eMedicine Specialties > Emergency Medicine > Infectious Diseases

Tick-Borne Diseases, Lyme: Follow-up

Author: 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
Contributor Information and Disclosures

Updated: Aug 26, 2009

Follow-up

Further Inpatient Care

  • The stages of Lyme disease that the ED physician normally sees rarely require inpatient care. Two noteworthy caveats must be considered.
    • Patients with Lyme meningitis may need to be admitted not only for pain control but also for administration of intravenous antibiotics. In addition, 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.
    • The patient with myocarditis generally is not very ill, and significant muscle dysfunction is unusual. Pericarditis with tamponade, while rare, has been reported. Perhaps of greatest importance, recognize that Lyme carditis is a reversible cause of complete heart block and rarely requires a permanent pacemaker; therefore, consider Lyme disease in patients with a third-degree heart block (in the appropriate epidemiologic circumstances). These patients require admission to a telemetry unit.

Further Outpatient Care

  • Patients with Lyme disease can have other manifestations in the future, especially if the disease is diagnosed late or if the patient is noncompliant with antibiotic therapy. Also, treatment failures have been reported with virtually every antibiotic regimen. Furthermore, serologic test results for Lyme disease are not available in time for care in the ED. Also, manifestations may be slow to resolve.
    • For these reasons, follow-up is imperative, preferably with a primary care physician.
    • The individual clinical situation determines the timing of the follow-up visit.

Deterrence/Prevention

  • Vaccination is one preventative measure.
    • In 1998, results of 2 large trials of vaccines directed toward the outer surface protein A (Osp A) were reported. One product (LYMErix, SmithKline Beecham) received the approval of the US Food and Drug Administration in December 1998, for use in the prevention of Lyme disease. However, because of poor demand for the product, the sale was later discontinued in the United States (2002). The original trial included nonpregnant patients aged 15-70 years, with 3 doses administered on a 0-, 1-, and 12-month schedule.23 Newer data suggest that a 0-, 1-, and 2-month dosing schedule is equally effective.
    • After 2 doses of vaccine, a protection rate of only about 50% protection rate was present; after the third dose, roughly 80% of the patients developed protective antibodies.
    • At the present time, no human vaccine for Lyme disease is on the market in North America.
    • Vaccinated individuals have positive results with enzyme-linked immunoassays for Lyme antibodies but can be distinguished on the basis of a Western blot test.
  • For other information about the prevention of tick-borne diseases, see Tick-borne Diseases, Introduction.
  • See Emergency Department Care for tick bite prophylaxis.

Complications

  • Lyme disease initially misdiagnosed or treated late may progress to harder-to-treat disease with some symptoms, especially neurologic, that can be debilitating. Thus, the emergency physician must be aware of Lyme disease and must promptly initiate treatment or refer patients to their primary care physician or other physician for appropriate antibiotic therapy; specific care depends on specific details of the situation.
  • Third-degree heart blocks often require a temporary pacemaker insertion and, on rare occasions, a permanent pacemaker insertion.
  • Doxycycline can cause severe cutaneous photosensitivity. Caution patients to use sunblock with an SPF of at least 30 and to wear wide-brimmed hats for further protection.
  • A primary care physician should follow-up patients receiving long-term intravenous ceftriaxone, because biliary colic can develop from the sludge that forms secondary to this therapy.
  • Some genetically predisposed patients develop chronic arthritis that is driven by immunopathogenic mechanisms and not active infection. This situation is resistant to antibiotics.
  • In some studies, as many as 10-15% of patients with Lyme disease have been co-infected with another tick-borne pathogen. Therefore, consider this possibility if the disease does not respond as expected with ordinary early Lyme disease. Evidence suggests that co-infected patients have more symptoms of longer duration compared with other patients. In addition, these patients may be sicker than others on first observation. Also, implications exist for choice of antibiotics.

Prognosis

  • Several studies report an excellent prognosis for patients who are promptly treated for early Lyme disease. As in most diseases, the earlier treatment begins, the better the results.
  • Patients with late disease may have symptoms that are hard to eradicate. Also, these symptoms tend to disappear more slowly than do early symptoms. Controversy exists regarding the best therapy for these patients.
  • The types of syndromes that emergency physicians generally treat, which is to say the early ones, respond well.

