Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Lyme Disease Treatment & Management

  • Author: John O Meyerhoff, MD; Chief Editor: Herbert S Diamond, MD  more...
 
Updated: Mar 14, 2016
 

Approach Considerations

Antibiotic selection, route of administration, and duration of therapy for Lyme disease are guided by the patient’s clinical manifestations and stage of disease, as well as the presence of any concomitant medical conditions or allergies. Prompt treatment increases the likelihood of therapeutic success. Of great importance, doxycycline is contraindicated in patients younger than 8 years and in pregnant women. See the tables below.

Table 1. Clinical presentation and therapy for the stages of Lyme Disease (Open Table in a new window)

Disease



Stage



Clinical



Manifestations



 



Treatment



 



Duration



Early localized Erythema migrans Oral 14-21 days
Early disseminated Multiple erythema migrans Oral 14-21 days
Isolated cranial nerve palsy Oral 14-21 days
Meningoradiculoneuritis Oral 14-28 days
Meningitis Intravenous or oral 14-21 days
Carditis    
-Ambulatory Oral 14-21 days
-Hospitalized Intravenous followed by oral 14-21 days
Borrelial lymphocytoma Oral 14-21 days
Late Arthritis Oral 28 days
Recurrent arthritis after oral therapy Oral or intravenous 28 days or 14-28 days
Encephalitis Intravenous 14-28 days
Acrodermatitis chronica atrophicans Oral 14-28 days

Table 2. Adult and Pediatric treatment options, dosages, and routes of administration (Open Table in a new window)

  Treatment Adult Dose Pediatric Dose
Oral Therapy Doxycycline



(patients =8 y)



100 mg twice a day 4 mg/kg (up to 100 mg)



twice a day



Amoxicillin 500 mg three times a day 50 mg/kg (up to 500 mg)



three times a day



Cefuroxime axetil 500 mg twice a day 30 mg/kg (up to 500 mg)



twice a day



Intravenous therapy Ceftriaxone 2 g once a day 50-75 mg/kg (up to 2 g)



once a day



Cefotaxime 2 g every 8 h 150-200 mg/kg (up to 2 g) every 8 h
Penicillin G 18-24 million U/d divided



every 4 h



200,000-400,000 mg/kg



(up to 2 g) every 8 h



In most patients with carditis, prompt institution of appropriate antibiotics is the only treatment needed. However, occasional patients with Lyme disease–related atrioventricular (AV) block may require hospitalization for temporary cardiac pacing. The indications for cardiac pacing are the same as for any other patient with varying degrees of heart block. Permanent pacing is very rarely needed.

Symptoms of arthritis may persist for a few weeks beyond adequate therapy. Repeat treatment usually is not necessary unless symptoms worsen or persist beyond 2 months.

Persistent arthritis after clearance of the infection is most likely related to autoimmunity and is more prevalent among individuals with HLA-DR2, HLA-DR3, or HLA-DR4 allotypes. These patients should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), plus hydroxychloroquine if necessary. As a last resort, such patients may need a synovectomy to eradicate the inflammatory arthritis in the involved joint.

Neurologic manifestations of Lyme disease in both adults and children respond well to penicillin, ceftriaxone, cefotaxime, and doxycycline. Although most studies of neuroborreliosis have used intravenous antibiotics, European studies support use of oral doxycycline in adults with meningitis, cranial neuritis, or radiculitis, with intravenous regimens reserved for patients with parenchymal central nervous system (CNS) involvement, other severe neurologic symptomatology, or failure to respond to oral treatment.[47]

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. Treatment is usually with 14-21 days of oral antibiotics. When symptoms of dissemination are noted, however, parenteral therapy sometimes is used.

Physicians should observe patients closely for possible Jarisch-Herxheimer reactions after the institution of therapy. This allergic/inflammatory response may manifest in the skin, mucous membranes, viscera, or nervous system.

In endemic areas, antibiotic prophylaxis may be appropriate for selected patients with a recognized tick bite (see Prevention). Prophylactic antibiotics are not routinely recommended, however, as tick bites rarely result in Lyme disease, and if infection does develop, early antibiotic treatment has excellent efficacy.

Several groups have published Lyme disease guidelines. The Infectious Diseases Society of America (IDSA) has released clinical practice guidelines for the assessment, treatment, and prevention of Lyme disease.[43] The American Academy of Neurology has established guidelines for the treatment of nervous system Lyme disease.[47]

The International Lyme and Associated Diseases Society (ILADS) issued updated recommendations for the management of Lyme disease in 2014.[52] The recommendations are all based on "very low quality evidence" and use patient preference as major portion of the support for the recommendations. In addition, the recommendations are limited to three specific aspects of Lyme disease. The differences between the IDSA and ILADS recommendations are outlined in the table below.

