Lyme Disease
In the primary care setting
Ella Chaffin, DO
Family Medicine PGY-2
NYP Columbia Family Medicine Resident
Special thanks to the CDC
Much of the information and graphics in this presentation were obtained from the Clinician Outreach and Communication Activity (COCA) Webinar presented in May 2021
https://emergency.cdc.gov/coca/ppt/2021/052021_Lyme_Disease_Slides.pdf
& special thanks to Dr. Krishna Desai!
Objectives
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Review populations at risk for Lyme disease in the US
Discuss diagnostic tests for Lyme disease
Describe signs & symptoms of Lyme disease
Understand use of antibiotics to treat Lyme disease
Table of Contents
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Epidemiology
Diagnosis
Transmission
Quiz
Etiology
Management
Clinical Presentations
Q&A
186. Three days after a camping trip in New Hampshire a patient develops influenza-like symptoms of a fever, mild myalgias, and malaise followed by an expanding, erythematous, annular rash with central clearing on his thigh. Which one of the following is the most likely diagnosis for the rash?
ANSWER: A
Annular lesions can be a presentation of several different conditions. This patient’s history of possible tick exposure and current prodromal constitutional symptoms suggest acute Lyme disease. Erythema migrans is the characteristic rash of acute Lyme disease. Erythema multiforme can be spontaneous, related to a viral or Mycoplasma infection, or associated with a medication reaction. Prodromal symptoms are uncommon in limited erythema multiforme and the clinical context of this case suggests a different etiology. Nummular eczema is an intensely pruritic, annular lesion that is not associated with constitutional symptoms. Pityriasis rosea is thought to be viral in etiology and is usually otherwise asymptomatic. Tinea corporis is a fungal infection and is not associated with systemic symptoms.
Ref: Lamoreux MR, Sternbach MR, Hsu WT: Erythema multiforme. Am Fam Physician 2006;74(11):1883-1888. 2) Drago F, Broccolo F, Rebora A: Pityriasis rosea: An update with a critical appraisal of its possible herpesviral etiology. J Am Acad Dermatol 2009;61(2):303-318. 3) Trayes KP, Savage K, Studdiford JS: Annular lesions: Diagnosis and treatment. Am Fam Physician 2018;98(5):283-291.
Epidemiology
https://www.cdc.gov/lyme/data-research/facts-stats/surveillance-data-1.html
https://www.cdc.gov/lyme/data-research/facts-stats/surveillance-data-1.html
https://www.cdc.gov/lyme/data-research/facts-stats/surveillance-data-1.html
Lyme disease is caused by bacterial infection with Borrelia species
Mobile, spirochete bacteria
Etiology
Transmitted by bite from Western blacklegged (Ixodes) ticks
Must be attached to skin for at least 24 hours
Ticks can’t fly, jump or drop from trees, they wait for a host by resting on grass and shrubs
Transmission
What do I do if I have a patient with a tick bite??
1. REMOVE THE TICK
2. Consider post exposure prophylaxis (PEP)
Doxycycline 200 mg once to patient’s who meet ALL the following criteria:
3. Discuss tick bite after care
Symptoms to watch for:
RASH
fever�malaise
186. A 34-year-old male sees you via your clinic’s electronic portal because of a rash. The rash, which he first noticed 3 days ago, was a large red patch on his upper leg at that time. He uploads an image of the rash (shown below) as it appears today. He started feeling feverish last night with chills, nausea, headache, and fatigue. He lives in Wisconsin and spends much of his free time hiking in the woods near his home. He removed two ticks from his legs last week. Which one of the following is the most likely cause of his current symptoms?
B) Babesiosis
C) Ehrlichiosis
D) Lyme disease
E) Tularemia
ANSWER: D
This patient has findings consistent with early localized Lyme disease, notably influenza-like symptoms and an erythema migrans (EM) rash with its typical bull’s-eye or target-like appearance. It is the most common tickborne disease in the United States, and it is most prevalent in states in the New England, mid-Atlantic, and upper Midwest regions. It is caused by the Borrelia burgdorferi bacteria, which is transmitted by the deer tick (Ixodes scapularis or Ixodes pacificus). Lyme disease can be diagnosed based on clinical criteria for patients in an endemic area who have a possible exposure. Serology is not required to make the diagnosis. The preferred treatment is doxycycline, 100 mg twice daily for 14 days, with alternatives available for children and pregnant women. Anaplasmosis, babesiosis, ehrlichiosis, and tularemia all may be spread by ticks and cause an influenza-like illness, but none of these conditions cause EM.
Ref: Pace EJ, O'Reilly M: Tickborne diseases: Diagnosis and management. Am Fam Physician 2020;101(9):530-540.
LYME DISEASE
Signs & Symptoms
3 to 30 days after tick bite
EARLY LOCALIZED DISEASE
Fever, chills, headache, fatigue, muscle and joint aches, swollen lymph nodes
Erythema Migrans
----->
Lab abnormalities
----->
1 to 3 months after tick bite
EARLY DISSEMINATED DISEASE
NEUROLOGIC
CARDIAC
SKIN
1 to 3 months after tick bite
EARLY DISSEMINATED DISEASE
NEUROLOGIC
CARDIAC
SKIN
3+ months after tick bite
LATE DISSEMINATED DISEASE
ARTHRITIS
Consider co-infection with other tickborne diseases
Especially in patients with severe or unusual symptoms: high fever, specific cytopenia’s (anaplasmosis), labs consistent with hemolysis (babesiosis)
Diagnosis, Serologic Testing & Treatment
Approach to diagnosis depends on disease stage:
If patient is presenting with EM and recent travel to/living in endemic area:
If unsure if rash is EM:
If no EM but high suspicion for early disseminated or late disease:
For Erythema Migrans:
Treatment
For neurologic Lyme disease:
Treatment
For Lyme Carditis:
Treatment
Mild: 1st degree AV block with PR <300 ms
Severe: symptomatic; 1st degree AV block with PR >300 ms; 2nd or 3rd degree AV block
For Lyme Arthritis:
Treatment
Recent study published April 2024 in Zoonoses Public Health found that:
Racial & Ethnic Disparities
Gould, L. H., Fathalla, A., Moïsi, J. C., & Stark, J. H. (2024). Racial and ethnic disparities in Lyme disease in the United States. Zoonoses and Public Health, 71, 469–479.
Thank You
References
AAN/ACR/IDSA 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease, Clinical Infectious Diseases 72, no. 1 (January 1, 2021): e1-e48, published November 30, 2020.
Centers for Disease Control and Prevention. (n.d.). Lyme disease. Centers for Disease Control and Prevention. https://www.cdc.gov/lyme/index.html
Centers for Disease Control and Prevention. (2023, March 10). Lyme disease Rashes. In Lyme Disease. Retrieved from [https://www.cdc.gov/lyme/signs-symptoms/lyme-disease-rashes.html].
Mead, P., & McCormick, D. (2024). Lyme disease. In CDC Yellow Book 2024: Travel-Associated Infections & Diseases. Centers for Disease Control and Prevention. Retrieved from [https://wwwnc.cdc.gov/travel/yellowbook/2024/infections-diseases/lyme-disease#clinical].
Schotthoefer AM, Green CB, Dempsey G, Horn EJ. The Spectrum of Erythema Migrans in Early Lyme Disease: Can We Improve Its Recognition? Cureus. 2022 Oct 25;14(10):e30673. doi: 10.7759/cureus.30673. PMID: 36439577; PMCID: PMC9687974.
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