Lyme disease - Acute
Rahul Soman, M. Pharm
Definition
A tickborne multisystem infectious disease causes by Borrelia species spirochetes
Medical History
* Environmental Exposure
* Occupational Exposure
* Exposure to animals
Findings
* Acute confusional state, of infective origin
* Bradyarrhythmia - Acute
* Dementia
* Dyspnea - Acute
* Increased heart rate
* Lyme neuroborreliosis
* Conjunctival finding
* Pleuritic pain
* Syncope - Acute
* Acrodermatitis atrophicans chronica
* Arthralgia
* Bladder dysfunction
* Erythema chronica migrans
* Facial palsy
* Fatigue
* Fever
* Headache
* Joint swelling
* Lymphadenopathy - Acute
* Myalgia
* Pain in eye
* Radicular pain
* Shoulder girdle weakness
* Skin lesion
* Tick bite
* Skin nodule
Tests
Suspected Lyme disease
* Complete blood count: In Lyme disease, an increased or decreased WBC count and a decreased HCT may be seen.
Suspected Lyme disease
* Erythrocyte sedimentation rate measurement: An elevated erythrocyte sedimentation rate (ESR) (greater than 30 mm/hr) may be seen in 25% to 50% of patients .
Suspected Lyme disease
* Borrelia burgdorferi antibody assay: A positive or equivocal ELISA result suggests past or current infection with Borrelia burgdorferi and should be confirmed by Western blot .
Suspected Lyme disease
* Borrelia burgdorferi DNA assay: PCR may be the preferred test for skin biopsy specimens in erythema migrans and may be useful as a supplemental test for CSF in neuroborreliosis .
Suspected neuroborreliosis
* Cerebrospinal fluid examination: Clinical diagnosis of neuroborreliosis can be confirmed by the presence of cerebrospinal (CSF) lymphocytic pleocytosis .
Suspected neuroborreliosis
* Borrelia burgdorferi antibody assay, Cerebrospinal fluid sample: Early neuroborreliosis may have higher levels of total IgM and IgM-specific antibodies in cerebrospinal fluid, and late stages have IgG predominance .
Suspected Lyme carditis
* 12 lead ECG: Sinus tachycardia and bradycardia, arrhythmias, heart block, conduction delays, and ST-T wave abnormalities have been seen in Lyme carditis.
Suspected Lyme arthritis
* Joint X-ray: Joint effusions and soft tissue edema are the most common changes.
Suspected inflammatory or noninflammatory arthritis
* Synovial fluid analysis: WBC count and percentage of polymorphonuclear cells are useful for distinguishing between inflammatory and noninflammatory arthritides .
Differential Diagnosis
* Lyme neuroborreliosis
* Lyme carditis
* Lyme arthritis
* Southern tick-associated rash illness
* Human anaplasmosis
* Babesiosis
* Cellulitis - Acute
* Hypersensitivity reaction
* Rocky Mountain spotted fever - Acute
* Viral meningitis - Acute
* Transfusion reaction due to serum protein reaction
* Infective endocarditis - Acute
* Bell's palsy - Acute
* Insect bite
* Tinea corporis
* Nummular eczema
* Granuloma annulare
* Contact dermatitis - Acute
* Urticaria - Acute
* Fixed drug eruption
* Erythema multiforme - Acute
* Pityriasis rosea
* PLANTS-TOXICODENDROL
* NECROTIC ARACHNIDISM
* Septic arthritis - Acute
* Rheumatic fever
* Parvovirus infection
* Reiter's disease
* Rheumatoid arthritis - Chronic
* Juvenile rheumatoid arthritis
* Relapsing fever
Treatment
Drug Therapy
Early localized or disseminated Lyme disease with erythema migrans without neurologic involvement or advanced atrioventricular heart block
DOXYCYCLINE
Adults: 100 mg orally twice daily for 14 (range 10 to 21) days
Pediatrics (?8 years): 4 mg/kg/day orally in 2 divided doses (maximum 100 mg/dose) for 14 (range 10 to 21) days
CEFUROXIME AXETIL
Adults: 500 mg orally twice daily for 14 to 21 days
Pediatrics: 30 mg/kg/day orally in 2 divided doses (maximum, 500 mg/dose) for 14 to 21 days
AMOXICILLIN
Adults: 500 mg orally 3 times daily for 14 to 21 days