Patient Education

  • Educate patients about tick avoidance and proper tick removal. For details, see Tick-borne Diseases, Introduction. This is very important since one episode of EM does not always confer immunity to the next. The same type of activity that led to the tick bite in the first place may still be occurring.
  • Educate patients with early stages of Lyme disease about symptoms that can develop later. Development of these symptoms necessitates re-examination and may indicate treatment failure or incorrect diagnosis.
  • For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Ticks.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose several tick-borne diseases, including Lyme disease, is a pitfall.
  • A related pitfall is a failure to consider Lyme disease because of the absence of a known tick bite. Only about 25-30% of patients with Lyme disease recall the bite. Far more importantly, inquire about activities that may increase the patient's risk for tick bites.
  • Another pitfall is a failure to consider Lyme disease because of the absence of central clearing in a patient with EM. This classic finding of clearing occurs in only a minority of patients and is not needed for making the diagnosis.
  • Patients with Lyme disease may be co-infected with other organisms, especially Ehrlichia and Babesia species. Patients with definite Lyme disease and symptoms such as higher fever or atypical manifestations (eg, leukopenia) may have such co-infections and require different therapies. Co-infections occur in roughly 10-15% of patients with Lyme disease.
  • Remember the limitations of the serologic tests for Lyme disease. Results can be false positive or false negative. Misinterpretation of results can lead to serious problems. This is especially true in early presenting patients and in those with asymptomatic tick bites. Those with EM often have negative serologic test results. If EM is the likely diagnosis, empiric treatment, not serologic testing, is the appropriate action.

Special Concerns

  • Avoid tetracyclines in pregnant patients and in those younger than 9 years.
  • Have a lower threshold for prophylaxis in pregnant women with asymptomatic tick bites.
 


More on Tick-Borne Diseases, Lyme

Overview: Tick-Borne Diseases, Lyme
Differential Diagnoses & Workup: Tick-Borne Diseases, Lyme
Treatment & Medication: Tick-Borne Diseases, Lyme
Follow-up: Tick-Borne Diseases, Lyme
Multimedia: Tick-Borne Diseases, Lyme
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Edlow JA. Bull's Eye - Unraveling the Medical Mystery of Lyme Disease. 2nd ed (paperback). Yale University Press; 2004.

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

  3. 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].

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

  5. Wormser GP, Brisson D, Liveris D, 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].

  6. 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].

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

  8. 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. Nov 2008;122(5):e1080-5. [Medline].

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

  10. 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. May 1996;100(5):502-8. [Medline].

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

  12. Wormser GP, Shapiro ED. Implications of gender in chronic Lyme disease. J Womens Health (Larchmt). Jun 2009;18(6):831-4. [Medline].

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

  14. 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].

  15. 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. Aug 2008;7(8):690-5. [Medline].

  16. [Guideline] 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].

  17. [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].

  18. [Guideline] Cameron D, Gaito A, Harris N, Bach G, Bellovin S, Bock K, et al. Evidence-based guidelines for the management of Lyme disease. Expert Rev Anti Infect Ther. 2004;2(1 Suppl):S1-13. [Medline].

  19. Nadelman RB, Nowakowski J, Fish D. 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].

  20. Dattwyler RJ, Luft BJ, Kunkel MJ, et al. Ceftriaxone compared with doxycycline for the treatment of acute disseminated Lyme disease. N Engl J Med. Jul 31 1997;337(5):289-94. [Medline].

  21. 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. May 6 2003;138(9):697-704. [Medline].

  22. Oksi J, Nikoskelainen J, Hiekkanen H, et al. Duration of antibiotic treatment in disseminated Lyme borreliosis: a double-blind, randomized, placebo-controlled, multicenter clinical study. Eur J Clin Microbiol Infect Dis. Aug 2007;26(8):571-81. [Medline].

