Lyme Disease Medication

  • Author: John O Meyerhoff, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Sep 27, 2011
 

Medication Summary

The goals of pharmacotherapy with antibiotics are to reduce morbidity and to prevent complications.

Cutaneous manifestations

In general, skin manifestations of Lyme disease respond promptly to appropriate antibiotic therapy. Early manifestations respond more rapidly than later manifestations. Data regarding the best route and duration of antibiotic therapy are evolving and are, to some extent, controversial. Some researchers claim an abundance of overtreatment and overdiagnosis of Lyme disease, pointing to several nonspecific conditions and symptoms that have been linked to Lyme disease. They indicate that if these sequelae remain after appropriate therapy, other causes must be carefully and conclusively excluded.[47]

For solitary erythema migrans, oral antibiotics clearly provide effective therapy. The duration of recommended therapy ranges from 10-30 days. Historically, some authors have recommended 3 weeks of treatment, as a sizable minority of patients with solitary erythema migrans have evidence of hematogenous dissemination, even in the absence of symptoms. In addition, strong evidence indicates that patients with early disseminated Lyme disease have equally good outcomes after 3 weeks of oral antibiotics compared with 2 weeks of parenteral therapy. Therefore, patients with erythema migrans and asymptomatic disseminated disease are treated adequately using the 3-week course.

Although the approach described above has inherent logic, newer studies based on actual outcomes have called into question duration of therapy beyond 10 days. In one retrospective study of 607 patients, 25% of whom had early disseminated disease, outcomes of patients treated for 10 days were equivalent to those treated with longer courses.[48] Based on this, and previous studies, many authorities consider 2 weeks of antibiotics to be adequate therapy for erythema migrans and some use as few as 10 days.

Pregnancy

For pregnant women with erythema migrans, some physicians recommend parenteral therapy, although data on this are limited. Isolated reports exist of transplacental transmission from the mother to fetus. One European descriptive study showed good results of parenteral ceftriaxone in pregnant women with erythema migrans.[49]

Borrelial lymphocytoma

Borrelial lymphocytoma usually is treated with 14-21 days of oral antibiotics, but when symptoms of dissemination are noted, parenteral therapy sometimes is used. Borrelial lymphocytoma is sufficiently uncommon that no comparative trials address the ideal duration of treatment, route of administration of the antibiotic, or the choice of medication. For the same reasons as in erythema migrans, some logic exists in using a 3-week course of antibiotics.

Acrodermatitis chronica atrophicans

Acrodermatitis chronica atrophicans is usually treated with 1-month course of oral antibiotics, usually a beta-lactam or doxycycline. One study showed fewer relapses with 30 days compared with 20 or fewer days of therapy. In the same study, 30 days of oral antibiotics were more effective than 15 days of intravenous ceftriaxone (2 g/d).[50] Ensure that no neurologic manifestations are present before embarking on oral therapy.

Next

Antibiotics

Class Summary

Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. These agents are usually directed against B burgdorferi sensu lato, but antibiotics are indicated for all the cutaneous manifestations of Lyme disease.

View full drug information

Doxycycline (Monodox, Doryx, Vibramycin)

 

Doxycycline is the preferred drug for oral treatment in all patients except for pregnant and nursing women and children < 8 y. This agent inhibits protein synthesis and thus bacterial growth by binding to the 30S and possibly the 50S ribosomal subunits of susceptible bacteria.

View full drug information

Penicillin VK

 

Penicillin VK inhibits the biosynthesis of cell wall mucopeptide. This agent is Bactericidal against sensitive organisms when adequate concentrations are reached, and penicillin VK is most effective during the stage of active multiplication. Inadequate concentrations of this drug may produce bacteriostatic effects only. In addition, penicillin VK can be used to treat erythema migrans, as it is safe in both pregnant and pediatric patients, although amoxicillin is used more commonly these patients.

View full drug information

Penicillin G (Pfizerpen)

 

Penicillin G is a penicillin antibiotic that inhibits cell-wall synthesis. This agent is an alternative drug to ceftriaxone in patients requiring parenteral therapy.