Pediatrics: 50 mg/kg/day in 3 divided doses (maximum, 500 mg/dose) for 14 to 21 days
Early Lyme neurologic disease with meningitis or radiculopathy
CEFTRIAXONE SODIUM
Adults: 2 g IV once daily for 14 (range 10 to 28) days
Pediatrics: 50 to 75 mg/kg (maximum, 2 g) IV once daily for 14 (range 10 to 28) days
CEFOTAXIME SODIUM
Adults (alternative): 2 g IV every 8 hours for 14 (range 10 to 28) days
Pediatrics (alternative): 150 to 200 mg/kg/day IV in 3 to 4 divided doses (maximum, 6 g/day) for 14 (range 10 to 28) days
PENICILLIN G POTASSIUM
Adults (alternative): 18 to 24 million units/day IV in divided doses every 4 hours for 14 (range 10 to 28) days
Pediatrics (alternative): 200,000 to 400,000 units/kg/day IV in divided doses every 4 hours (maximum, 18 to 24 million units/day) for 14 (range 10 to 28) days
DOXYCYCLINE
Adults (beta-lactam intolerance): 100 to 200 mg orally or intravenously twice daily for 14 (range 10 to 21) days
Pediatrics (?8 years, beta-lactam intolerance): 4 to 8 mg/kg/day orally or intravenously in 2 divided doses (maximum, 200 mg/dose) for 14 (range 10 to 21) days
Early neurologic Lyme disease with cranial nerve palsy
DOXYCYCLINE
Adults (normal CSF exam, no clinical signs of meningitis): 100 mg orally twice daily for 14 to 21 days
Pediatrics (?8 years, normal CSF exam, no clinical signs of meningitis): 4 mg/kg/day orally in 2 divided doses (maximum 100 mg/dose) for 14 to 21 days
CEFUROXIME AXETIL
Adults (normal CSF exam, no clinical signs of meningitis): 500 mg orally twice daily for 14 to 21 days
Pediatrics (normal CSF exam, no clinical signs of meningitis): 30 mg/kg/day orally in 2 divided doses (maximum, 500 mg/dose) for 14 to 21 days
AMOXICILLIN
Adults (normal CSF exam, no clinical signs of meningitis): 500 mg orally 3 times daily for 14 to 21 days
Pediatrics (normal CSF exam, no clinical signs of meningitis): 50 mg/kg/day in 3 divided doses (maximum, 500 mg/dose) for 14 to 21 days
CEFTRIAXONE SODIUM
Adults (clinical and laboratory evidence of CNS involvement): 2 g IV once daily for 14 (range 10 to 28) days
Pediatrics (clinical and laboratory evidence of CNS involvement): 50 to 75 mg/kg (maximum, 2 g) IV once daily for 14 (range 10 to 28) days
CEFOTAXIME SODIUM
Adults (alternative, clinical and laboratory evidence of CNS involvement): 2 g IV every 8 hours for 14 (range 10 to 28) days
Pediatrics (alternative, clinical and laboratory evidence of CNS involvement): 150 to 200 mg/kg/day IV in 3 to 4 divided doses (maximum, 6 g/day) for 14 (range 10 to 28) days
PENICILLIN G POTASSIUM
Adults (alternative, clinical and laboratory evidence of CNS involvement): 18 to 24 million units/day IV in divided doses every 4 hour for 14 (range 10 to 28) days
Pediatrics (alternative, clinical and laboratory evidence of CNS involvement): 200,000 to 400,000 units/kg/day IV in divided doses every 4 hours (maximum, 18 to 24 million units/day) or 14 (range 10 to 28) days
Late Lyme neurologic disease affecting the central or peripheral nervous system
CEFTRIAXONE SODIUM
Adults: 2 g IV once daily for 14 to 28 days
Pediatrics: 50 to 75 mg/kg (maximum, 2 g) IV once daily for 14 to 28 days
CEFOTAXIME SODIUM
Adults (alternative): 2 g IV every 8 hours for 14 to 28 days
Pediatrics (alternative): 150 to 200 mg/kg/day IV in 3 to 4 divided doses (maximum, 6 g/day) for 14 to 28 days
PENICILLIN G POTASSIUM
Adults (alternative): 18 to 24 million units/day IV in divided doses every 4 hour for 14 to 28 days
Pediatrics (alternative): 200,000 to 400,000 units/kg/day IV in divided doses every 4 hours (maximum 18 to 24 million units/day) for 14 to 28 days
Lyme carditis (atrioventricular heart block, myopericarditis)
DOXYCYCLINE
Adults (outpatients or completion of IV therapy): 100 mg orally twice daily for 14 to 21 days