Table 3. Comparison of Infectious Diseases Society of America (IDSA) and International Lyme and Associated Diseases Society (ILADS) recommendations for Lyme disease treatment (Open Table in a new window)

Treatment Focus IDSA ILADS
Treatment of a tick bite without symptoms of Lyme disease Doxycycline, 200 mg as a single dose Doxycycline, 100 mg bid for 20 days
Erythema migrans Doxycycline, amoxicillin, or cefuroxime for 14-21 days Doxycycline, amoxicillin, or cefuroxime for 28-42 days or azithromycin for at least 21 days
“Persisting symptoms of Lyme disease” No antibiotic therapy Multiple agents (individually or in combination) are mentioned without specific doses or duration recommended

Controversy regarding the treatment of Lyme disease abounds, including an antitrust investigation initiated in 2008 by the Connecticut Attorney General (CAG) into the development process for the 2006 IDSA Lyme disease treatment guidelines. The CAG claimed the process was tainted by suppression of scientific evidence and conflicts of interest.[53]

In April 2008, the CAG and the IDSA reached an agreement to end the investigation. In 2010, a review panel convened as part of that agreement concluded that “the IDSA’s 2006 Lyme disease guidelines were based on the highest-quality medical and scientific evidence available at the time and are supported by evidence that has been published in more recent years.”[54]

Next

Treatment of Early Lyme Disease

Early localized Lyme disease refers to isolated erythema migrans and to an undifferentiated febrile illness. This stage occurs 1-30 days after the tick bite. In endemic areas, patients with erythema migrans and a recent history of possible or proven tick exposure can be treated empirically, without laboratory confirmation of the diagnosis. Serologic testing is appropriate for patients who present more than 3 weeks after tick exposure.

Doxycycline, amoxicillin, or cefuroxime axetil is recommended for the treatment of adult patients with early localized or early disseminated Lyme disease associated with erythema migrans, in the absence of specific neurologic manifestations or third-degree heart block. Antibiotics recommended for children include amoxicillin and cefuroxime axetil; in children 8 years and older, doxycycline may be used. Because of its cost, cefuroxime axetil is reserved for patients unable to take amoxicillin or doxycycline

Macrolides are alternative agents, but they are used only when the first-line agents are not tolerated or are contraindicated. Those macrolides that have been compared with other antimicrobials in clinical trials of Lyme disease have been found to be less effective.[43]

Treatment for 14 days is recommended (range, 10-21 d for doxycycline and 14-21 d for amoxicillin or cefuroxime axetil). Longer treatment was previously recommended, but several studies have shown similar efficacy between 10-day and longer courses (20-21 d).[55, 56] Erythema migrans typically shows improvement within a few days after the institution of appropriate antibiotic therapy.

Patients with other manifestations who are treated with oral formulations should be treated for 30 days because, with these manifestations, accurately pinpointing the date of infection is not always possible. This regimen may also be effective for neurologic disease.

Neurologic Lyme disease is effectively treated with a 2-week course of parenteral penicillin, ceftriaxone, or cefotaxime.[47, 57] Oral doxycycline is as efficacious as parenteral antibiotics in patients who have Lyme-associated meningitis, facial nerve palsy, or radiculitis.[47]

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.[58]

Pregnant women who develop Lyme disease should not be treated with doxycycline or another tetracycline. Risks to the fetus include permanent discoloration of the teeth, enamel hypoplasia, and retardation of skeletal development.

Previous
Next

Lyme Arthritis

In patients without neurologic disease, Lyme arthritis can usually be treated successfully with oral antibiotics, with an extended treatment time of 28 days. Recommended regimens for adult patients are as follows[43] :

  • Doxycycline, 100 mg twice daily
  • Amoxicillin, 500 mg three times daily
  • Cefuroxime axetil, 500 mg twice daily per day

Recommended regimens for pediatric patients are as follows[43] :

  • Amoxicillin, 50 mg/kg/day in three divided doses (maximum of 500 mg/dose)
  • Cefuroxime axetil, 30 mg/kg/day in two divided doses (maximum of 500 mg/dose)
  • Doxycycline, 4 mg/kg/day in two divided doses (maximum of 100 mg/dose), if the patient is 8 years of age or older

Patients with mild residual joint swelling after a recommended course of oral antibiotic therapy can be re-treated with another 4-week course of oral antibiotics. Patients whose arthritis fails to improve or worsens can be re-treated with a 2- to 4-week course of intravenous ceftriaxone. IDSA guidelines suggest that clinicians consider waiting several months before starting a second round of antibiotics, as joint inflammation tends to resolve slowly even when the infection has been eliminated.[43]

In patients with persistent arthritis despite intravenous therapy, polymerase chain reaction (PCR) of synovial fluid (and synovial tissue, if available) can be done. PCR results may remain positive for several weeks after the eradication of Borrelia burgdorferi; nevertheless, if PCR is positive for B burgdorferi DNA, the patient can be treated with oral antibiotic therapy for another month.[20]

If PCR is negative, the patient should be given symptomatic treatment with nonsteroidal anti-inflammatory drugs NSAIDs). If necessary, NSAID treatment can be supplemented with oral hydroxychloroquine, 20 mg twice daily.[20, 43] Consultation with a rheumatologist is recommended in these cases.

