Review Question - QID 107418

This patient with fevers, malaise and a rash consistent with erythema migrans likely has early localized Lyme disease. Without appropriate antibiotic therapy, patients with Lyme disease may develop neurological complications to include facial nerve palsies.

Lyme disease occurs due to infection with Borrelia burgdorferi, a spirochete bacteria most commonly transmitted to humans through bites from the Ixodes scapularis tick. The disease occurs in a relatively predictable course in stages. Early localized disease typically presents with flu-like symptoms, mild fevers, and the classic erythema migrans rash, as in this patient. Patients that do not receive treatment may progress to early or late disseminated disease. Complications include neurologic manifestations such as facial nerve palsy. Notably, bilateral facial nerve palsy may occur in patients with disseminated Lyme disease. Other common complications include atrioventricular block and arthritis. For patients such as this one with early localized disease, the most appropriate next step in management is treatment with oral doxycycline. Patients with disseminated disease often require treatment with different, prolonged antibiotic regimens. Complications of disseminated disease such as facial nerve palsies generally resolve with antibiotic therapy.

Wright et al. discuss the diagnosis and management of Lyme disease. The presence of erythema migrans rash alone is sufficient to make the diagnosis of Lyme disease. The diagnosis may be confirmed with an enzyme-linked immunosorbent assay (ELISA) followed by a Western blot (if the ELISA results are positive or equivocal). Doxycycline is the recommended initial treatment; however, for more advanced disease, IV ceftriaxone or penicillin G is appropriate.

Meier discusses neurological complications of Lyme disease. Meningoradiculoneuritis occurs in the second stage and manifests with painful asymmetrical motor and sensory dysfunction as well as evidence of inflammation on CSF analysis. Mononeuritis multiplex occurs in the third stage of infection, causes damage to at least two separate nerve distributions, and results in painful assymetrical motor and sensory symptoms.

Figure A is a photograph demonstrating a rash consistent with erythema migrans. Note the erythematous rings with central clearing in the classic "bullseye" appearance.

Incorrect Answers:
Answer 1: Disseminated intravascular coagulopathy may occur as a result of a variety of different infectious disease including Rocky Mountain Spotted Fever, another tick-borne infection caused by infection with Rickettsia ricketsii. However, this patient's clinical presentation and history are more consistent with Lyme disease, which is not associated with disseminated intravascular coagulopathy.

Answer 3: Flaccid paralysis occurs due to toxin-mediated effects of Clostridium botulinum. Patients typically report a history of exposure to improperly canned foods or fermented foods. Lyme disease is not associated with flaccid paralysis.

Answer 4: Paralytic myelitis occurs as a complication of poliovirus infection. Poliovirus has been largely eradicated in the United States due to vaccination. Lyme disease is not commonly associated with paralytic myelitis.

Answer 5: Toxic megacolon is a feared complication of pseudomembranous colitis that occurs due to infection with Clostridium difficile. It is not commonly associated with Lyme disease.

Bullet Summary:
Without appropriate antibiotic therapy, patients with Lyme disease may develop neurological complications to include facial nerve palsies.