Pediatrics (?8 years, outpatients or completion of IV therapy): 4 mg/kg/day orally in 2 divided doses (maximum 100 mg/dose) for 14 to 21 days
CEFUROXIME AXETIL
Adults (outpatients or completion of IV therapy): 500 mg orally twice daily for 14 to 21 days
Pediatrics (outpatients or completion of IV therapy): 30 mg/kg/day orally in 2 divided doses (maximum, 500 mg/dose) for 14 to 21 days
AMOXICILLIN
Adults (outpatients or completion of IV therapy): 500 mg orally 3 times daily for 14 to 21 days
Pediatrics (outpatients or completion of IV therapy): 50 mg/kg/day in 3 divided doses (maximum, 500 mg/dose) for 14 to 21 days
CEFTRIAXONE SODIUM
Adults (hospitalized patients): 2 g IV once daily; may switch to oral regimen to complete therapy (total course, 14 to 21 days)
Pediatrics (hospitalized patients): 50 to 75 mg/kg (maximum, 2 g) IV once daily; may switch to oral regimen to complete therapy (total course, 14 to 21 days)
CEFOTAXIME SODIUM
Adults (alternative, hospitalized patients): 2 g IV every 8 hours; may switch to oral regimen to complete therapy (total course, 14 to 21 days)
Pediatrics (alternative, hospitalized patients): 150 to 200 mg/kg/day IV in 3 to 4 divided doses (maximum, 6 g/day) may switch to oral regimen to complete therapy (total course, 14 to 21 days)
PENICILLIN G POTASSIUM
Adults (alternative, hospitalized patients): 18 to 24 million units/day IV in divided doses every 4 hours; may switch to oral regimen to complete therapy (total course, 14 to 21 days)
Pediatrics (alternative, hospitalized patients): 200,000 to 400,000 units/kg/day IV in divided doses every 4 hours (maximum, 8 to 24 million units/day); may switch to oral regimen to complete therapy (total course, 14 to 21 days)
Lyme arthritis
DOXYCYCLINE
Adults (no neurologic involvement): 100 mg orally twice daily for 28 days; may repeat course up to 2 times for persistent or recurrent arthritis
Pediatrics (>8 years, no neurologic involvement): 4 mg/kg/day orally in 2 divided doses (maximum, 100 mg/dose) for 28 days; may repeat course up to 2 times for persistent or recurrent arthritis
AMOXICILLIN
Adults (no neurologic involvement): 500 mg orally 3 times daily for 28 days; may repeat course up to 2 times for persistent or recurrent arthritis
Pediatrics (>8 years, no neurologic involvement): 50 mg/kg/day orally in 3 divided doses (maximum, 500 mg/dose) for 28 days; may repeat course up to 2 times for persistent or recurrent arthritis
CEFUROXIME AXETIL
Adults (no neurologic involvement): 500 mg orally twice daily for 28 days; may repeat course up to 2 times for persistent or recurrent arthritis
Pediatrics (>8 years, no neurologic involvement): 30 mg/kg/day orally in 2 divided doses (maximum, 500 mg/dose) for 28 days; may repeat course up to 2 times for persistent or recurrent arthritis
Acrodermatitis chronica atrophicans
DOXYCYCLINE
Adults: 100 mg orally twice daily for 21 (range 14 to 28) days
Pediatrics (?8 years): 4 mg/kg/day orally in 2 divided doses (maximum 100 mg/dose) for 21 (range 14 to 28) days
CEFUROXIME AXETIL
Adults: 500 mg orally twice daily for 21 (range 14 to 28) days
Pediatrics: 30 mg/kg/day orally in 2 divided doses (maximum, 500 mg/dose) for 21 (range 14 to 28) days
AMOXICILLIN
Adults: 500 mg orally 3 times daily for 21 (range 14 to 28) days
Pediatrics: 50 mg/kg/day in 3 divided doses (maximum, 500 mg/dose) for 21 (range 14 to 28) days
Procedural Therapy
Tick bite
* Tick removal: A thorough examination of the patient for a tick should be performed. Specific steps should be followed in the removal of the tick .
Reportable infectious diseases
* Infectious disease notification: In the United States, specific infectious diseases must be reported to the state or local public health department .
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