Eventual resolution of chronic Lyme arthritis can be expected in all patients. However, patients who continue to have significant pain or limitation of function after 3-6 months of symptomatic therapy can be considered for arthroscopic synovectomy.[20, 43]

Intra-articular corticosteroids should not be given before antibiotic treatment, as they may promote persistent Lyme arthritis. Intra-articular corticosteroids are rarely indicated after antibiotic treatment.[57]

Previous
Next

Lyme Carditis

The patient with myocarditis generally is not very ill, and significant muscle dysfunction is unusual. Pericarditis with tamponade, while rare, has been reported.

Patients with atrioventricular (AV) heart block and/or myopericarditis associated with early Lyme disease may be treated with either oral or parenteral antibiotic therapy for 14 days (range, 14-21 days). Hospitalization and continuous monitoring are advisable for patients with any of the following[59] :

  • Associated symptoms (eg, syncope, dyspnea, or chest pain)
  • Second-degree or third-degree AV block
  • First-degree heart block with prolongation of the PR interval to more than 30 milliseconds (the degree of block may fluctuate and worsen very rapidly in such patients)

For patients with advanced heart block, a temporary pacemaker may be required; consultation with a cardiologist is recommended. Use of the pacemaker may be discontinued when the advanced heart block has resolved. An oral antibiotic treatment regimen should be used for completion of therapy and for outpatients, as is used for patients with erythema migrans without carditis.

Previous
Next

Neurologic Manifestations

Although facial palsies may resolve without treatment, oral antibiotic therapy may prevent further sequelae. Encephalitis/encephalopathy should be treated with intravenous antibiotic therapy for 28 days.

The use of ceftriaxone in early Lyme disease is recommended for adult patients with acute meningitis or radiculopathy. Possible satisfactory alternatives include parenteral therapy with cefotaxime or penicillin G. For patients who are intolerant of β-lactam antibiotics, increasing evidence indicates that oral doxycycline (200-400 mg/d in two divided doses orally for 10-28 d) may be adequate.[60, 61, 62] With any regimen, neurologic symptoms may take 6 months to reach maximum improvement.

Patients with Lyme meningitis may need to be admitted not only for pain control but also for administration of intravenous antibiotics. If diagnostic uncertainty exists regarding the etiology of the meningitis, the antibiotic coverage may need to be extended for other more serious bacterial pathogens until the precise etiology is clarified.

Adult patients with late neurologic disease affecting the central or peripheral nervous system should be treated with intravenous medication. Response to treatment is usually slow and may be incomplete. Retreatment is not recommended unless relapse is shown by reliable objective measures.

Previous
Next

Ocular Manifestations

Conjunctivitis and photophobia in stage 1 Lyme disease require no therapy. Bell palsy in stage 2 Lyme disease is self-limited, but patients require supportive therapy to prevent the complications of exposure keratitis. Keratitis and episcleritis benefit from topical corticosteroids, usually a short course of prednisolone acetate 1% or fluorometholone 0.1%.

A treatment regimen for severe neuro-ophthalmic disease (involving the optic nerve) or posterior segment disease (eg, pars planitis, vitreitis) has not been established. Oral corticosteroids without concomitant antibiotics should not be used.

The best approach for these patients might be a trial of antibiotic therapy, in which patients receive 2-3 weeks of intravenous penicillin or ceftriaxone. If patients respond to treatment, the trial is successful, ocular Lyme disease is diagnosed, and no further therapy is needed. Recurrences of Lyme uveitis, once adequate intravenous therapy has been given, can be treated with judicious corticosteroids.

Previous
Next

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).[63] It is important to ensure that no neurologic manifestations are present before embarking on oral therapy.

Previous
Next

Post-Treatment Lyme Disease Syndrome

Despite appropriate antibiotic treatment, patients with Lyme disease may experience lingering symptoms similar to fibromyalgia (eg, fatigue, pain, joint and muscle aches). This condition has been termed chronic Lyme disease or, more precisely, post-treatment Lyme disease syndrome (PTLDS).[64]

These symptoms have not been shown in any controlled trials to be responsive to antibiotic therapy.[57] A study by Klempner et al failed to show a benefit of treatment with 2 g of intravenous ceftriaxone daily for 30 days, followed by oral doxycycline at 200 mg/d for 60 days.[65] Long-term IV ceftriaxone therapy can result in the formation of biliary sludge, which can lead to biliary colic.