  23. Steere AC, Sikand VK, Meurice F, et al. Vaccination against Lyme disease with recombinant Borrelia burgdorferi outer-surface lipoprotein A with adjuvant. Lyme Disease Vaccine Study Group. N Engl J Med. Jul 23 1998;339(4):209-15. [Medline].

  24. Brown SL, Hansen SL, Langone JJ. Role of serology in the diagnosis of Lyme disease. JAMA. Jul 7 1999;282(1):62-6. [Medline].

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

  26. Edlow JA. Lyme disease and related tick-borne illnesses. Ann Emerg Med. Jun 1999;33(6):680-93. [Medline].

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

  28. Feder HM Jr, Whitaker DL. Misdiagnosis of erythema migrans. Am J Med. Oct 1995;99(4):412-9. [Medline].

  29. Fish D. Environmental risk and prevention of Lyme disease. Am J Med. Apr 24 1995;98(4A):2S-8S; discussion 8S-9S. [Medline].

  30. Halperin JJ. Nervous system Lyme disease. Infect Dis Clin North Am. Jun 2008;22(2):261-74, vi. [Medline].

  31. Krause PJ, Telford SR 3rd, Spielman A, et al. Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness. JAMA. Jun 5 1996;275(21):1657-60. [Medline].

  32. Luft BJ, Steinman CR, Neimark HC, et al. Invasion of the central nervous system by Borrelia burgdorferi in acute disseminated infection. JAMA. Mar 11 1992;267(10):1364-7. [Medline].

  33. Philipp MT, Wormser GP, Marques AR, et al. A decline in C6 antibody titer occurs in successfully treated patients with culture-confirmed early localized or early disseminated Lyme Borreliosis. Clin Diagn Lab Immunol. Sep 2005;12(9):1069-74. [Medline].

  34. Shah SS, Zaoutis TE, Turnquist J, et al. Early differentiation of Lyme from enteroviral meningitis. Pediatr Infect Dis J. Jun 2005;24(6):542-5. [Medline].

  35. Shapiro ED, Gerber MA, Holabird NB, et al. A controlled trial of antimicrobial prophylaxis for Lyme disease after deer-tick bites. N Engl J Med. Dec 17 1992;327(25):1769-73. [Medline].

  36. Steere AC. Lyme disease. N Engl J Med. Jul 12 2001;345(2):115-25. [Medline].

  37. Strle F, Nadelman RB, Cimperman J, et al. Comparison of culture-confirmed erythema migrans caused by Borrelia burgdorferi sensu stricto in New York State and by Borrelia afzelii in Slovenia. Ann Intern Med. Jan 5 1999;130(1):32-6. [Medline].

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

  39. Wormser GP. Clinical practice: early Lyme disease. N Engl J Med. Jun 29 2006;354(26):2794-801. [Medline].

  40. Wormser GP, Masters E, Nowakowski J, et al. Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions. Clin Infect Dis. Oct 1 2005;41(7):958-65. [Medline].

[ CLOSE WINDOW ]

Keywords

tick-borne disease, Lyme disease, tick bite, Borrelia burgdorferi, Ixodes, vector-borne disease, juvenile arthritis, B burgdorferi, spirochete, tick-borne pathogens, myalgias, arthralgias, flulike illness, borrelial lymphocytoma

acrodermatitis chronicum atrophicans, lymphocytic meningitis, facial weakness, Bell palsy, borrelial facial palsy, lymphocytic pleocytosis, Bannwarth syndrome, chronic encephalopathy, syncope, heart block, complete heart block, lyme pericarditis, lyme myocarditis, lyme myopericarditis, myositis, tendonitis, bursitis, synovitis, conjunctivitis, keratitis, iritis, erythematous papule, erythematous macule, polycranial neuropathy

meningoradiculitis, lyme encephalopathy, peripheral axonal neuropathy, tamponade, congestive heart failure, monoarthritis, oligoarthritis, retinal hemorrhages, retinal exudates, papilledema, pseudotumor cerebral-like syndrome, splenomegaly, hepatomegaly, regional lymphadenopathy, , white matterencephalitis, HLA-DR4 antigen

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

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.

Medical Editor

Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, 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.

Pharmacy Editor

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

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
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.