Understanding Lyme Disease: Symptoms, Diagnosis, and Treatment Options
Lyme disease is an infectious inflammatory disease caused by Borrelia burgdorferi and spread by tick bites. It presents with a range of symptoms, including fever, headache, fatigue, and a characteristic erythema migrans rash. Prompt diagnosis and treatment are essential to prevent complications such as Lyme arthritis and neurological problems. Risk factors include spending time in wooded areas and not removing ticks promptly. Recognizing the signs and symptoms early can lead to better outcomes for patients.
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Lyme Disease Paul LaBarbera, PharmD Candidate 2022
Patient Case Day 1 JW is a 33yo Caucasian male who presents to the emergency department with fever, muscle ache and progressing numbness in extremities. He states that the last week he has been feeling tired and has had a growing red rash on trunk of body. He has progressing ascending weakness. Had previously went to see his PCP and received steroids several days prior He reported later on that he went disc golfing a few weeks back
Patient Case Allergies: NKDA PMH: No Known medical Hx Day 1: Admission The patient was admitted, and the following were ordered: Ceftriaxone (IV): 2g every 24 hours Pip-Tazo (IV): 4.5g every 8 hours Enoxaparin (SQ inj): 40mg once daily PRN Pain Medications Current Home Medications: APAP 325mg: PRN Omeprazole 40mg: once daily Labs Labs: WBC/Hgb/Hctt/Pits: 12.33 Na/K+/Phos/Mg/Ca: 138/3.9/3.6/2.3 (5/1 @1150) BUN/ SCr/ Cl/CO2/Glucose: 11/1.30 12.33/17.0/51.1/192 (5/1 @1150) 1.30/103/28/94 (5/1 @1150)
Lyme Disease (Lyme borreliosis) Infectious inflammatory disease caused by Borrelia burgdorferi and spread by tick (Ixodes spp.) bites
Epidemiology Caused by Caused by: Borrelia burgdorferi Spread by ticks (Ixodes) Endemic Areas: United States Northeast Upper Midwest Mid-Atlantic Parts of Canada, Europe, & Asia Risk Factors Spending time in wooded and/or grassy area (hiking, camping, disk golf) Exposed skin while outdoors Not removing ticks promptly and properly Residing in an endemic area The likelihood of transmission increases with duration of attachment (3) www.cdc.gov/lyme
Signs & Symptoms Early Stages Late Stage Fever, Chills Headache Fatigue Body ache Swollen lymph nodes May occur in absence of rash Erythema migrans rash Erythema migrans rash Bullseye Rash 70 - 80% all LD cases (2) Can present from 1 - 30 days after tick bite Does not always appear as a classic erythema migrans rash Erythema migrans rash Erythema migrans rash Severe Joint pain Neurological problems: Altered mental status Numbness or weakness of limbs Paralysis Disseminated Infection (3) www.cdc.gov/lyme
Complications & Manifestations Lyme Arthritis Typically presents with marked swelling of 1 or a few large joints, most often the knee, with less pain than expected based on the degree of swelling Lyme Carditis Symptoms include dyspnea, edema, palpitations, lightheadedness, chest pain, and syncope. Lyme Neuroborreliosis (LNB) Types of Manifestations (CNS & PNS) PNS: Facial Nerve Palsy CNS: meningoencephalitis Symptoms: range from mild confusional state to severe encephalitis. Neurologic involvement secondary to systemic infection by the spirochete Borrelia burgdorferi With typical inflammatory imaging characteristics that could be confused with the first episode of demyelinating disease Post-Treatment Lyme Disease Syndrome (PTLDS) Symptoms of pain, fatigue, or difficulty thinking that lasts for >6 months after completing treatment
Diagnosis and Testing Serum antibody test is the recommended lab test used when needed for diagnostic confirmation. Lab testing (Ab test) not recommended in patients with 1+ skin lesions compatible with erythema migrans Patients with 1+ skin lesions that are suggestive of but atypical of erythema migrans: Antibody testing performed on an acute-phase serum sample
Chemoprophylaxis for High-Risk Tick Bite Population: Population: Adults & Children within 72 hours of removal of an identified high-risk tick bite, but not for bites that are equivocal risk or low risk (5) Medication Treatment: Medication Treatment: All Age Groups: Doxycycline (single dose) by mouth within 72 hrs of tick removal Dosing: Adults: 200mg Children: 4.4 mg/kg (max dose: 200mg) High Risk Tick Bite: - Must meet the following 3 criteria: a. An identified Ixodes spp. vector species b. It occurred in a highly endemic area c. The tick was attached for 36 hours.