Extended antibiotic therapy, sometimes for longer than 6 months, has been advocated for PTLDS. This not only can cause great harm to patients but also has resulted in one or more deaths.[66]

The existence of PTLDS has been called into question as a result of a lack of direct evidence of persistent infection.[67, 68] Hassett and colleagues reported that rates of psychiatric comorbidity and other psychological factors (eg, depression, anxiety, tendency to catastrophize pain) were higher in patients with “chronic Lyme disease” (defined as symptomatic patients with previously treated Lyme disease and patients whose symptoms were attributed to Lyme disease without good evidence for Lyme disease) than in other patients commonly seen in Lyme disease referral centers, and that those factors were related to poor functional outcomes.[69]

Previous
Next

Co-infection

Co-infection with other tick-borne illnesses occur in roughly 10-15% of patients with Lyme disease and should be considered in patients with a poor response to conventional antimicrobial therapy or atypical clinical presentations (eg, high fever, leukopenia). Co-transmitted infective organisms can include the following:

  • Babesia microti, the primary cause of babesiosis
  • Anaplasma phagocytophilum and Ehrlichia chaffeensis, which cause ehrlichiosis
  • Flavivirus, the cause of tick-borne encephalitis
  • Powassan or tick-borne encephalitis-like virus
Previous
Next

Prevention

Prevention of tick-borne disease can be divided into personal and environmental measures. Clinicians in endemic areas should provide patient education on personal measures for tick avoidance and management of tick exposure (see Patient Education).

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.

Tick removal

In patients in endemic areas who present with an attached tick, prompt removal can reduce the likelihood of contracting Lyme disease. Transmission of infection is unlikely if the duration of tick attachment is less than 24 hours, but is very likely for ticks attached for longer than 72 hours.

Removal of a tick is ideally accomplished using fine-tipped forceps and wearing gloves. Grasp the tick as close to the skin surface as possible, including the mouth parts, and pull upward with steady, even traction. (See the image below). 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. Wear gloves to avoid possible infection.

To remove a tick, use fine-tipped forceps and wear 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.

The use of forceps and gloves represents an optimal method of removal. However, removal of the tick should not be delayed in order to obtain forceps and it is extremely unlikely that one can become infected by touching an engorged tick even if the tick is carrying Borrelia (which most of them are not, even in endemic areas).

Using lidocaine (subcutaneously or topically) may actually irritate the tick and prompt it to regurgitate its stomach contents. Once the tick is removed, wash the bite area with soap and water or with an antiseptic to destroy any contaminating microorganisms.

For more information, see Tick Removal.

Antibiotic prophylaxis

Routine prophylaxis after a recognized tick bite is not recommended. A guideline from the Infectious Disease Society of America recommends prophylactic antibiotic therapy for adults and children older than 8 years, using a single 200-mg dose of doxycycline (in children, 4 mg/kg up to a maximum dose of 200 mg) only if all of the following criteria are met[43] :

  • The attached tick can be reliably recognized as a nymphal or adult Ixodes scapularis
  • The tick has been attached for at least 36 hours, as determined by the degree of engorgement of the tick or certainty about the time of exposure to the tick
  • Prophylaxis can be started within 72 hours of the time the tick was removed
  • The local rate of infection of these ticks with Borrelia burgdorferi is at least 20% (unlikely outside of select areas in New England, the mid-Atlantic States, Minnesota, and Wisconsin)
  • Doxycycline treatment is not contraindicated

The species of tick is important because non-Ixodes ticks (and other insects), although they can contain the organism, are highly unlikely to cause disease. The one clinically relevant exception may be bites by Amblyomma americanum in the central and southern midwestern United States, but few data exist on treating these tick bites prophylactically.

Doxycycline is relatively contraindicated in children younger than 8 years and in pregnant women. Amoxicillin should not be substituted for doxycycline in persons for whom doxycycline prophylaxis is contraindicated, for the following reasons[70] :

  • The absence of data on an effective short-course regimen for prophylaxis
  • The likely need for a multiday regimen (and its associated adverse effects)
  • The excellent efficacy of antibiotic treatment of Lyme disease if infection develops
  • The extremely low risk that a person with a recognized bite will develop a serious complication of Lyme disease

Even in areas where about 15-30% of ticks are infected with Borrelia burgdorferi, tick bites rarely result in Lyme disease. Nevertheless, appropriate prophylaxis can significantly reduce that risk.[71] In a 2010 meta-analysis of trials in which patients with no clinical evidence of Lyme disease were randomly allocated to treatment or placebo groups within 72 hours after an Ixodes tick bite, the risk of Lyme disease in the control group was 2.2% compared with 0.2% in the antibiotic-treated group.[72]

Vaccination

In December 1998, the FDA approved a vaccine (LYMErix Lyme disease vaccine [recombinant OspA]) directed against the outer surface protein A of B burgdorferi, after trials indicated efficacy. In 2002, this vaccine was pulled off the market by the manufacturer because of poor demand.[73] Patients who received this vaccine are no longer protected against Lyme disease, because the vaccine’s effect was not long lasting.

