Lyme Disease

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Lyme Disease


Signs and symptoms

Signs and symptoms of Lyme disease vary by disease stage. Physical findings in patients with early disease are as follows:
  • Erythema migrans (EM) - Rash
  • Fever
  • Myalgias
  • Malaise
  • Arthralgia
  • Headache
  • Tender local adenopathy (local, not diffuse)
Physical findings in patients with early disseminated disease are as follows:
  • EM (single or multiple lesions)
  • Headache
  • Fever
  • Tender adenopathy (regional or generalized)
  • Conjunctivitis (uncommon, never prominent)
  • Carditis (usually manifests as heart block)
  • Meningismus as a sign of aseptic meningitis
  • Cranioneuropathy, especially cranial nerve VII and Bell palsy (peripheral seventh nerve palsy with decreased unilateral function, including the forehead)
In patients with late disease, the typical physical finding is arthritis. Arthritis is located mostly in large joints, especially the knee. Warmth, swelling from effusion, and limited range of motion help distinguish arthritis from simple arthralgia.

Diagnosis

In endemic areas, patients with probable erythema migrans and a recent source of tick exposure should be started on treatment without blood tests. For serologic testing, the CDC recommends a two-tier testing procedure, as follows [2] :
  • Step 1: enzyme immunoassay (EIA) or immunofluorescence assay (IFA) - Total Lyme titer or IgG and IgM titers
  • Step 2: Western blot testing
Western blot testing is performed only if step 1 test results are positive or equivocal. If signs and symptoms have been present for 30 days or less, both IgM and IgG Western blot testing are performed; if signs and symptoms have been present for more than 30 days, only IgG Western blot testing is performed.
Since Western blot testing is necessary to exclude false-positive EIA or IFA results, but unnecessary if the initial test is negative, Lyme titers should always be ordered with a reflex confirmatory test. Most commercial laboratories will perform both IgG and IgM Western blots.
If the patient has been in Europe, where different strains of Borrelia are more common, a C6 peptide ELISA is a more accurate confirmatory test than the Western blots, which have been developed to B burgdorferi, which is the most common strain found in the United States. The C6 peptide is less expensive than the Western blots and is as sensitive and specific for B burgdorferi; it is a reasonable alternative for the Western blots, but has not replaced it as the usual confirmatory test in the United States.
Other studies that may be used are as follows:
  • Joint aspiration - To exclude other causes of effusion (eg, septic arthritis, gout, pseudogout)
  • CSF analysis - In patients with meningitis
  • ECG - To identify Lyme carditis
See Workup for more detail.

Management

Antibiotic selection, route of administration, and duration of therapy for Lyme disease are guided by the patient’s clinical manifestations and stage of disease, as well as the presence of any concomitant medical conditions or allergies.
Treatment of Lyme disease is as follows:
  • Adult patients with early localized or early disseminated Lyme disease associated with erythema migrans: Doxycycline, amoxicillin, or cefuroxime axetil
  • Children under 8 years and pregnant or nursing women with early localized or early disseminated Lyme disease: Amoxicillin or cefuroxime axetil
  • Neurologic Lyme disease: IV penicillin, ceftriaxone, or cefotaxime; oral doxycycline, when not contraindicated, in patients with Lyme-associated meningitis, facial nerve palsy, or radiculitis
Treatment of Lyme arthritis is as follows:
  • Oral antibiotics for 28 days
  • Re-treatment with oral antibiotics for mild residual joint swelling
  • Re-treatment with IV antibiotics for refractory cases
  • Oral antibiotics for another month in patients with positive PCR of synovial fluid
  • NSAIDs in patients with negative PCR, supplemented if necessary with hydroxychloroquine
  • Consideration of arthroscopic synovectomy in patients unresponsive to symptomatic therapy
Lyme carditis may be treated with either oral or parenteral antibiotic therapy for 14 days (range, 14-21 days). Hospitalization and continuous monitoring, with consideration for temporary pacing, are advisable for patients with any of the following:
  • Associated symptoms (eg, syncope, dyspnea, or chest pain)
  • Second-degree or third-degree AV block
  • First-degree heart block with prolongation of the PR interval to more than 30 milliseconds (the degree of block may fluctuate and worsen very rapidly in such patients)
  • New Cause for Lyme Disease Complicates Already Murky Diagnosis

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