Lyme Disease Treatment & Management

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

Approach Considerations

The goals of treatment are to cure B burgdorferi infection, to speed the resolution of the clinical manifestations, and to prevent complications.

Lyme disease is treated primarily with outpatient antibiotics. Patients with cutaneous manifestations of Lyme disease (without concurrent extracutaneous disease) do not require hospitalization. The selection of pharmacologic modality should always be based on the patient's allergies, age, clinical manifestations, stage of disease, and concomitant medical conditions. Of great importance, doxycycline is contraindicated in patients younger than 8 years and in pregnant women.

Patients with carditis may need hospitalization to prevent syncope during episodes of atrioventricular (AV) block. In these patients, prompt institution of appropriate antibiotics is usually the only treatment needed. Rarely, patients with carditis require a temporary pacemaker.

Patients with chronic arthritis that does not respond to intravenous antibiotics may need a synovectomy to eradicate the inflammatory arthritis in the involved joint. Prior to surgery, however, patients should be treated with NSAIDs and/or hydroxychloroquine.

Prophylactic antibiotics are not recommended in pregnant women.[16] Antibiotic treatment of pregnant patients is restricted to those who have a reliable clinical diagnosis of Lyme disease.[16]

The Infectious Diseases Society of America released clinical practice guidelines for the assessment, treatment, and prevention of Lyme disease.[24] The recommendations presented in this article are consistent with those treatment guidelines.

Go to Pediatric Lyme Disease for complete information on this topic.

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Antibiotic Therapy

Wormser et al suggested that patients with Lyme disease can be treated with only 10 days of doxycycline.[32] 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.

Doxycycline, amoxicillin, or cefuroxime axetil for 10-14 days is indicated for early localized or early disseminated disease associated with erythema migrans in the absence of neurologic involvement or third-degree heart block. This regimen is also recommended for patients with cranial nerve palsy with normal cerebrospinal fluid (CSF) findings and those with borrelial lymphocytoma. One clinical trial indicated that 10-day treatment with doxycycline was as effective as 20-day treatment with doxycycline in patients with erythema migrans.

Cefuroxime axetil is effective; however, because of its cost, it 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.

Lyme disease arthritis without neurologic disease may be treated with the above drugs for 28 days. The preferred duration of the oral regimen for acrodermatitis chronica atrophicans is 21 days.

Neurologic Lyme disease in patients aged at least 8 years is effectively treated with a 2-week course of parenteral penicillin, ceftriaxone, or cefotaxime.[29, 33] Oral doxycycline is as efficacious as parenteral antibiotics in patients who have Lyme-associated meningitis, facial nerve palsy, or radiculitis.[29]

Evidence from 3 trials suggested a lack of benefit from prolonged antibiotic treatment of what is known as post-Lyme syndrome (symptoms persisting or recurring after appropriate treatment in the absence of evidence of ongoing infection).[33]

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Management of Specific Manifestations

Treatment recommendations for specific clinical findings are briefly discussed in this section.

Tick bites and cutaneous manifestations

Until recently, no therapy was indicated for tick bites, even in endemic areas. However, a 2001 article in the New England Journal of Medicine suggested that treatment with a single dose of 200 mg of doxycycline within 72 hours of removing a tick can prevent the development of Lyme disease.[15] However, this therapy should be limited to patients who have had possible tick exposure in endemic areas.

Cutaneous manifestations of Lyme disease are treated using antibiotics. Important considerations include the stage of the disease, presence of associated neurologic symptoms or signs (especially in borrelial lymphocytoma and acrodermatitis chronica atrophicans), and patient factors (duration of symptoms, allergies, age, pregnancy status). Institute an oral antibiotic regimen for 30 days.

Arthritis

Institute an oral antibiotic regimen for 30 days. Intra-articular steroids should be avoided, as such therapy may lead to a persistent bacterial infection.

Retreat for 30 days with an oral regimen or intravenous ceftriaxone if the first oral course is unsuccessful. If synovitis persists after a second course of antibiotics, hydroxychloroquine has been shown to be effective.[34]

Neurologic manifestations

Institute an oral antibiotic regimen for 30 days in those with facial palsies. Although facial palsies may resolve without treatment, antibiotic therapy may prevent further sequelae.