Previous
Next

Consultations

In most patients with erythema migrans, no consultation is needed. However, consultation with appropriate specialists (eg, rheumatologist, neurologist, cardiologist) may be indicated to ensure that other diseases are not the cause of unusual presenting symptoms in a patient with a positive Lyme titer.

Difficulties can arise in choosing the appropriate antibiotic treatment regimen, especially in children or potentially pregnant women. An infectious disease consult is helpful in these situations.[74]

Consultation with a rheumatologist may be helpful in the evaluation and treatment of patients with persistent arthritis despite conventional antimicrobial therapy and those who present with fibromyalgia occurring after treated Lyme disease.

Consultation with a neurologist is recommended in patients with persistent or chronic manifestations of Lyme disease, such as chronic fatigue syndrome. In addition, in patients with acrodermatitis chronica atrophicans, neurologic disease is not uncommon and its presence alters the treatment plan; therefore, consultation is appropriate if neurologic signs or symptoms are present.

Consultation with a cardiologist may be indicated in patients with coexisting cardiac disease.

Previous
Next

Long-Term Monitoring

Follow-up monitoring until all signs and symptoms have completely resolved is indicated for all patients with Lyme disease. In early Lyme disease, lack of prompt resolution should lead the physician to question the original diagnosis. Later manifestations tend to resolve much more slowly than early ones. Follow-up monitoring by the primary care physician or an appropriate specialist is indicated for patients with extracutaneous manifestations.

Patients with Lyme disease whose specific symptoms of Lyme disease (not symptoms of fibromyalgia or chronic fatigue) do not improve may need retreatment. Patients who plateau in their improvement may also need retreatment. Given the cost and convenience, a 30-day course of oral antibiotic therapy may be indicated before repeating intravenous therapy.

Repeat serologic testing is not indicated, because IgM titers may persist with treatment, and changes in IgG titers do not reflect the efficacy of treatment. That is, the standard serologic tests, with initial positive results, may remain positive for long periods and should not be used as a test of cure. Data suggest that C6-peptide may return negative results after treatment with antibiotics.

Follow-up may be of particular importance in patients with the chronic sequelae of the controversial post-Lyme disease syndrome. These patients’ condition may be refractory to conventional therapies.

Previous
 
 
Contributor Information and Disclosures
Author

John O Meyerhoff, MD 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, American College of Rheumatology

Disclosure: Nothing to disclose.

Coauthor(s)

Gerald W Zaidman, MD Professor of Clinical Ophthalmology, New York Medical College; Chief of Cornea Service, Director, Department of Ophthalmology, Westchester Medical Center

Gerald W Zaidman, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Medical Society of Virginia, American Uveitis Society, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, Medical Society of the State of New York, Phi Beta Kappa

Disclosure: Nothing to disclose.

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

Stephen C Aronoff, MD Waldo E Nelson Chair and Professor, Department of Pediatrics, Temple University School of Medicine

Stephen C Aronoff, MD is a member of the following medical societies: Pediatric Infectious Diseases Society and Society for Pediatric Research

Disclosure: Nothing to disclose.

Richard G Bachur, MD Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Disclosure: Nothing to disclose.

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

William E Caputo, MD Chief Resident Physician, Department of Emergency Medicine, Kings County Hospital

William E Caputo, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

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.

Kilbourn Gordon III, MD, FACEP Urgent Care Physician

Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society

Disclosure: Nothing to disclose.

Marvin Harper, MD Assistant Professor of Pediatrics, Departments of Emergency Medicine and Infectious Disease, Harvard Medical School; Director, Informatics Program, Children's Hospital of Boston

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Jon Mark Hirshon, MD, MPH Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

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.

Larry I Lutwick, MD Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

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.

Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

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.

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

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.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

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.

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Sarah L Wingerter, MD Attending Physician, Department of Emergency Medicine, St Christopher's Hospital for Children; Clinical Assistant Professor of Pediatrics (Adjunct), Temple University School of Medicine

Sarah L Wingerter, MD is a member of the following medical societies: American Academy of Pediatrics

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. 2008 Jun. 22(2):315-26, vii. [Medline].

  2. Centers for Disease Control and Prevention. Two-step Laboratory Testing Process. CDC. Available at http://www.cdc.gov/lyme/diagnosistesting/LabTest/TwoStep/index.html. March 26, 2015; Accessed: March 14, 2016.

  3. Centers for Disease Control and Prevention. Lyme Disease Data. CDC. Available at http://www.cdc.gov/lyme/stats/index.html?s_cid=cs_281. September 24, 2015; Accessed: March 14, 2016.

  4. Project Plan: Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease by the Infectious Disease s Society of America, the American Academy of Neurology, and the American College of Rheumatology. Infectious Diseases Society of America. Available at http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/LD%20Project%20Plan%20March%202015%282%29.pdf. Accessed: March 14, 2016.

