Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites,erythema migrans rashes and persistent disease

Evidence-based guidelines for the management of patients with Lyme disease were developed by the International Lyme and Associated Diseases Society (ILADS). The guidelines address three clinical questions – the usefulness of antibiotic prophylaxis for known tick bites, the effectiveness of erythema migrans treatment and the role of antibiotic retreatment in patients with persistent manifestations of Lyme disease. Healthcare providers who evaluate and manage patients with Lyme disease are the intended users of the new ILADS guidelines, which replace those issued in 2004 (Exp Rev Anti-infect Ther 2004;2:S1–13). These clinical practice guidelines are intended to assist clinicians by presenting evidence-based treatment recommendations, which follow the Grading of Recommendations Assessment, Development and Evaluation system. ILADS guidelines are not intended to be the sole source of guidance in managing Lyme disease and they should not be viewed as a substitute for clinical judgment nor used to establish treatment protocols.     

Chronic Lyme disease: the controversies and the science

The diagnosis of chronic Lyme disease has been embroiled in controversy for many years. This is exacerbated by the lack of a clinical or microbiologic definition, and the commonality of chronic symptoms in the general population. An accumulating body of evidence suggests that Lyme disease is the appropriate diagnosis for only a minority of patients in whom it is suspected. In prospective studies of Lyme disease, very few patients go on to have a chronic syndrome dominated by subjective complaints. There is no systematic evidence that Borrelia burgdorferi, the etiology of Lyme disease, can be identified in patients with chronic symptoms following treated Lyme disease. Multiple prospective trials have revealed that prolonged courses of antibiotics neither prevent nor alleviate such post-Lyme syndromes. Extended courses of intravenous antibiotics have resulted in severe adverse events, which in light of their lack of efficacy, make them contraindicated.     

Factors influencing the utilization of Lyme disease-prevention behaviors in a high-risk population

PURPOSE: To evaluate factors motivating high-risk individuals to implement Lyme disease-prevention behaviors. DATA SOURCES: Patients presenting to the Lyme Disease Diagnostic Center in New York State completed a voluntary, anonymous questionnaire. CONCLUSIONS: Of the 219 persons completing the questionnaire, participants who reported having had Lyme disease in the past were significantly more likely to use preventive behaviors than those without a history of Lyme disease (p = .01). Additionally, persons who reported having a family member or close friend with Lyme disease were more likely to use preventive behaviors than those without such a relationship (p = .02). Increasing age was associated with increased use of preventive behaviors only for participants without a history of Lyme disease (p = .04). IMPLICATIONS FOR PRACTICE: These findings provide information that may be important in developing community prevention programs for Lyme disease. Younger persons without a history of Lyme disease should be targeted for programs that will educate them about Lyme disease.     

以发作性头痛为主要表现的莱姆病两例报道

莱姆病是一种由蜱传播的感染性疾病，１９７５年首先在美国发现，８０年代国内陆续有人报道。本病是一种可累及多个系统的疾病。以发作性头痛为主要表现者尚未报道。本文报道两例以发作性头痛为主要表现的莱姆病，对其临床特征进行了描述，并对其治疗进行了讨论。作者指出，及时明确诊断对于莱姆病头痛的治疗十分重要。     

Bell palsy in lyme disease-endemic regions of canada: a cautionary case of occult bilateral peripheral facial nerve palsy due to Lyme disease

ABSTRACTLyme disease caused by the spirochete Borrelia burgdorferi is a multisystem disorder characterized by three clinical stages: dermatologic, neurologic, and rheumatologic. The number of known Lyme disease-endemic areas in Canada is increasing as the range of the vector Ixodes scapularis expands into the eastern and central provinces. Southern Ontario, Nova Scotia, southern Manitoba, New Brunswick, and southern Quebec are now considered Lyme disease-endemic regions in Canada. The use of field surveillance to map risk and endemic regions suggests that these geographic areas are growing, in part due to the effects of climate warming. Peripheral facial nerve palsy is the most common neurologic abnormality in the second stage of Lyme borreliosis, with up to 25% of Bell palsy (idiopathic peripheral facial nerve palsy) occurring due to Lyme disease. Here we present a case of occult bilateral facial nerve palsy due to Lyme disease initially diagnosed as Bell palsy. In Lyme disease-endemic regions of Canada, patients presenting with unilateral or bilateral peripheral facial nerve palsy should be evaluated for Lyme disease with serologic testing to avoid misdiagnosis. Serologic testing should not delay initiation of appropriate treatment for presumed Bell palsy.     