View full drug information

Amoxicillin

 

Amoxicillin is the drug of choice for oral treatment for pregnant or nursing women and children < 8 y. This agent interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

View full drug information

Erythromycin (E.E.S., Ery-Tab, Erythrocin, EryPed)

 

Limit the use of erythromycin to patients who cannot take the drugs listed previously. This agent inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. In children, age, weight, and severity of infection determine the proper dosage. When twice-daily dosing is desired, half the total daily dose may be taken q12h. For more severe infections, double dose.

View full drug information

Ceftriaxone (Rocephin)

 

Ceftriaxone is a third-generation cephalosporin that arrests bacterial growth by binding to one or more penicillin-binding proteins. This agent is the preferred drug for intravenous therapy.

View full drug information

Cefuroxime (Ceftin)

 

Cefuroxime is a second-generation cephalosporin that is the only drug approved by Food and Drug Administration (FDA) for use in Lyme disease. It binds to penicillin-binding proteins and inhibits the final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death. Cefuroxime is approved for use in adults.

View full drug information

Cefotaxime (Claforan)

 

Cefotaxime is a third-generation cephalosporin that inhibits bacterial cell-wall synthesis. This agent is an alternative drug to ceftriaxone in patients requiring parenteral therapy.

View full drug information

Azithromycin (Zithromax)

 

Azithromycin is a second-line drug. Like erythromycin, this agent has excellent in vitro sensitivities, but in a large study, it underperformed compared with amoxicillin. Conversely, in several European studies, azithromycin has been shown to be equal to beta-lactam and tetracycline group antibiotics.

Because of its once-daily dosing, azithromycin should be considered in pregnant patients who are allergic to beta-lactams and in patients in whom compliance is a major issue.

View full drug information

Tetracycline

 

Tetracycline is used to treat gram-positive and gram-negative organisms, as well as mycoplasmal, chlamydial, and rickettsial infections, by inhibiting bacterial protein synthesis via binding with the 30S and possibly 50S ribosomal subunit(s). Tetracycline is an alternative drug to doxycycline. Because of its dosing schedule, doxycycline is preferred for compliance reasons; however, tetracycline may be less expensive.

View full drug information

Clarithromycin (Biaxin)

 

Clarithromycin is a macrolide antibiotic that inhibits protein synthesis by binding to the 50S ribosomal subunit. This drug is not first-line therapy but an alternative agent in patients intolerant of doxycycline, amoxicillin, and cefuroxime.

Previous
Next

Antimalarial Agents

Class Summary

By acting as lysosomotropic agents, derivatives of 4-aminoquinoline may improve the effectiveness of antibiotics such as macrolides. Lysosomotropic agents, such as chloroquine, can penetrate acidic compartments of the cell and raise the pH, which, in turn, may render antibiotics more effective.

View full drug information

Hydroxychloroquine (Plaquenil)

 

Hydroxychloroquine may increase the vacuolar pH, which, in turn, may increase the effectiveness of some antibiotics such as macrolides.

Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.

Previous
 
Contributor Information and Disclosures
Author

John O Meyerhoff, MD  Assistant Professor, Department of Internal Medicine, Johns Hopkins University School of Medicine; Clinical Scholar in Rheumatology, Department of Medicine, Sinai Hospital of Baltimore

John O Meyerhoff, MD is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Abbott Honoraria Speaking and teaching; Centocor Consulting fee Consulting; Genentech Grant/research funds Other; HGS/GSK Honoraria Speaking and teaching; Omnicare Consulting fee Consulting; Pfizer Honoraria Speaking and teaching; Roche Speaking and teaching; Savient Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching

Eugene Y Cheng, MD, FCCM Consulting Staff, Department of Anesthesiology, The Permanente Medical Group

Disclosure: Nothing to disclose.

