Updated: 12/19/2019

Lyme Disease

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Questions
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Topic
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
  • Prognosis
    • the rash typically self-resolves without treatment
    • untreated Lyme disease can result in arthritis
    • excellent prognosis with early antibiotic treatment 
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

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(M2.ID.15.4686) A 29-year-old male presents to an urgent care clinic with complaints of fever, malaise, fatigue, and a rash on his upper arm (Figure A). He reports that he just returned from a camping trip in Connecticut this past weekend. Which of the following is a known complication of failing to appropriately treat this patient's presenting condition?

QID: 107418
FIGURES:
1

Toxic megacolon

0%

(0/23)

2

Flaccid paralysis

9%

(2/23)

3

Hydrophobia

0%

(0/23)

4

Cranial nerve VII palsy

87%

(20/23)

5

Paralytic myelitis

0%

(0/23)

M 7 C

Select Answer to see Preferred Response

(M2.ID.14.71) A 55-year-old woman presents to her primary doctor for a 1-day history of left knee swelling and mild pain. She has also felt generally unwell for the past several days which she attributed to a viral illness and her rheumatoid arthritis. The patient works as a commerical sex worker and generally does not see her physician. Review of systems is notable for her complaining of palpitations during this time frame as well, which she attributes to anxiety. Her temperature is 100°F (37.8°C), blood pressure is 127/81 mmHg, pulse is 60/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient's left knee appears swollen and warm to the touch; however, she is able to ambulate and passive range of motion does not elicit significant pain. An ECG is performed as seen in Figure A. Which of the following is the most likely etiology of this patient's symptoms?

QID: 103012
FIGURES:
1

Borrelia burgdorferi

31%

(5/16)

2

Neisseria gonorrhoeae

44%

(7/16)

3

Rickettsia rickettsii

0%

(0/16)

4

Sarcoidosis

0%

(0/16)

5

Staphylococcus aureus

25%

(4/16)

M 6 E

Select Answer to see Preferred Response

Evidence (6)
EXPERT COMMENTS (8)
Private Note