Treatment of Lyme disease: a medicolegal assessment

Lyme disease is the most common tick-borne disease in the world today. Despite extensive research into the complex nature of Borrelia burgdorferi, the spirochetal agent of Lyme disease, controversy continues over the diagnosis and treatment of this protean illness. This report will focus on two aspects of the treatment of Lyme disase. First, the medical basis for diagnostic and therapeutic uncertainty in Lyme disease, including variability in clinical presentation, shortcomings in laboratory testing procedures, and design defects in therapeutic trials. Second, the standard of care and legal issues that have resulted from the clinical uncertainty of Lyme disease diagnosis and treatment. Specifically, the divergent therapeutic standards for Lyme disease are addressed, and the difficult process of creating treatment guidelines for this complex infection is explored. Consideration by healthcare providers of the medicolegal issues outlined in this review will support a more rational approach to the diagnosis and treatment of Lyme disease and related tick-borne illnesses.     

A qualitative approach to understanding patients' diagnosis of Lyme disease

OBJECTIVEs: The purpose of this study was to explore the lived experience of becoming diagnosed with Lyme disease. DESIGN: A qualitative, phenomenological study was conducted to investigate the experience of becoming diagnosed with Lyme disease.SAMPLE: A purposive sample of 10 participants diagnosed with Lyme disease were interviewed and tape-recorded. Data saturation guided the size of the sample. METHODS: The interviews were transcribed verbatim. Key words or phrases were extracted and clustered; clusters were interpreted into themes. Analyzed data were confirmed with the participants for trustworthiness and reliability. RESULTS: Six themes emerged from the interviews. Participants expressed feelings of frustration during the long road to diagnosis. They endured multiple diagnostic tests and were seen by numerous health care providers. Participants voiced financial stress. They expressed the need for self-advocacy and felt validation when a diagnosis was made. Despite the chronicity of their illness, the participants voiced a sense of hopefulness for their future. CONCLUSION: A deep understanding of the lived experience of becoming diagnosed with Lyme disease allows for nurses to prioritize health care interventions and strategize ways to implement quality improvement systems as clients enter the health care environment.     

Lyme disease prevention and vaccine prophylaxis.

OBJECTIVE: To provide a comprehensive review of the epidemiology, diagnosis, and prevention of Lyme disease with a focus on the Lyme disease vaccine. DATA SOURCE: A computerized search of MEDLINE (January 1996-December 1998) was used to identify articles regarding Lyme disease, Borrelia burgdorferi, epidemiology, prevention, and vaccine. DATA SYNTHESIS: Lyme disease is a condition caused by infection with B. burgdorferi. The organism is carried by certain species of Ixodes ticks and is the most common tick-borne disease in the US. In patients with clinical manifestations of Lyme disease, various pharmacotherapeutic approaches have proven effective in treatment of the clinical features. Prevention strategies exist; however, their application is sometimes difficult. A vaccine for the prevention of Lyme disease is available, and another is being considered for approval. The recombinant outer surface protein A (OspA) vaccines to prevent Lyme disease are immunogenic and have an acceptable adverse effect profile. These vaccines are highly efficacious for the prevention of Lyme disease. CONCLUSIONS: Lyme disease is the most common tick-borne disease in the US. The infection, caused by B. burgdorferi, results in dermatologic, neurologic, cardiovascular, and musculoskeletal manifestations. Until recently, tick bite prevention strategies were the only means of decreasing the risk of acquiring the infection. The OspA vaccines are efficacious for the prevention of infection. Although universal immunization with these vaccines is unlikely, the availability of effective vaccines represents an important tool for the prevention of Lyme disease in endemic regions of the US.     