  5. Edlow JA. Bull's Eye - Unraveling the Medical Mystery of Lyme Disease. 2nd ed. New Haven: Yale University Press; 2004.

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

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

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

  9. 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. 2008 Oct. 15(10):1519-22. [Medline]. [Full Text].

  10. 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. 2008 Oct. 76(10):4385-95. [Medline]. [Full Text].

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

  12. Pritt BS, Mead PS, Johnson DKH, et al. Identification of a novel pathogenic Borrelia species causing Lyme borreliosis with unusually high spirochaetaemia: a descriptive study. Lancet Infect Dis. February 05, 2016. [Full Text].

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

  14. Adams D, Fullerton K, Jajosky R, Sharp P, Onweh D, Schley A, et al. Summary of Notifiable Infectious Diseases and Conditions - United States, 2013. MMWR Morb Mortal Wkly Rep. 2015 Oct 23. 62 (53):1-122. [Medline]. [Full Text].

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

  16. Smith R, Takkinen J. Lyme borreliosis: Europe-wide coordinated surveillance and action needed?. Euro Surveill. 2006 Jun 22. 11(6):E060622.1. [Medline].

  17. Centers for Disease Control and Prevention. Lyme disease statistics: 2009. CDC. Available at http://www.cdc.gov/ncidod/dvbid/lyme/ld_statistics.htm. Accessed: January 4, 2011.

  18. Lyme disease--United States, 2003-2005. MMWR Morb Mortal Wkly Rep. 2007 Jun 15. 56(23):573-6. [Medline].

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

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

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

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

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

  24. Sood SK, Salzman MB, Johnson BJ, 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. 1997 Apr. 175(4):996-9. [Medline].

  25. American Association of Pediatrics Committee on Environmental Health. Follow safety precautions when using DEET on children. Available at http://aapnews.aappublications.org/content/22/5/200399.full. Accessed: January 5, 2011.

  26. Tibbles CD, Edlow JA. Does this patient have erythema migrans?. JAMA. 2007 Jun 20. 297(23):2617-27. [Medline].

  27. Nigrovic LE, Thompson AD, Fine AM, Kimia A. Clinical predictors of Lyme disease among children with a peripheral facial palsy at an emergency department in a Lyme disease-endemic area. Pediatrics. 2008 Nov. 122(5):e1080-5. [Medline].

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

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

  30. Nadelman RB, Nowakowski J, Forseter G, et al. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. Am J Med. 1996 May. 100(5):502-8. [Medline].

  31. Edlow JA. Erythema migrans. Med Clin North Am. 2002 Mar. 86(2):239-60. [Medline].

  32. Karma A, Seppala I, Mikkila H, Kaakkola S, Viljanen M, Tarkkanen A. Diagnosis and clinical characteristics of ocular Lyme borreliosis. Am J Ophthalmol. 1995 Feb. 119(2):127-35. [Medline].

  33. Lesser RL. Ocular manifestations of Lyme disease. Am J Med. 1995 Apr 24. 98(4A):60S-62S. [Medline].

  34. Lesser RL, Kornmehl EW, Pachner AR, et al. Neuro-ophthalmologic manifestations of Lyme disease. Ophthalmology. 1990 Jun. 97(6):699-706. [Medline].

  35. Steere AC, Sikand VK. The presenting manifestations of Lyme disease and the outcomes of treatment. N Engl J Med. 2003 Jun 12. 348(24):2472-4. [Medline].

  36. Rothermel H, Hedges TR 3rd, Steere AC. Optic neuropathy in children with Lyme disease. Pediatrics. 2001 Aug. 108(2):477-81. [Medline].

  37. Klig JE. Ophthalmologic complications of systemic disease. Emerg Med Clin North Am. 2008 Feb. 26(1):217-31, viii. [Medline].

  38. Deanehan JK, Kimia AA, Tan Tanny SP, et al. Distinguishing Lyme from septic knee monoarthritis in Lyme disease-endemic areas. Pediatrics. 2013 Mar. 131(3):e695-701. [Medline].

  39. Engstrom SM, Shoop E, Johnson RC. Immunoblot interpretation criteria for serodiagnosis of early Lyme disease. J Clin Microbiol. 1995 Feb. 33(2):419-27. [Medline]. [Full Text].

  40. Cohn KA, Thompson AD, Shah SS, et al. Validation of a clinical prediction rule to distinguish Lyme meningitis from aseptic meningitis. Pediatrics. 2012 Jan. 129(1):e46-53. [Medline].

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

  42. 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. 2011 Aug. 30(8):1027-32. [Medline]. [Full Text].

  43. [Guideline] Wormser GP, Dattwyler RJ, Shapiro ED, 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. 2006 Nov 1. 43(9):1089-134. [Medline].

