Lyme Disease in Emergency Medicine Follow-up

  • Author: William E Caputo, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 24, 2011
 

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.

Next

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.

Previous
Next

Deterrence/Prevention

Prevention

Lyme disease prevention has focused traditionally on reducing human exposure to the bites of infected ticks. Current recommendations include practices such as the following:[24]

  • Avoiding tick-infested areas
  • Using insect repellants
  • Wearing light-colored clothing on which ticks are more readily detected
  • Wearing long trousers and tucking them into socks to keep ticks on outer clothing
  • Performing bodily tick checks, followed by prompt tick removal
  • Landscape management
  • Acaricide applications on property or targeted to hosts
  • Management of deer populations

Vaccination

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.[25] Newer data suggest that a 0-month, 1-month, 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. Vaccinated individuals have positive results with enzyme-linked immunoassays for Lyme antibodies but can be distinguished on the basis of a Western blot test.

At the present time, no human vaccine for Lyme disease is on the market in North America.

For other information about the prevention of tick-borne diseases, see Tick-borne Diseases, Introduction. See Emergency Department Care for tick bite prophylaxis.

Previous
Next

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.

Previous
Next

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.

Previous
Next

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 patient education information, visit eMedicine's Bites and Stings Center, as well as Ticks.

Previous
 
Contributor Information and Disclosures
Author

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

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

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Associate 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.

Specialty Editor Board

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.

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

Disclosure: eMedicine Salary Employment

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.

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 

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

References

  1. Centers for Disease Control and Prevention. Summary of notifiable diseases—United States, 2008. MMWR 2008. 06/2010;57:1-94. [Full Text].

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

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

  4. 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].

  5. 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].

  6. 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].

  7. 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].

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

  9. 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].

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

  11. 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].

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

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

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

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

  16. 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].

  17. 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].

  18. [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].

  19. [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].

  20. [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].

  21. 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].

  22. 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].

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

  24. Hayes EB, Piesman J. How can we prevent Lyme disease?. N Engl J Med. Jun 12 2003;348(24):2424-30. [Medline].

  25. 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].

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

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

  28. 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].

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

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

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

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

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

  34. 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].

  35. 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].

  36. Murray TS, Shapiro ED. Lyme disease. Clin Lab Med. Mar 2010;30(1):311-28. [Medline].

  37. 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].

  38. 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].

  39. 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].

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

  41. 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].

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

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

  44. 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].