Jonathan A Edlow, MD Associate Professor of Medicine, Department of Emergency Medicine, Harvard Medical School; Vice Chairman, Department of Emergency Medicine, Beth Israel Deaconess Medical Center

Jonathan A Edlow, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Cindy R Hennen, RPh Assistant Director of Clinical Pharmacy Practice, Froedtert Hospital, Medical College of Wisconsin

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Tarun Madappa, MD, MPH Attending Physician, Department of Pulmonary and Critical Care Medicine, Elkhart General Hospital

Tarun Madappa, MD, MPH is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

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.

Christen M Mowad, MD Associate Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Wendy Peltier, MD Program Director, Assistant Professor, Department of Neurology, Medical College of Wisconsin

Disclosure: Nothing to disclose.

Julie L Puotinen, PharmD Clinical Coordinator of Pharmaceutical Services, Department of Pharmacy, Clinical Instructor, Saint Luke's Medical Center

Disclosure: Nothing to disclose.

Karen L Roos, MD John and Nancy Nelson Professor of Neurology, Professor of Neurological Surgery, Department of Neurology, Indiana University School of Medicine

Karen L Roos, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association

Disclosure: Nothing to disclose.

Michael J Schneck, MD Associate Professor, Departments of Neurology and Neurosurgery, Stritch School of Medicine, Loyola University; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center

Michael J Schneck, MD is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, Neurocritical Care Society, and Stroke Council of the American Heart Association

Disclosure: Boehringer-Ingelheim Honoraria Speaking and teaching; Sanofi/BMS Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; UCB Pharma Honoraria Speaking and teaching; Talecris Consulting fee Other; NMT Medical Grant/research funds Independent contractor; NIH Independent contractor; Sanofi Grant/research funds Independent contractor; Boehringer-Ingelheim Grant/research funds Independent contractor; Baxter Labs Consulting fee Consulting

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Suyung Wu, MD Consulting Staff, Neuroscience Department, Elkhart Clinic

Suyung Wu, MD is a member of the following medical societies: American Academy of Neurology and American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

References

  1. Feder HM Jr. Lyme disease in children. Infect Dis Clin North Am. Jun 2008;22(2):315-26, vii. [Medline].

  2. Wormser GP, Nowakowski J, Nadelman RB, Visintainer P, Levin A, Aguero-Rosenfeld ME. Impact of clinical variables on Borrelia burgdorferi-specific antibody seropositivity in acute-phase sera from patients in North America with culture-confirmed early Lyme disease. Clin Vaccine Immunol. Oct 2008;15(10):1519-22. [Medline]. [Full Text].

  3. Wormser GP, McKenna D, Carlin J, Nadelman RB, Cavaliere LF, Holmgren D, et al. Brief communication: hematogenous dissemination in early Lyme disease. Ann Intern Med. May 3 2005;142(9):751-5. [Medline].

  4. Bernardino AL, Myers TA, Alvarez X, Hasegawa A, Philipp MT. Toll-like receptors: insights into their possible role in the pathogenesis of lyme neuroborreliosis. Infect Immun. Oct 2008;76(10):4385-95. [Medline]. [Full Text].

  5. Stanek G, Strle F. Lyme disease: European perspective. Infect Dis Clin North Am. Jun 2008;22(2):327-39, vii. [Medline].

  6. Masters EJ, Grigery CN, Masters RW. STARI, or Masters disease: Lone Star tick-vectored Lyme-like illness. Infect Dis Clin North Am. Jun 2008;22(2):361-76, viii. [Medline].

  7. Varela AS, Luttrell MP, Howerth EW, Moore VA, Davidson WR, Stallknecht DE, et al. First culture isolation of Borrelia lonestari, putative agent of southern tick-associated rash illness. J Clin Microbiol. Mar 2004;42(3):1163-9. [Medline]. [Full Text].

  8. Bacon RM, Kugeler KJ, Mead PS. Surveillance for Lyme disease--United States, 1992-2006. MMWR Surveill Summ. Oct 3 2008;57(10):1-9. [Medline].

  9. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. Lyme disease statistics: 2009. Available at http://www.cdc.gov/ncidod/dvbid/lyme/ld_statistics.htm. Accessed January 4, 2011.