  44. Li X, McHugh GA, Damle N, Sikand VK, Glickstein L, Steere AC. Burden and viability of Borrelia burgdorferi in skin and joints of patients with erythema migrans or lyme arthritis. Arthritis Rheum. 2011 Aug. 63(8):2238-47. [Medline].

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

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

  47. Halperin JJ, Shapiro ED, Logigian E, 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. 2007 Jul 3. 69(1):91-102. [Medline].

  48. Blanc F, Jaulhac B, Fleury M, et al. Relevance of the antibody index to diagnose Lyme neuroborreliosis among seropositive patients. Neurology. 2007 Sep 4. 69(10):953-8. [Medline].

  49. 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. 2006 Apr. 27(4):892-4. [Medline].

  50. Donta ST, Noto RB, Vento JA. SPECT brain imaging in chronic Lyme disease. Clin Nucl Med. 2012 Sep. 37(9):e219-22. [Medline].

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

  52. [Guideline] Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther. 2014 Sep. 12(9):1103-35. [Medline]. [Full Text].

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

  54. Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA). April 22, 2010. Available at http://www.idsociety.org/Lyme_Final_Report/. Accessed: June 25, 2014.

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

  56. 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. 2010 Feb 15. 50(4):512-20. [Medline].

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

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

  59. Fish AE, Pride YB, Pinto DS. Lyme carditis. Infect Dis Clin North Am. 2008 Jun. 22(2):275-88, vi. [Medline].

  60. Borg R, Dotevall L, Hagberg L, 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].

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

  62. 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. 2006 Nov. 118(21-22):696-701. [Medline].

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

  64. Centers for Disease Control and Prevention. Post-Treatment Lyme Disease Syndrome. CDC. Available at http://www.cdc.gov/lyme/postLDS/index.html. 2014 Feb 24; Accessed: June 27, 2014.

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

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

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

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

  69. Hassett AL, Radvanski DC, Buyske S, et al. Role of psychiatric comorbidity in chronic Lyme disease. Arthritis Rheum. 2008 Dec 15. 59(12):1742-9. [Medline].

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

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

  72. Warshafsky S, Lee DH, Francois LK, Nowakowski J, Nadelman RB, Wormser GP. Efficacy of antibiotic prophylaxis for the prevention of Lyme disease: an updated systematic review and meta-analysis. J Antimicrob Chemother. 2010 Jun. 65(6):1137-44. [Medline].