Clinical manifestations, pathogenesis, and effect of antibiotic treatment on Lyme borreliosis in dogs

BACKGROUND: Borrelia burgdorferi, the causative agent of Lyme disease, infects humans and animals. In humans, the disease primarily affects the skin, large joints, and the nervous system days to months after infection. Data generated with appropriate animal model help to understand the fundamental mechanisms of the disease. OBJECTIVE: 1) More clearly define the clinical manifestation and pathogenetic mechanisms of Lyme disease in dogs; 2) evaluate the effect of antibiotics in dogs infected with B. burgdorferi; 3) describe the effects of corticosteroids on dogs persistently infected with B. burgdorferi. DESIGN: Specific-pathogen-free beagles were infected with B. burgdorferi using ticks collected in an endemic Lyme disease area. Clinical signs were recorded daily. Antibody titers were measured by ELISA at two-week intervals. B. burgdorferi organisms were detected in tissues by culture and PCR. Synovial fluids were evaluated microscopically and with a chemotaxis cell migration assay. Histological sections were examined for pathological lesions. Specific cytokine up-regulation in tissues was detected by RT-PCR. INTERVENTIONS: In three separate experiments, B. burgdorferi-infected dogs received antibiotic treatment (amoxicillin; azithromycin; ceftriaxone; doxycycline) for 30 consecutive days. Two subclinical persistently infected dogs received oral prednisone for 14 consecutive days starting at day 420 post-infection. RESULTS: Dogs developed acute arthritis in the joints closest to the tick bites after a median incubation period of 68 days. Synovial membranes of lame and non-lame dogs produced the chemokine IL-8 in response to B. burgdorferi. Antibiotic treatment prevented or resolved episodes of acute arthritis, but failed to eliminate the bacterium from infected dogs. Corticosteroid treatment reactivated Lyme disease in persistently infected dogs, which had not received antibiotics previously. CONCLUSIONS: B. burgdorferi disseminates through tissue by migration following tick inoculation, produces episodes of acute arthritis, and establishes persistent infection. The spirochete survives antibiotic treatment and disease can be reactivated in immunosuppressed animals.     

Lyme disease: the cause, diagnosis, and treatment.

OBJECTIVE: To present a brief history of Lyme disease, identify its vectors, examine its pathogenesis, and discuss current methods of testing for and treating the disease. DATA SOURCES: Current literature. STUDY SELECTION: Determined by the author. DATA EXTRACTION: Determined by the author. DATA SYNTHESIS: Lyme disease is the most commonly reported vector-transmitted disease in the United States. The Borrelia burgdorferi spirochete has been identified as the infectious agent of the disease. Although symptoms vary, stage 1 Lyme disease is most often characterized by erythema chronicum migrans, stage 2 by Bell's palsy, and stage 3 by chronic shoulder, knee, and wrist pain. Diagnostic tests currently in use, which include indirect immunofluorescent assay and enzyme-linked immunosorbent assay, often show false-positive results. Antibiotic treatment is recommended. CONCLUSION: Further study is needed to develop an accurate test for Lyme disease.     

Chronic Lyme disease: the controversies and the science

The diagnosis of chronic Lyme disease has been embroiled in controversy for many years. This is exacerbated by the lack of a clinical or microbiologic definition, and the commonality of chronic symptoms in the general population. An accumulating body of evidence suggests that Lyme disease is the appropriate diagnosis for only a minority of patients in whom it is suspected. In prospective studies of Lyme disease, very few patients go on to have a chronic syndrome dominated by subjective complaints. There is no systematic evidence that Borrelia burgdorferi, the etiology of Lyme disease, can be identified in patients with chronic symptoms following treated Lyme disease. Multiple prospective trials have revealed that prolonged courses of antibiotics neither prevent nor alleviate such post-Lyme syndromes. Extended courses of intravenous antibiotics have resulted in severe adverse events, which in light of their lack of efficacy, make them contraindicated.     

Late Lyme Borreliosis: Epidemiology,Diagnosis and Clinical Features

Lyme borreliosis is endemic in the Aland Islands. Exposure of the inhabitants to bites of the tick Ixodes ricinus is heavy. The purpose of this study was to describe symptoms and signs of patients with late Lyme borreliosis in this area, and to correlate the findings with the epidemiological setting. The first 100 consecutive patients with late Lyme borreliosis found in the region since 1984 are included in this study. Neurological, articular and muscular symptoms and signs dominate.