  10. Seltzer EG, Gerber MA, Cartter ML, Freudigman K, Shapiro ED. Long-term outcomes of persons with Lyme disease. JAMA. Feb 2 2000;283(5):609-16. [Medline].

  11. Shadick NA, Phillips CB, Sangha O, Logigian EL, Kaplan RF, Wright EA, et al. Musculoskeletal and neurologic outcomes in patients with previously treated Lyme disease. Ann Intern Med. Dec 21 1999;131(12):919-26. [Medline].

  12. Kugeler KJ, Griffith KS, Gould LH, Kochanek K, Delorey MJ, Biggerstaff BJ, et al. A review of death certificates listing lyme disease as a cause of death in the United States. Clin Infect Dis. Feb 2011;52(3):364-7. [Medline].

  13. Sood SK, Salzman MB, Johnson BJ, Happ CM, Feig K, Carmody L, et al. Duration of tick attachment as a predictor of the risk of Lyme disease in an area in which Lyme disease is endemic. J Infect Dis. Apr 1997;175(4):996-9. [Medline].

  14. American Association of Pediatrics Committee on Environmental Health. Follow safety precautions when using DEET on children. Available at http://aapnews.aappublications.org/cgi/content/full/e200399v1. Accessed January 5, 2011.

  15. Nadelman RB, Nowakowski J, Fish D, Falco RC, Freeman K, McKenna D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. Jul 12 2001;345(2):79-84. [Medline].

  16. Maraspin V, Strle F. How do I manage tick bites and Lyme borreliosis in pregnant women?. Curr Probl Dermatol. 2009;37:183-90. [Medline].

  17. Centers for Disease Control and Prevention. Vaccines and preventable diseases: Lyme disease vaccination. Available at http://www.cdc.gov/vaccines/vpd-vac/lyme/default.htm#vacc. Accessed January 5, 2011.

  18. Nardelli DT, Munson EL, Callister SM, Schell RF. Human Lyme disease vaccines: past and future concerns. Future Microbiol. May 2009;4(4):457-69. [Medline].

  19. Demicheli V, Debalini MG, Rivetti A. Vaccines for preventing tick-borne encephalitis. Cochrane Database Syst Rev. Jan 21 2009;CD000977. [Medline].

  20. Wormser GP, Brisson D, Liveris D, Hanincová K, Sandigursky S, Nowakowski J, et al. Borrelia burgdorferi genotype predicts the capacity for hematogenous dissemination during early Lyme disease. J Infect Dis. Nov 1 2008;198(9):1358-64. [Medline]. [Full Text].

  21. Dandache P, Nadelman RB. Erythema migrans. Infect Dis Clin North Am. Jun 2008;22(2):235-60, vi. [Medline].

  22. Weber K, Wilske B. Mini erythema migrans--a sign of early Lyme borreliosis. Dermatology. 2006;212(2):113-6. [Medline].

  23. Steere AC, McHugh G, Damle N, Sikand VK. Prospective study of serologic tests for lyme disease. Clin Infect Dis. Jul 15 2008;47(2):188-95. [Medline].

  24. [Guideline] Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. Nov 1 2006;43(9):1089-134. [Medline].

  25. Aguero-Rosenfeld ME. Lyme disease: laboratory issues. Infect Dis Clin North Am. Jun 2008;22(2):301-13, vii. [Medline].

  26. Ang CW, Notermans DW, Hommes M, Simoons-Smit AM, Herremans T. Large differences between test strategies for the detection of anti-Borrelia antibodies are revealed by comparing eight ELISAs and five immunoblots. Eur J Clin Microbiol Infect Dis. Aug 2011;30(8):1027-32. [Medline]. [Full Text].

  27. Rupprecht TA, Pfister HW. What are the indications for lumbar puncture in patients with Lyme disease?. Curr Probl Dermatol. 2009;37:200-6. [Medline].