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

  74. Nadelman RB, Wormser GP. A clinical approach to Lyme disease. Mt Sinai J Med. 1990 May. 57(3):144-56. [Medline].

 
Previous
Next
 
The bacterium Borrelia burgdorferi (darkfield microscopy technique, 400X; courtesy of the US Centers for Disease Control and Prevention).
Magnified ticks at various stages of development.
Ticks are the most common vectors for vector-borne diseases in the United States. In North America, tick bites can cause Lyme disease, human granulocytic and monocytic ehrlichiosis, babesiosis, relapsing fever, Rocky Mountain spotted fever, Colorado tick fever, tularemia, Q fever, and tick paralysis. Europe has a similar list of illnesses caused by ticks, but additional concerns include boutonneuse fever and tick-borne encephalitis. Lyme disease is one of the most prominent tick-borne diseases, and its main vector is the tick genus Ixodes, primarily Ixodes scapularis. Image courtesy of the US Centers of Disease Control and Prevention.
Approximate US distribution of Ixodes scapularis. Image courtesy of the US Centers for Disease Control and Prevention.
In general, Ixodes scapularis must be attached for at least 24 hours to transmit the spirochete to the host mammal. Prophylactic antibiotics are more likely to be helpful if feeding is longer. This photo shows 2 I scapularis nymphs. The one on the right is unfed; the other has been feeding for 48 hours. Note its larger size and the fact that the midgut diverticula (delicate brown linear areas on the body) are blurred. Photo by Darlyne Murawski; reproduced with permission.
Normal and engorged Ixodes ticks.
Amblyomma americanum is the tick vector for monocytic ehrlichiosis and tularemia. An adult and a nymphal form are shown (common match shown for size comparison). Image by Darlyne Murawski; reproduced with permission.
Approximate US distribution of Amblyomma americanum. Image courtesy of the US Centers for Disease Control and Prevention.
The soft-bodied tick of the genus Ornithodoros transmits various Borrelia species that cause relapsing fever. Photo courtesy of Julie Rawlings, MPH, Texas Department of Health. Relapsing fever is characterized by recurrent acute episodes of fever (usually >39°C). It is a vector-borne illness spread by lice and ticks. The spirochete species Borrelia is responsible.
The Ixodes scapularis tick is considerably smaller than the Dermacentor tick. The former is the vector for Lyme disease, granulocytic ehrlichiosis, and babesiosis. The latter is the vector for Rocky Mountain spotted fever. This photo displays an adult I scapularis tick (on the right) next to an adult Dermacentor variabilis; both are next to a common match displayed for scale. Photo by Darlyne Murawski; reproduced with permission.
Approximate US distribution of Dermacentor andersoni. Image courtesy of the US Centers for Disease Control and Prevention.
Rhipicephalus ticks are vectors for babesiosis and rickettsial infections, among others. Image courtesy of Dirk M. Elston, MD. In typical practice, testing ticks for tick-borne infectious organisms is not generally recommended. However, healthcare practitioners should become familiar with the clinical manifestations of tick-borne diseases (eg, Lyme disease, especially those practicing in endemic areas) and maintain a high index of suspicion during warmer months. Ticks can be placed in a sealed container with alcohol if they need to be transported and identified.
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.
This patient's erythema migrans rash demonstrates several key features of the rash, including size, location, and presence of a central punctum, which can be seen right at the lateral margin of the inferior gluteal fold. Note that the color is uniform; this pattern probably is more common than the classic pattern of central clearing. On history, this patient was found to live in an endemic area for ticks and to pull ticks off her dog daily.
Erythema migrans, the characteristic rash of early Lyme disease.
The thorax and torso are typical locations for erythema migrans. The lesion is slightly darker in the center, a common variation. In addition, this patient worked outdoors in a highly endemic area. Physical examination also revealed a right axillary lymph node.
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.
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 clotrimazole/betamethasone for 1 week for a presumed tineal infection, but the initial lesion grew, and new ones developed. He then presented 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 (presentation in July, in an area highly endemic for Lyme disease). In this situation, treatment with a drug that covers both diseases (eg, cefuroxime or amoxicillin-clavulanate) is an effective strategy.
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.
A rarely reported noninfectious complication for tick bites is alopecia. It can begin within a week of tick removal and typically occurs in a 3- to 4-cm circle around a tick bite on the scalp. A moth-eaten alopecia of the scalp caused by bites of Dermacentor variabilis (the American dog tick) has also been described. No particular species appears more likely to cause alopecia. Hair regrowth typically occurs within 1-3 months, although permanent alopecia has been observed.
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.
Blood smear showing likely babesiosis. Babesiosis can be difficult to distinguish from malaria on a blood smear.
Life cycle of the Ixodes dammini tick. Courtesy of Elsevier.
Lyme disease in the United States is concentrated heavily in the northeast and upper Midwest; it does not occur nationwide. Dots on the map indicate the infected person's county of residence, not the place where they were infected. Courtesy of the US Centers for Disease Control and Prevention (CDC).
Table 1. Clinical presentation and therapy for the stages of Lyme Disease
Disease



Stage



Clinical



Manifestations



 



Treatment



 



Duration



Early localized Erythema migrans Oral 14-21 days
Early disseminated Multiple erythema migrans Oral 14-21 days
Isolated cranial nerve palsy Oral 14-21 days
Meningoradiculoneuritis Oral 14-28 days
Meningitis Intravenous or oral 14-21 days
Carditis    
-Ambulatory Oral 14-21 days
-Hospitalized Intravenous followed by oral 14-21 days
Borrelial lymphocytoma Oral 14-21 days
Late Arthritis Oral 28 days
Recurrent arthritis after oral therapy Oral or intravenous 28 days or 14-28 days
Encephalitis Intravenous 14-28 days
Acrodermatitis chronica atrophicans Oral 14-28 days
Table 2. Adult and Pediatric treatment options, dosages, and routes of administration
  Treatment Adult Dose Pediatric Dose
Oral Therapy Doxycycline



(patients =8 y)



100 mg twice a day 4 mg/kg (up to 100 mg)



twice a day



Amoxicillin 500 mg three times a day 50 mg/kg (up to 500 mg)



three times a day



Cefuroxime axetil 500 mg twice a day 30 mg/kg (up to 500 mg)



twice a day



Intravenous therapy Ceftriaxone 2 g once a day 50-75 mg/kg (up to 2 g)



once a day



Cefotaxime 2 g every 8 h 150-200 mg/kg (up to 2 g) every 8 h
Penicillin G 18-24 million U/d divided



every 4 h



200,000-400,000 mg/kg



(up to 2 g) every 8 h



Table 3. Comparison of Infectious Diseases Society of America (IDSA) and International Lyme and Associated Diseases Society (ILADS) recommendations for Lyme disease treatment
Treatment Focus IDSA ILADS
Treatment of a tick bite without symptoms of Lyme disease Doxycycline, 200 mg as a single dose Doxycycline, 100 mg bid for 20 days
Erythema migrans Doxycycline, amoxicillin, or cefuroxime for 14-21 days Doxycycline, amoxicillin, or cefuroxime for 28-42 days or azithromycin for at least 21 days
“Persisting symptoms of Lyme disease” No antibiotic therapy Multiple agents (individually or in combination) are mentioned without specific doses or duration recommended
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.