eMedicine Specialties > Neurology > Neurological Infections

Lyme Disease: Follow-up

Author: Augusto A Miravalle, MD, Fellow, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School
Coauthor(s): R Philip Kinkel, MD, FAAN, Associate Professor of Neurology, Harvard Medical School; Director, Multiple Sclerosis Center, Beth Israel Deaconess Medical Center; Consultant Neurologist, Children's Hospital of Boston
Contributor Information and Disclosures

Updated: Jul 23, 2009

Follow-up

Further Outpatient Care

  • Depending on the clinical presentation, continued follow-up by the treating rheumatologist, psychiatrist, and/or neurologist may be warranted.
  • Follow-up may be of particular importance in patients with the chronic sequelae of the controversial post-LD syndrome, in which symptoms may be refractory to conventional therapies.

Deterrence/Prevention

  • Avoid areas that nymphal B burgdorferi -infected ticks inhabit.
  • Wear appropriate clothing for outdoor exposure in endemic areas. Wear long-sleeved shirts and pants, and tuck them in whenever possible. Wear light-colored clothing, which may aid the detection of ticks. Inspect the entire body daily to locate and remove any ticks.
  • Use a tick repellent containing N,N- diethyl-m-toluamide (DEET) or permethrin when exposure to an endemic environment is imminent.
    • DEET is available in 5-100% concentrations as sprays, creams, gels, lotions, solutions, towelettes, and other formulations.
    • In most circumstances, products containing 10-35% DEET are sufficient to provide adequate protection from ticks.
    • The American Academy of Pediatrics has issued a recommendation that children not be exposed to products containing more than 10% DEET because of several case reports of neurotoxicity occurring in children exposed to high concentrations. To prevent accidental exposure to the mucous membranes, DEET repellent should not be applied to children's hands.
    • The degree of protection is proportionally related to the concentration of DEET. That is, products with a high DEET concentration provide a long duration of protection. Extended-release liposphere microdispersion DEET preparations (6.5% and 10%) may decrease exposure to high concentrations of DEET while maintaining a relatively long (2-4 h) duration of activity.
    • Other proposed guidelines to reduce DEET exposure include using a minimal amount of product to cover the exposed skin and clothes; avoiding contact with mucous membranes, open cuts, or irritated skin; and washing treated areas with soap and water as soon as the person goes indoors.
  • The US Food and Drug Administration approved a vaccine for LD (LYMErix Lyme disease vaccine [recombinant OspA]; SmithKlineBeecham Biologicals, Philadelphia, Pa). The vaccine was discontinued because of poor demand. Currently, no vaccine is available.
    • Previous vaccination does not alter current treatment recommendations.
    • Vaccinated individuals have positive results with ELISAs for LD antibodies but can be distinguished from those with active infection using a Western blot test.
  • Prophylactic antibiotic therapy (single 200-mg dose of doxycycline) is only recommended for adults and children older than 8 years if all of the following circumstances exist:
    • The attached tick can be recognized as I scapularis (adult or nympha) and it is estimated to have been attached for more than 36 hours.
    • Prophylaxis can be started within 72 hours of the time the tick was removed.
    • Ecologic information indicates that the local rate of infection of these ticks with B burgdorferi is greater than 20%.
    • Doxycycline is not contraindicated.

Prognosis

  • The prognosis for most patients receiving conventional antimicrobial therapy is excellent. A recent study of the long-term symptoms and effect on activities of daily living revealed no significant difference between patients previously treated for LD and age-matched control subjects 15-135 months after diagnosis.
  • Post-LD syndromes have not been well defined. Proposed criteria include the presence of fatigue, musculoskeletal pain, and/or cognitive difficulties within 6 months of the diagnosis of LD and a persistence of symptoms for at least 6 months after completion of generally accepted antibiotic therapy. The presence of co-infections (babesiosis, human granulocytic anaplasmosis) and objective evidence of associated conditions or underlying disorders that may explain the patient's symptoms exclude the existence of a post-LD syndrome.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Given the lack of specificity in the clinical presentation of LD and given the limitations of serologic testing, both misdiagnosis and underdiagnosis of LD continue to be problems.
  • Unnecessary serologic testing and inappropriate therapy contribute to excessive financial costs.
  • Lack of recognition of LD imposes considerable burdens on patients with chronic manifestations and their caregivers.

Special Concerns

  • Pregnancy
    • Extremely rare cases of neonatal death or stillbirth have been reported after pregnancies complicated by untreated or inadequately treated symptomatic maternal Lyme borreliosis. Subsequent findings from Centers for Disease Control and Prevention studies suggest that congenital infection with B burgdorferi is unlikely and that it is not directly responsible for adverse fetal outcomes.
    • Special consideration should be given to drug therapy in pregnant women. Doxycycline is contraindicated in pregnancy (pregnancy category D) because of fetal risks, such as permanent discoloration of the teeth, enamel hypoplasia, and retardation of skeletal development.
  • Co-infection
    • Co-infection with other tick-borne illnesses should be considered in patients with a poor response to conventional antimicrobial therapy or altered clinical presentations.
    • Co-transmitted infective organisms can include Babesia microti, the primary cause of babesiosis; Anaplasma phagocytophilium, the cause of human granulocytic anaplasmosis; flavivirus, the cause of tick-borne encephalitis; and Powassan or tick-borne encephalitislike virus.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Michael J Schneck, MD; Julie L Puotinen, PharmD; Eugene Y Cheng, MD, FCCM; Wendy Peltier, MD; and Cindy R Hennen, RPh, BS to the development and writing of this article.



More on Lyme Disease

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References
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Further Reading

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Keywords

Lyme arthritis, Lyme borreliosis, Garin-Boujadoux-Bannwarth syndrome, Garin-Bujadoux-Bannwarth syndrome, Bannwarth syndrome, Borrelia burgdorferi sensu lato, B burgdorferi sensu lato, Borrelia burgdorferi sensu stricto, B burgdorferi sensu stricto, Ixodes ricinus, I ricinus, Borrelia garinii, B garinii, Borrelia afzelii, B afzelii ticks, tick-borne disease, Lyme disease

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Contributor Information and Disclosures

Author

Augusto A Miravalle, MD, Fellow, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School
Augusto A Miravalle, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

R Philip Kinkel, MD, FAAN, Associate Professor of Neurology, Harvard Medical School; Director, Multiple Sclerosis Center, Beth Israel Deaconess Medical Center; Consultant Neurologist, Children's Hospital of Boston
R Philip Kinkel, MD, FAAN is a member of the following medical societies: American Academy of Neurology and Consortium of Multiple Sclerosis Centers
Disclosure: Nothing to disclose.

Medical Editor

Aashit K Shah, MD, Associate Professor of Neurology, Wayne State University; Program Director, Clinical Neurophysiology Fellowship, Department of Neurology, Detroit Medical Center
Aashit K Shah, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, and American Epilepsy Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Michael K Racke, MD, Professor of Neurology and Molecular Virology, Immunology, and Medical Genetics, Chairman of Neurology, Chief of Neurology Service, Ohio State University Medical Center
Michael K Racke, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for the Advancement of Science, American Association of Immunologists, and American Neurological Association
Disclosure: Teva Neuroscience Consulting fee Consulting; Peptimmune Inc. Consulting fee Consulting; Bristol Myers Squibb Consulting fee Consulting; EMD Serono Honoraria Speaking and teaching

 
 
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