Treatment Guidelines Medication Dosing Medication Route Dose (Adults) Dose (Children) Doxycycline PO 100mg BID 4.4 mg/kg/day - In 2 divided doses (Max: 200mg/day) Amoxicillin PO 500mg TID 50 mg/kg/day - In 3 divided doses (Max: 500mg/dose) Cefuroxime axetil PO 500mg BID 30 mg/kg/day - In 2 divided doses (Max: 500mg/dose) Ceftriaxone (1stline IV) IV 2g QDay 50 - 75 mg/kg QDay (Max: 2000mg/dose) Azithromycin PO 500mg QDay 10 mg/kg once daily (maximum 500 mg per dose) (Only 1stline Erythema migrans)
Duration of Treatment Disease Manifestation Route Medication Duration (days) Erythema migrans Doxycycline 10 Amoxicillin or cefuroxime axetil 14 PO Azithromycin 5 10 Meningitis, Cranial Neuropathy, Radiculopathy PO Doxycycline 14 21 IV Ceftriaxone 14 21 Cranial nerve palsy PO Doxycycline 14 21 Carditis PO Doxycycline, Amoxicillin, or Cefuroxime axetil 14 21 Carditis (Initial Inpt) IV Ceftriaxone 14 21 Arthritis (Initial) PO Doxycycline, Amoxicillin, or Cefuroxime axetil 28 Arthritis (Recurrent or refractory) PO Doxycycline, Amoxicillin, or Cefuroxime axetil 28 IV Ceftriaxone 14 28 Acrodermatitis chronica atrophicans PO Doxycycline, Amoxicillin, or Cefuroxime axetil 21 28 Borrelial lymphocytoma PO Doxycycline, Amoxicillin, or Cefuroxime axetil 14
Treatment of Lyme Disease Manifestations Erythema Migrans Treatment options: Doxycycline: x10 days Amoxicillin or cefuroxime axetil: x14 days Azithromycin: x5-10 days Lyme Carditis Outpatient: Oral Abx (Doxy, Amox, Cefuroxime, or Azithromycin) Inpatient: Initial treatment: IV: Ceftriaxone Duration: until evidence of clinical improvement Treatment after clinical improvement: PO: Doxycycline, Amoxicillin, Cefuroxime axetil, or Azithromycin Total Abx Treatment Duration: 14 - 21 days Lyme Arthritis Treatment: Doxycycline, Amoxicillin, or Cefuroxime axetil Treatment Duration: 28 days
Treatment of Lyme Disease Manifestations Cont. Lyme Neuroborreliosis: (Meningitis, Cranial Neuropathy, Radiculopathy, Cranial Nerve Palsy): Treatment Options: IV: Ceftriaxone, Cefotaxime, Penicillin G PO: Doxycycline Treatment Duration: 14 - 21 days Post Treatment Lyme Disease: Not recommended for additional antibiotic therapy Pt s who lack objective evidence of reinfection or treatment failure
Patient Case Day 15 of Admission: JW s paralysis rapidly progressed and is now quadriplegic. It is believed to be the result of either Lyme Neuroborreliosis or Guillain-Barre Syndrome. A Lyme antibody test was done, and it came back positive for Lyme antibodies JW is still currently on IV antibiotics and being monitored
References 1. About Lyme Disease Symptoms. Lyme Disease Association, 20 May 2021, lymediseaseassociation.org/about-lyme/medical/lyme- disease-symptoms/. Lantos, Paul M, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. OUP Academic, Oxford University Press, 30 Nov. 2020, academic.oup.com/cid/article/72/1/e1/6010652. Lyme Disease. Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 5 Mar. 2021, www.cdc.gov/lyme/index.html. Lexicomp - Doxycycline, Wolters Kluwer, online-lexi-com.proxy.lib.ohio- state.edu/lco/action/doc/retrieve/docid/patch_f/6792?cesid=5c8fUx9LxYa&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Ddoxyc ycline%26t%3Dname%26va%3Ddoxycycline. Warshafsky S, Lee DH, Francois LK, Nowakowski J, Nadelman RB, Wormser GP. Efficacy of antibiotic prophylaxis for the prevention of Lyme disease: an updated systematic review and meta-analysis. J Antimicrob Chemother. 2010;65(6):1137-1144. doi:10.1093/jac/dkq097 P. Hildenbrand, et al. Manifestations of a Rapidly Emerging Zoonosis. American Journal of Neuroradiology Jun 2009, 30 (6) 1079- 1087; DOI: 10.3174/ajnr.A1579 2. 3. 4. 5. 6.
