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Updated: Aug 19 2022

Lyme Disease

Images
https://upload.medbullets.com/topic/120066/images/bullseye_lyme_disease_rash.jpg
https://upload.medbullets.com/topic/120066/images/ixodesnymphstage350x235.jpg
  • Snapshot
    • A 16-year-old boy presents to his primary care physician with fatigue, malaise, and a rash. His symptoms began approximately 1 week ago and have progressively worsened. He said he recently hiked in northern Connecticut but is unsure if he was bitten by a tick. On physical exam, there is an erythematous and slightly raised lesion that appears "target-like" on the right thigh. He is given oral doxycycline.
  • Introduction
    • Definition
      • a tick-borne illness characterized by 3 stages
        • early localized stage (within 1 month of the tick bite)
          • erythema migrans
        • early disseminated stage
          • multiple erythema migrans
          • neurological symptoms (e.g., facial nerve palsy, meningitis, and mononeuritis multiplex)
          • cardiac symptoms (e.g., carditis)
        • late stage
          • arthritis
          • encephalopathy or polyneuropathy
  • Epidemiology
    • Incidence
      • most cases in the northeast and upper midwest
  • Etiology
    • Borrelia burgdorferi, a spirochete transmitted by the Ixodes tick
      • this tick is also a vector for
        • Anaplasma spp.
        • Babesia microti
  • Presentation
    • Symptoms
      • early localized stage
        • erythema migrans (7-14 days post-tick bite)
          • round erythema that expands and can result in the classic target lesion
          • may be accompanied by systemic symptoms such as
            • fevers
            • myalgias
            • arthralgias
            • headache
            • fatigue
      • early disseminated stage
        • multiple erythema migrans
        • neurological symptoms (e.g., facial nerve palsy, meningitis, and mononeuritis multiplex)
        • lyme carditis
          • may present as an atrioventricular block and/or myopericarditis
      • late stage
        • arthritis
          • the knees are classically involved
        • encephalopathy or polyneuropathy
  • Differential Diagnosis
    • Ehrlichiosis
      • fever, malaise, aches, without a rash
      • leukopenia, thrombocytopenia and elevated aminotransferases
  • Studies
    • Making the diagnosis
      • this is a clinical diagnosis
    • Cerebrospinal fluid analysis when there is central nervous system involvement
    • Synovial fluid analysis when arthritis is suspected
    • Serologic studies
      • performed to support the clinical diagnosis
  • Treatment
    • Medical
      • doxycycline or amoxicillin
        • indication
          • erythema migrans
          • Lyme arthritis
        • macrolides can be used in patients who are allergic to doxycycline, ceftriaxone, and cefuroxime
      • ceftriaxone
        • indication
          • neurologic Lyme disease
          • Lyme carditis
  • Prognosis
    • The rash typically self-resolves without treatment
    • Untreated Lyme disease can result in arthritis
    • Excellent prognosis with early antibiotic treatment
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