  28. Roos KL, Berger JR. Is the presence of antibodies in CSF sufficient to make a definitive diagnosis of Lyme disease?. Neurology. Sep 4 2007;69(10):949-50. [Medline].

  29. Halperin JJ, Shapiro ED, Logigian E, Belman AL, Dotevall L, Wormser GP, et al. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Jul 3 2007;69(1):91-102. [Medline].

  30. Blanc F, Jaulhac B, Fleury M, de Seze J, de Martino SJ, Remy V, et al. Relevance of the antibody index to diagnose Lyme neuroborreliosis among seropositive patients. Neurology. Sep 4 2007;69(10):953-8. [Medline].

  31. Agosta F, Rocca MA, Benedetti B, Capra R, Cordioli C, Filippi M. MR imaging assessment of brain and cervical cord damage in patients with neuroborreliosis. AJNR Am J Neuroradiol. Apr 2006;27(4):892-4. [Medline].

  32. Wormser GP, Ramanathan R, Nowakowski J, McKenna D, Holmgren D, Visintainer P, et al. Duration of antibiotic therapy for early Lyme disease. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. May 6 2003;138(9):697-704. [Medline].

  33. Halperin JJ. Nervous system lyme disease: diagnosis and treatment. Rev Neurol Dis. Winter 2009;6(1):4-12. [Medline].

  34. Steere AC, Angelis SM. Therapy for Lyme arthritis: strategies for the treatment of antibiotic-refractory arthritis. Arthritis Rheum. Oct 2006;54(10):3079-86. [Medline].

  35. Borg R, Dotevall L, Hagberg L, Maraspin V, Lotric-Furlan S, Cimperman J, et al. Intravenous ceftriaxone compared with oral doxycycline for the treatment of Lyme neuroborreliosis. Scand J Infect Dis. 2005;37(6-7):449-54. [Medline].

  36. Ljøstad U, Skogvoll E, Eikeland R, Midgard R, Skarpaas T, Berg A, et al. Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trial. Lancet Neurol. Aug 2008;7(8):690-5. [Medline].

  37. Ogrinc K, Logar M, Lotric-Furlan S, Cerar D, Ruzic-Sabljic E, Strle F. Doxycycline versus ceftriaxone for the treatment of patients with chronic Lyme borreliosis. Wien Klin Wochenschr. Nov 2006;118(21-22):696-701. [Medline].

  38. Klempner MS, Hu LT, Evans J, Schmid CH, Johnson GM, Trevino RP, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med. Jul 12 2001;345(2):85-92. [Medline].

  39. Johnson L, Stricker RB. Attorney General forces Infectious Diseases Society of America to redo Lyme guidelines due to flawed development process. J Med Ethics. May 2009;35(5):283-8. [Medline].

  40. Stricker RB, Johnson L. Chronic Lyme disease and the 'Axis of Evil'. Future Microbiol. Dec 2008;3(6):621-4. [Medline].

  41. Kemperman MM, Bakken JS, Kravitz GR. Dispelling the chronic Lyme disease myth. Minn Med. Jul 2008;91(7):37-41. [Medline].

  42. Marques A. Chronic Lyme disease: a review. Infect Dis Clin North Am. Jun 2008;22(2):341-60, vii-viii. [Medline]. [Full Text].

  43. Baker PJ. Perspectives on "chronic Lyme disease". Am J Med. Jul 2008;121(7):562-4. [Medline].

  44. Hassett AL, Radvanski DC, Buyske S, Savage SV, Gara M, Escobar JI, et al. Role of psychiatric comorbidity in chronic Lyme disease. Arthritis Rheum. Dec 15 2008;59(12):1742-9. [Medline].

  45. Cameron DJ. Clinical trials validate the severity of persistent Lyme disease symptoms. Med Hypotheses. Feb 2009;72(2):153-6. [Medline].

  46. Cameron DJ. Insufficient evidence to deny antibiotic treatment to chronic Lyme disease patients. Med Hypotheses. Jun 2009;72(6):688-91. [Medline].

