As we have discussed previously, Lyme disease is a hot button topic not only in health care, but also in the community. In a previous article this summer, we discussed a variety of topics regarding tick bites and made some recommendations for who should receive prophylaxis with doxycycline.
In today’s article, we will review more of one of my personal favorite topics, going over the signs and symptoms, manifestations, diagnosis, and eventually treatment of the nation’s most common tick borne illness.
In primary care and urgent care, the summer months see a fade in upper respiratory symptoms and an increase in tick bites, fatigue, and other miscellaneous concerns. In my practice, I will see two to three tick bites or suspected cases of Lyme disease per week. Obviously it is very important to be well versed in Lyme disease.
To review the history taking regarding a tick bite, one should review the previous article. The questioning regarding a possible tick exposure is very important to determine whether a patient needs a prophylactic dose of antibiotics or if watchful waiting is warranted. It is important to note that in some cases, there may not be a history of a tick bite.
The presentation of patients with consideration related to Lyme disease is on a spectrum. In the simplest cases, a patient shows up with a history of a tick bite and a new onset rash without any other symptoms. Erythema migrans is diagnostic of Lyme disease and no further work up is needed. The rash is pictured below and is one that clinicians and students are very familiar with. Without history of tick exposure in an endemic region, it is still diagnostic. Patients presenting with Lyme disease are usually separated into three groups, early localized disease, early disseminated disease, and late disease.
Other patients presenting with symptoms or concerns related to Lyme disease may not be as straight forward. After a tick bite, an incubation period of 3 to 30 days is common (Chang, 2016). In this period of time, patients may be asymptomatic and can even be unaware that they have a rash. Other symptoms include insidious onset of fever, headache, myalgia, and arthralgia. In early localized disease, patients may have rash and some of the above symptoms. It is important to note that early symptoms may also mimic a viral infection.
In patients presenting with fatigue, the differential diagnosis is tremendous. One could (and we will) spend a whole future article discussing fatigue. Arthralgia tends to be in single joints, but can be diffuse. Myalgia can be hard to quantify, but may be diffuse as well.
In cases of early disseminated Lyme disease, the symptoms may be more severe. If there is cardiac involvement, Lyme disease can cause chest pain, palpitations, and heart block. An EKG can be performed to assess for heart block if the history warrants it.
The neurologic manifestations of Lyme disease can be very severe as well. Patients maypresent with headaches, cognitive slowing, significant fatigue, or even significant altered mental status. In cases of altered mental status, a work up should be performed for meningitis. A facial nerve palsy, peripheral neuropathy, or mononeuritis multiplex are common in early disseminated disease.
In terms of testing, there can be controversy. As discussed previously, many patients may demand testing even when it is clinically not indicated. For patients with a tick attached for less than 48 hours, there is no indication for testing. It is important to note that in patients with active Lyme disease, testing can be negative in the first two weeks of illness. Patients presenting with Erythema migrans should not be tested, as result should not change clinical management.
As discussed previously, if there is question about the diagnosis, one should be thorough with choices for laboratory testing to help rule out other possible etiologies. In terms of specific testing for Lyme, the best initial test is the ELISA for antibodies for both IgG and IgM antibodies. If initial tests are positive, a follow up western blot can help secure the diagnosis.
In cases where meningitis or other neurological complications are suspected, a CSF analysis for Borrelia burgdorferi can be performed. When making a diagnosis, the entire clinical picture and results of testing should be taken into account in order for the clinician to make the best informed treatment decision.
The treatment for Lyme disease depends on many factors, including patient age, allergies, and involvement of Lyme. For patients presenting with erythema migrans, the treatment is doxycycline 100 mg BID for 10 to 21 days. Doxycycline is also a reasonable choice as it can cover other tick borne illnesses if the diagnosis is in question.
It is important to note that doxycycline, also known as vibramycin, is contraindicated in the pediatric population as well as in pregnant patients. This medication may also cause photosensitivity. Other options include amoxicillin or cefuroxime axetil, which have been studied and are equally as effective. Amoxicillin is the best drug for children.
In patients with significant nervous system involvement or evidence for a meningitis, these patients should be admitted to the hospital. Intravenous antibiotics are warranted.
Lyme disease remains a commonly encountered topic during the summer months across much of the geography of the United States. Recognizing the signs, symptoms and knowing who and how to properly test for the disease is very important.
Chang, F.B. (2016). Lyme Disease. 5 Minute Clinical Consult. McGraw Hill.
Hu, Linden (2018). Clinical Manifestations of Lyme disease in adults. UpToDate. Date of Access 15 July 2018.
This article, blog, or podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony.No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.