eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Lyme Disease: Follow-up
Updated: Apr 17, 2009
Follow-up
Deterrence/Prevention
- The best prevention for Lyme disease is education and awareness. Long pants and socks should be worn when in areas of likely tick exposure. Parents of children in endemic areas must be vigilant to check for ticks (especially the nymphs because of their smaller size) from the spring to the fall. Checking inside skin folds, behind ears, the umbilicus, groin, axilla, hairline, and scalp must be routine. Through education, parents can recognize early symptoms and signs.
- Insecticides, sprayed on clothing or directly on the skin, can deter ticks, but use of these agents must be weighed against toxicity from overzealous application.
- A Lyme disease vaccine was licensed by the US Food and Drug Administration (FDA) in 1998 but was subsequently withdrawn from the market in 2002 due to concerns regarding efficacy and side effects. The vaccine was made of recombinant outer surface protein A (OspA). Newer vaccines are in development.
- Prophylactic antibiotics after any tick exposure are not recommended. Even in endemic areas, the risk of transmission from a tick is estimated to be only 1-2%. In hyperendemic areas, a single dose of doxycycline (adults) has been shown to decrease development of disease if given within 72 hours of tick bite.
- Preventing exposure and removing ticks promptly is a much better strategy. However, in an endemic area, prolonged attachment, a concerned parent, or pregnancy may prompt consideration of prophylaxis or empiric treatment. For a known tick exposure, a thorough search for other ticks is necessary. Following discovery of an attached tick, education about symptoms and signs of Lyme disease is the most appropriate treatment.
Complications
- One nonmedical complication of Lyme disease has been the public and media's misconceptions about the disease. Unfortunately, many clinicians perform too many tests when the prior probability of disease is low, resulting in many false-positive tests. The combination of nonspecific symptoms and suboptimal test results has led to overtreatment for suspected (but not proven) Lyme disease and to the concept of refractory Lyme disease. In endemic areas, some physicians have capitalized on the hysteria by offering nontraditional testing and treatment and fostering the notion that all ailments (behavioral, academic, medical) are related to the elusive spirochete.
- The agents responsible for babesiosis and ehrlichiosis share the same tick vector as B burgdorferi, making co-infection possible. Acute infection caused by these agents is more common in asplenic individuals (babesiosis) or older adults (Ehrlichia); however, unlike B burgdorferi, chronic infection by these agents is not observed. To add to the confusion, ehrlichial infection may cause a false-positive result for Lyme disease on immunoglobulin M (IgM) Western blot analysis.
Prognosis
- The prognosis of all stages of Lyme disease is excellent with appropriate antibiotic treatment. Symptoms of arthritis may persist for a few weeks beyond adequate therapy; therefore, retreatment usually is not necessary unless symptoms worsen or persist beyond 2 months.
- Unfortunately, antibodies induced by the infection are not protective against further exposures to B burgdorferi; therefore, reinfection easily could be confused with a recurrence. Because antibodies may persist for years following an infection, repeat infection is a difficult diagnosis without specific signs of Lyme disease (eg, erythema migrans [EM] rash). Increasing titers after adequate treatment certainly raises suspicion of an active infection.
- Some individuals with arthritis may have persistent symptoms after clearance of the infection. This phenomenon is most likely related to autoimmunity and is more prevalent among individuals with HLA-DR2, HLA-DR3, or HLA-DR4 allotypes.
Patient Education
- Primary care providers should educate parents and children who live in endemic areas about the risk of Lyme disease. Anticipatory guidance should focus on prevention measures and post–tick exposure counseling on watching for symptoms and signs of Lyme disease.
- For excellent patient education resources, visit eMedicine's Bites and Stings Center and Muscle Disorders Center. Also, see eMedicine's patient education articles Lyme Disease, Ticks, Chronic Fatigue Syndrome, and Chronic Pain.
Miscellaneous
Medicolegal Pitfalls
- In the absence of specific signs, particularly in the early stage of infection, the diagnosis of Lyme disease can be difficult because of the limitations of current diagnostic tests.
- Testing should be performed in patients with aseptic meningitis, facial nerve palsy, or arthritis for Lyme disease if they live in or have traveled to an endemic area.
- Diagnosis of reinfection or recurrent infection is complicated by the persistence of antibody beyond the eradication of disease.
- Because interpretation of testing is related to stage of disease and requires a 2-stage test, laboratory results are often misinterpreted. Clinicians unfamiliar with Lyme disease or Lyme testing may falsely exclude the diagnosis (early disease) or falsely diagnose disease (old antibody or using Western blot in those with negative enzyme-linked immunosorbent assay [ELISA] test results).
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Richard G Bachur, MD and Marvin Harper, MD, to the original writing and development of this article.
More on Lyme Disease |
| Overview: Lyme Disease |
| Differential Diagnoses & Workup: Lyme Disease |
| Treatment & Medication: Lyme Disease |
 Follow-up: Lyme Disease |
| Multimedia: Lyme Disease |
| References |
| Further Reading |
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References
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Further Reading
- Practice parameter: treatment of nervous system Lyme disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology
- Evidence-based guidelines for the management of Lyme disease
- Infectious Diseases Society of America practice guidelines for clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis
Keywords
lyme borreliosis, Borrelia burgdorferi, B burgdorferi, Ixodes scapularis, deer tick, tickbite, tick bite, tick-borne illness, Lyme arthritis, Lyme disease, Lyme meningitis, Ixodid ticks, erythema migrans, EM, aseptic meningitis, cranioneuropathies, Bell palsy, encephalitis, carditis, rash, treatment, diagnosis, skin rash, meningismus
