Lyme Disease in Emergency Medicine Workup

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

Laboratory Studies

Laboratory testing depends entirely on the presenting problem of the patients.[14] Evaluation of the CBC, erythrocyte sedimentation rate, and liver function generally is unnecessary, and serologic tests can be misleading if performed in the wrong setting.

The patient with solitary, typical EM requires no laboratory testing whatsoever. Expected results for the CBC and erythrocyte sedimentation rate are likely normal. At this stage of illness, serologic testing is unnecessary because the pretest probability of Lyme disease is high, and the sensitivity of the serologic test is low (during the first several weeks).

Leukopenia or thrombocytopenia suggests co-infection with Ehrlichia or Babesia species.

Elevation of at least one liver function test result is reported to occur in 40% of patients with Lyme disease. This finding also is common in ehrlichiosis.

Diagnosis

Laboratory criteria for diagnosis are as follows:

For the purposes of surveillance, the definition of a qualified laboratory assay is

  • Positive culture for B burgdorferi, or
  • Two-tier testing interpreted using established criteria, where positive immunoglobulin M (IgM) is sufficient only when 30 days or less from symptom onset or positive immunoglobulin G (IgG) is sufficient at any point during illness
  • Single-tier IgG immunoblot seropositivity using established criteria
  • CSF antibody positive for B burgdorferi by enzyme immunoassay (EIA) or immunofluorescence assay (IFA), when the titer is higher than it was in serum[15]

Culture testing

Because of the fastidious growth requirements for B burgdorferi, culture has not been a useful test in the past; however, this situation is improving. Its usefulness depends on the specimen being cultured. Nevertheless, in routine practice, borrelial cultures are often unavailable.[14]

In the skin, where findings are most likely to be positive, culturing is least likely to be clinically useful, except in cases of atypical rash.

In other body fluids (eg, blood, synovial fluid, CSF), the yield is lower. However, recent data suggest that if a high volume (9 mL) of plasma is used, approximately 44% of patients with EM are determined to be spirochetemic at presentation.

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Imaging Studies

Imaging studies are almost never indicated in patients with Lyme disease who present with early syndromes. Patients with some clinical syndromes may require imaging studies, depending on the specifics of the case. For example, a patient with fever and severe back pain, with signs of radiculopathy, might require spine imaging.

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Other Tests

Serologic testing for Lyme disease is complex. Rational ordering and interpretation of these test results requires some understanding of the basic underlying principles and performance characteristics of the test.

Most importantly, the most commonly performed test measures antibodies to various proteins of the spirochete, some of which are very specific for the organism and others of which are nonspecific. The test results do not rule in or rule out Lyme disease; however, the results make a clinical diagnosis of Lyme disease more (or less) likely.

The CDC recommends a 2-step procedure consisting of a screening enzyme-linked immunoassay (ELISA) (or immunofluorescent assay [IFA]) and a confirmatory Western blot for specimens that have positive or equivocal results with the ELISA. Furthermore, in patients with a high likelihood of having Lyme disease (eg, classic EM in an endemic area), no serologic test should be ordered. Conversely, in a patient with a low pretest likelihood of having Lyme disease (eg, someone with vague symptoms where the test is being used as a screening test), testing is also not recommended because in such a population, the number of false-positive results greatly outnumbers the true positive results.

Numerous conditions (eg, viral and bacterial infections, inflammatory diseases, neoplasms) can cause false-positive ELISA results. Also, a small percentage of the healthy population has positive test results with ELISA testing. For these reasons, confirmatory Western blot testing is recommended.

Timing is extremely important. Seroconversion may take several weeks in patients infected with the spirochete, so early seronegativity is to be expected.

Even occasional patients with facial nerve palsy or carditis (ie, early disseminated disease) may be seronegative on presentation. However, testing is recommended in these individuals. Furthermore, early or partial treatment with antibiotics may blunt or abrogate the subsequent serologic response. Some patients with late disease are seronegative, but significant controversy exists regarding the frequency of late seronegativity. Most authorities suggest that this phenomenon is rare.

On the other hand, patients with prior Lyme disease may have persistently positive results. Also, vaccinated patients will have a positive ELISA result (although Western blot results should be negative). Lack of attention to the details of the test result and the reliability of the laboratory performing the test might lead the physician to an erroneous conclusion about the cause for a given patient's symptoms.

Patients may remain seropositive for long periods; therefore, serologic test results cannot be used as a proof or test of cure. Also, if a patient with past Lyme disease who remains seropositive comes in with new symptoms, care should be taken to not necessarily ascribe these new symptoms to Lyme disease.

The emergency physician must remember 2 important concepts. First, a negative Lyme test result does not indicate the absence of disease, nor does a positive result indicate the presence of disease. Second, a positive result is not required for someone with clear-cut EM; these early-presenting patients frequently have negative results, and they should be treated for EM empirically.

In the last few years, research on newer serologic tests—specifically the C6 peptide and the VlsE—is promising. These test results may well turn positive earlier and revert to negative after successful treatment. In July 2008, investigators published a prospective comparison between the standard 2-tier testing and an IgG of the VlsE of the C6 peptide. They found that both tests were sensitive, but the 2-tier testing had slightly better specificity.[16] The current CDC recommended 2-tier testing remains the preferred method in routine practice, and serological testing is still not recommended for patients with erythema migrans.

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Procedures

Because the spirochete can enter the CSF early in the course of infection and because the finding of meningitis (defined here as abnormal CSF in the setting of active Lyme disease) changes the treatment, many physicians have a low threshold for performing a lumbar puncture (LP) in patients with EM and any CNS symptoms or in patients with isolated seventh nerve palsy due to Lyme disease. They do this with the notion that an elevated protein level or pleocytosis mandates parenteral therapy.

A 2008 study randomized 118 European patients with CNS lyme to 2 weeks of oral doxycycline versus parenteral ceftriaxone therapy.[17] They found that clinical outcomes were the same in both groups, indicating that an LP may not be necessary if the purpose is to decide on route of therapy. Because of the differences in causative borrelial species, it is not clear if this finding is relevant to North American patients.

In addition, a lumbar puncture ought to be performed if Lyme meningitis is in the differential diagnosis.

Occasional patients with Lyme disease–related heart block will require temporary cardiac pacing. The indications for cardiac pacing are the same as for any other patient with varying degrees of heart block. Permanent wires are very rarely needed.

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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

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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



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