In individuals with paresthesias/radiculopathy, institute intravenous antibiotic therapy for 14 days. In Europe, oral doxycycline for 14 days at 200 mg/day and 30 days at 100 or 200 mg bid has been reported to be as effective as a 14-day course of intravenous ceftriaxone for neuroborreliosis.[35, 36, 37]

Encephalitis/encephalopathy should be treated with intravenous antibiotic therapy for 28 days.

Fibromyalgia

The treatment of fibromyalgia and fibromyalgialike symptoms following Lyme disease has not been shown in any controlled trials to be responsive to antibiotic therapy. 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.[38]

Pregnancy

Special consideration should be given to drug therapy in pregnant women. Pregnant women who develop Lyme disease should be treated, but not with doxycycline or another tetracycline because of fetal risks, such as permanent discoloration of the teeth, enamel hypoplasia, and retardation of skeletal development.

No evidence indicates an increase in congenital heart or neurologic disease in endemic areas. This suggests that if a pregnant woman is bitten by a tick, antibiotic treatment is not indicated.

Extremely rare cases of neonatal death or stillbirth have been reported after pregnancies complicated by untreated or inadequately treated symptomatic maternal Lyme borreliosis. Subsequent findings from CDC studies suggest that congenital infection with B burgdorferi is unlikely and that it is not directly responsible for adverse fetal outcomes.

Co-infection

Co-infection with other tick-borne illnesses should be considered in patients with a poor response to conventional antimicrobial therapy or altered clinical presentations. Co-transmitted infective organisms can include Babesia microti, the primary cause of babesiosis; Anaplasma phagocytophilum, the cause of human granulocytic anaplasmosis; flavivirus, the cause of tick-borne encephalitis; and Powassan or tick-borne encephalitislike virus.

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Diagnosis and Treatment Controversies

Controversy regarding the treatment of Lyme disease abounds, including an antitrust investigation reported in 2009 by the Connecticut Attorney General into the development process for the Lyme disease treatment guidelines from the Infectious Disease Society of America. The Attorney General claimed the process was tainted by suppression of scientific evidence and conflicts of interest.[39]

In addition, some authors have proposed existence of an "Axis of Evil," which would include the Internet, for promoting Lyme hysteria; particular specialty laboratories, for allegedly performing inaccurate testing; and physicians, specifically those who prescribe prolonged and unnecessary courses of antibiotic treatment.[40]

The existence and treatment of conditions termed chronic Lyme disease and posttreatment Lyme disease have been called into question as a result of a lack of direct evidence of persistent infection.[41, 42] Extended antibiotic therapy, sometimes longer than 6 months, has been advocated for these poorly defined conditions, which not only can cause great harm to patients but has resulted in one or more deaths.[43] Hassett et al report associated psychiatric comorbidity in patients with chronic Lyme disease.[44]

In 2006, the guidelines committee of the Infectious Disease Society of America stated that a group of symptoms termed "persistent Lyme disease symptoms" (eg, headaches, mood disturbances, fatigue, poor memory, joint pain) are merely the "aches and pains of daily living." Further, an ad hoc international Lyme group stated they are "symptoms common in persons who have never had Lyme disease." Cameron has proposed that despite the controversy surrounding persistent Lyme disease symptoms, evidence to deny care is lacking and to do so is neglectful to patient care.[45, 46]

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Complications

In early Lyme disease (erythema migrans), treatment is highly effective and complications are unusual. Complications consist of later manifestations of Lyme disease.

In patients with late-stage cutaneous disease, the physician must look for additional, especially neurologic, manifestations. Neurologic disease constitutes an indication for parenteral therapy.

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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.

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.

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Long-Term Monitoring

Follow-up monitoring is indicated for all patients with Lyme disease until complete resolution of all signs and symptoms. 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 continue to improve but 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 immunoglobulin (Ig) M 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. Recent 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, in which symptoms may be refractory to conventional therapies.

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Proceed to Medication
 
 
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.

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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.
 
 
 
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