  47. Nau R, Christen HJ, Eiffert H. Lyme disease--current state of knowledge. Dtsch Arztebl Int. Jan 2009;106(5):72-81; quiz 82, I. [Medline]. [Full Text].

  48. Kowalski TJ, Tata S, Berth W, Mathiason MA, Agger WA. Antibiotic treatment duration and long-term outcomes of patients with early lyme disease from a lyme disease-hyperendemic area. Clin Infect Dis. Feb 15 2010;50(4):512-20. [Medline].

  49. Maraspin V, Cimperman J, Lotric-Furlan S, Pleterski-Rigler D, Strle F. Treatment of erythema migrans in pregnancy. Clin Infect Dis. May 1996;22(5):788-93. [Medline].

  50. Aberer E, Breier F, Stanek G, Schmidt B. Success and failure in the treatment of acrodermatitis chronica atrophicans. Infection. Jan-Feb 1996;24(1):85-7. [Medline].

  51. Norman MU, Moriarty TJ, Dresser AR, Millen B, Kubes P, Chaconas G. Molecular mechanisms involved in vascular interactions of the Lyme disease pathogen in a living host. PLoS Pathog. Oct 3 2008;4(10):e1000169. [Medline]. [Full Text].

 
Previous
Next
 
Normal and engorged Ixodes ticks.
Erythema migrans, the characteristic rash of early Lyme disease.
Magnified ticks at various stages of development.
Erythema migrans in a woman who presented to the emergency department after treatment with cephalexin for 2 days, which was prescribed by another physician for treatment of cellulitis. On history, she was found to live in an endemic area for ticks and to pull ticks off her dog daily. The location and size of the rash are typical of erythema migrans and the central punctum can be seen at the lateral margin of the inferior gluteal fold. The uniform color is common.
Hematoxylin and eosin stained section from a biopsy performed at the periphery of an eruption from a woman with erythema migrans who presented to the emergency department after treatment with cephalexin for 2 days. Note the perivascular lymphocytic infiltrate, a pattern that is not specific for, but is characteristic of, erythema migrans.
Photomicrograph demonstrates perivascular infiltrate in a biopsy specimen from the border of an erythema migrans lesion (hematoxylin and eosin stain). Courtesy of J. Edlow.
Photo of the torso of a young man who had been working outdoors in northern New Jersey in late June. He was under treatment for a spider bite, although he did not have a history of a bite and had no pain, as is typical in a spider bite. The location, size, and epidemiologic context favor a diagnosis of erythema migrans. Examination was remarkable for a palpable right axillary lymph node. His symptoms resolved within 48 hours of initiating doxycycline.
Photo of the left side of the neck of a patient who had pulled a tick from this region 7 days previously. Note the raised vesicular center, which is a variant of erythema migrans. The patient had a Jarisch-Herxheimer reaction approximately 18 hours after the first dose of doxycycline.
Classic target lesion with concentric rings of erythema, which often show central clearing. Although this morphology was emphasized in earlier North American literature, it only represents approximately 40% of erythema migrans lesions in the United States. This pattern is more common in Europe. Courtesy of Lyme Disease Foundation, Hartford, Conn.
Typical appearance of erythema migrans, the bull's-eye rash of Lyme disease.
Bulls-eye rash.
rash. Courtesy of M. Fergione, B. Tucker, and L. Zernel; Pfizer Laboratories
Borrelial lymphocytoma of the earlobe, which shows a bluish red discoloration. The location is typical in children, as opposed to the nipple in adults. This manifestation of Lyme disease is uncommon and occurs only in Europe. Courtesy of Lyme Disease Foundation, Hartford, Conn.
Acrodermatitis chronica atrophicans is found almost exclusively in European patients and comprises an early inflammatory phase and a later atrophic phase. As the term suggests, the lesion occurs acrally and ultimately results in skin described as being like cigarette paper. Courtesy of Lyme Disease Foundation, Hartford, Conn.
: Photo of erythema migrans on the right thigh of a toddler. The size and location are typical of erythema migrans, as is the history of the patient vacationing on Fire Island, NY, in the month of August. No tick bite had been noted at this location. Approximately 25% of patients with Lyme disease are children, which is the same percentage of patients who do not recall a tick bite. Courtesy of Dr John Hanrahan.
