyme disease/ post-Lyme disease syndrome is currently not recommended as there is no scientific evidence of proven benefit .
Antibiotic treatment : cephalosporins
Intravenous cefotaxime & cephtriaxine are used for cardiac and neurologic Lyme disease and refractory Lyme arthritis . The recommended dosing for cefotaxime is 2g 8 hourly while for cephtriaxone is 2g daily for 14 to 28 days .
important: As cephtraixone is not superior to oral antibiotics and has more adverse effects, it is not recommended to use in early Lyme disease unless the patient is having cardiac or neurologic symptoms .

Note: prolonged antibiotic therapy for chronic Lyme disease/ post-Lyme disease syndrome is currently not recommended as there is no scientific evidence of proven benefit .
Post-exposure prophylaxis This is recommended for engorged ticks that have been attached for 36 hours or more in an area of at least 20% rate of tick infection. A single 200mg dose of oral doxycycline is the drug of choice and should be given within 72 hours of tick removal . Post-exposure prophylaxis
This is recommended for engorged ticks that have been attached for 36 hours or more in an area of at least 20% rate of tick infection. A single 200mg dose of oral doxycycline is the drug of choice and should be given within 72 hours of tick removal .

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