 
Previous
Next
 
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.
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.
This patient recalled pulling a tick from the left side of his neck 7 days previously. His rash displays the vesicular variant. Roughly 18 hours after the first dose of doxycycline, he developed a typical Jarisch-Herxheimer reaction.
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.
In general, Ixodes scapularis must be attached for 24-48 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.
This is the classic target lesion of erythema migrans (EM). Although this morphology has been emphasized in the older literature, in North America, it represents only about 40% of all EM lesions. This morphology is more commonly found in Europe. Photo reproduced with permission; Lyme Disease Foundation, Hartford, CT.
Lyme disease frequently affects children. Pictured below is a young girl with no known tick bite in the area. While vacationing with her family on Fire Island in August, this young girl developed the rash shown below. She was treated successfully with amoxicillin. Photo courtesy of Dr John Hanrahan.
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.
This patient from Nantucket presented in early July with this rash. When the rash started, he had been treated for 1 week with Lotrisone for a presumed tineal infection, but the initial lesion grew, and new ones developed. He worked outside as a carpenter but had no definite tick bite.
This patient from a highly endemic area presented in July with a lesion on his ankle. It was mildly painful and had been present for 2-3 days. Mild tenderness was evident on physical examination. Both cellulitis and erythema migrans were possibilities; therefore, the patient was treated for both. Cefuroxime axetil or amoxicillin-clavulanate is useful in this situation because of their antimicrobial spectra.
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.
The bacterium Borrelia burgdorferi (darkfield microscopy technique, 400X; courtesy of the US Centers for Disease Control and Prevention).
Approximate US distribution of Ixodes scapularis. Image courtesy of the US Centers for Disease Control and Prevention.
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. Ehrlichiosis is a tick-borne infection of the white blood cells caused by Ehrlichia species. Typical symptoms include fever, headache, malaise, and myalgia, and they occur 5-14 days after the tick bite. It is sometimes referred to as "spotless" Rocky Mountain spotted fever. The treatment of choice is doxycycline, 100 mg twice daily, either orally or intravenously for 10 days. This regimen will also treat Lyme disease and the often mistaken Rocky Mountain spotted fever. Rifampin, 200 mg twice daily for 7 days, is a second-line option because chloramphenicol does not treat Ehrlichia chaffeensis. Tularemia is a zoonosis caused by infection with Francisella tularensis. Typical symptoms include fever, lethargy, anorexia, and in some forms, extensive ulcerating lymphadenopathy. With early diagnosis and treatment, mortality is rare (1%). Antibiotic treatment with streptomycin, 1 g intramuscularly twice daily for 10 days, eradicates the bacteria.
Approximate US distribution of A 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. For tick-borne relapsing fever, treatment is with tetracycline, 500 mg orally every 6 hours, or doxycycline, 100 mg orally twice daily, for 10 days. The louse-borne illness usually only requires a single dose of tetracycline or erythromycin, 500 mg orally.
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.
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.
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.
Hematoxylin and eosin stained section from a biopsy performed at the periphery of an eruption. Note the perivascular lymphocytic infiltrate, a pattern that is not specific for, but is characteristic of, erythema migrans.
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.
Multiple lesions of erythema migrans occur in approximately 20% of patients. This patient, a carpenter from Nantucket who worked predominantly outside, had been treated with Lotrisone for 1 week prior to presenting to the emergency department with this rash. The patient had no fever and only mild systemic symptoms. He was treated with a 3-week course of oral antibiotics.
Blood smear showing likely babesiosis. Babesiosis can be difficult to distinguish from malaria on a blood smear.
Magnified ticks at various stages of development.
Typical appearance of erythema migrans, the bull's-eye rash of Lyme disease
Lyme rash. Courtesy of M. Fergione, B. Tucker, and L. Zernel; Pfizer Laboratories.
Normal and engorged Ixodes ticks.
Erythema migrans, the characteristic rash of early Lyme disease.
Bulls-eye rash
MMWR June 25, 2010 LymeDisease. Incidence (Per 100,000 population) of reported cases, by county — United States, 2008
Clinical presentation and therapy for the stages of Lyme Disease
Adult and Pediatric treatment options, dosages, and routes of administration
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.
Table 1. Clinical presentation and therapy for the stages of Lyme Disease
Disease



Stage



Clinical



Manifestations



Treatment Duration
Early localizedErythema migransOral14-21 days
Early disseminatedMultiple erythema migransOral14-21 days
Isolated cranial nerve palsyOral14-21 days
MeningoradiculoneuritisOral14-28 days
MeningitisIntravenous or oral14-21 days
Carditis
-AmbulatoryOral 14-21 days
-HospitalizedIntravenous followed by oral14-21 days
Borrelial lymphocytoma Oral14-21 days
LateArthritisOral28 days
Recurrent arthritis after oral therapyOral or intravenous28 days or 14-28 days
EncephalitisIntravenous14-28 days
Acrodermatitis chronica atrophicansOral14-28 days
Table 2. Adult and Pediatric treatment options, dosages, and routes of administration
TreatmentAdult DosePediatric Dose
Oral TherapyDoxycycline



(patients ≥8 y)



100 mg twice a day4 mg/kg (up to 100 mg)



twice a day



Amoxicillin500 mg three times a day50 mg/kg (up to 500 mg)



three times a day



Cefuroxime axetil500 mg twice a day30 mg/kg (up to 500 mg)



twice a day



Intravenous therapyCeftriaxone2 g once a day50-75 mg/kg (up to 2 g)



once a day



Cefotaxime2 g every 8 h 150-200 mg/kg (up to 2 g) every 8 h
Penicillin G18-24 million U/d divided



every 4 h



200,000-400,000 mg/kg



(up to 2 g) every 8 h



Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

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