Multiple lesions of erythema migrans occur in approximately 20% of patients. A carpenter from Nantucket who worked predominantly outside had been treated with Lotrisone for 1 week before presenting to the emergency department with the rashes seen in this photo. The patient had no fever and only mild systemic symptoms. He was treated with a 3-week course of oral antibiotics.
The rash on the ankle seen in this photo is consistent with both cellulitis (deep red hue, acral location, mild tenderness) and erythema migrans (July presentation in an area highly endemic for Lyme disease). In this situation, treatment with a drug that covers both diseases (eg, cefuroxime or amoxicillin and clavulanate combination) is one effective strategy.
Blood smear showing likely babesiosis. Babesiosis can be difficult to distinguish from malaria on a blood smear.
This is an ECG from a 21-year-old man with severe weakness and near syncope. Ten days earlier, while in upstate New York, he had a febrile illness without rash. No tick bite was known to occur, and the serologic result for Lyme disease was negative at the time. Seroconversion occurred when this ECG was obtained. He was admitted to a telemetry unit, had a temporary pacemaker inserted, and was given 2 g of intravenous ceftriaxone daily. He was well and did not need the pacemaker after 4 days
The bacterium Borrelia burgdorferi (darkfield microscopy technique, 400X; courtesy of the US Centers for Disease Control and Prevention).
To remove a tick, use fine-tipped forceps and wear gloves. Grasp the tick as close to the skin surface as possible, including the mouth parts, and pull upward with steady, even traction. Do not twist or jerk the tick because this may cause the mouth parts to break off and remain in the skin; however, note that the mouth parts themselves are not infectious. When removing, wear gloves to avoid possible infection. Children, elderly persons, and immunocompromised persons may be at greater risk for infection and should avoid removing ticks if possible. A common misperception is that pressing a hot match to the tick or trying to smother it with petroleum jelly, gasoline, nail polish, or other noxious substances is beneficial. This only prolongs exposure time and may cause the tick to eject infectious organisms into the body. Additionally, using lidocaine (subcutaneously or topically) may actually irritate the tick and prompt it to regurgitate its stomach contents. Finally, do not squeeze, crush, or puncture the body of the tick because its fluids (saliva, hemolymph, gut contents) may contain infectious organisms. Once the tick is removed, wash the bite area with soap and water or with an antiseptic to destroy any contaminating microorganisms. Additionally, the person who removed the tick should wash his or her hands.
Tick-borne disease prevention can be divided into environmental and personal measures. Patients exposed to tick-endemic areas should wear long-sleeved, light-colored clothing when outside. Lighter colors allow for easier identification of ticks. Chemical repellents with DEET (N,N-diethyl-3-methylbenzamide) and picaridin are available in numerous over-the-counter skin preparations as sprays or lotions. Permethrin is an acaricide that can be applied to clothing and is used in conjunction with chemical repellents. All individuals should perform regular skin checks. Ticks prefer warm, moist areas, such as the beltline, groin, and axilla, although in children, the hairline is a common site. Environmental prevention involves clearing underbrush and spraying acaricides in the spring around property sites. These measures prevent both mice and ticks from encroaching on properties. Studies involving the treatment of wild deer and mice have not been conclusive in reducing tick-borne diseases in humans. Currently, no Lyme disease vaccines are available in the United States. Lyme disease vaccine (Lymerix™) was discontinued in 2002, so some patients may still have residual protective antibodies. Image courtesy of the National Library of Medicine.
Approximately 90% of Lyme disease cases are reported from the northeastern and upper midwestern United States. A rash that can be confused with early Lyme disease sometimes occurs following bites of the lone star tick (Amblyomma americanum). These ticks, which do not transmit the Lyme disease bacterium, are common human-biting ticks in the southern and southeastern United States.
Peripheral smear showing babesiosis.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.