General screening for Lyme disease is not recommended in the area due to uncertainty about how to deal with seropositive healthy persons in this heavily exposed population. The recognition and prompt treatment of erythema migrans and other manifestations of primary Lyme borreliosis is important in order to avoid the late stages of the disease. Treatment of all those suffering tick-bites with an antibiotic would be an option in view of the incidence of infected ticks, but cannot be considered because tick-bites are extremely common among the inhabitants. The region would be suitable for general immunization against Borrelia burgdorferi if the means for doing this becomes available in the future.     

Prospective Evaluation of Heart Block Complicating Early Lyme Disease

Lyme disease is a recognized cause of heart block/carditis. The incidence of heart block complicating early Lyme disease has not been prospectively evaluated. In this study, 61 patients with early Lyme disease documented by the rash of erythema migrans were prospectively evaluated for carditis. Fifty five of 61 patients had a repeat examination 3 to 4 weeks after initiation of antibiotic therapy. Only one of 61 patients (1.6%) presented with heart block, which resolved with antibiotics. None of the 54 patients without heart block on initial presentation had a change in any measured electrocardiographic parameter or progressed to heart block after antibiotics. Therefore, early Lyme disease appears to be infrequently complicated by heart block. Early administration of antibiotics may prevent the development of heart block/carditis.     

Neurologic aspects of Lyme disease

Lyme disease has emerged as a major infection with frequent neurologic manifestations. These manifestations probably reflect several predominantly indirect pathogenetic mechanisms and involve host, vector, and organism factors. With early diagnosis and appropriate antibiotic treatment, patients do well. Because culture is not reliable, diagnosis has relied on positive serology to document exposure. Serology should improve as second-generation assays become available. Although there is a preventive vaccine based on the lipoprotein OspA, newer vaccines in development may prove more desirable. Lyme disease provides a valuable model to study how infectious pathogens cause neurologic disease.     

Identifying the vector of Lyme disease

Lyme disease is the most common vector-borne illness in the United States. It is caused by the spirochete Borrelia burgdorferi, which is transmitted by the deer tick. Deer ticks have a four-stage life cycle (egg, larva, nymph, and adult), and nymphal ticks transmit B. burgdorferi to humans more frequently than adult ticks. Transmission of this spirochete typically requires a minimum of 24 to 48 hours of tick attachment. Early stages of Lyme disease are characterized by a hallmark rash, erythema migrans. The overall risk of acquiring Lyme disease is low in a person who has a deer tick bite. If erythema migrans develops at the site of the bite, treatment may include doxycycline in persons who are at least eight years of age. Administration of amoxicillin is appropriate for pregnant women or children younger than eight years. For those who are allergic to these medications, cefuroxime axetil may be used.     

Lyme Disease: Emergency Department Considerations

Background

Lyme disease (LD) is the most common vector-borne illness in North America. Reported cases of LD have increased from approximately 10,000 cases annually in 1991 to >25,000 cases in 2014. Greater recognition, enhanced surveillance, and public education have contributed to the increased prevalence, as have geographic expansion and the number of infected ticks. Cases are reported primarily in the Northeastern United States, Wisconsin, and Minnesota, with children having the highest incidence of LD among all age groups. The increased incidence and prevalence of LD in the United States makes it increasingly more common for patients to present to the emergency department (ED) for tick bites and LD-related chief complaints, such as the characteristic erythema migrans skin manifestation.

Treatment of Lyme disease: a medicolegal assessment

Lyme disease is the most common tick-borne disease in the world today. Despite extensive research into the complex nature of Borrelia burgdorferi, the spirochetal agent of Lyme disease, controversy continues over the diagnosis and treatment of this protean illness. This report will focus on two aspects of the treatment of Lyme disease. First, the medical basis for diagnostic and therapeutic uncertainty in Lyme disease, including variability in clinical presentation, shortcomings in laboratory testing procedures, and design defects in therapeutic trials. Second, the standard of care and legal issues that have resulted from the clinical uncertainty of Lyme disease diagnosis and treatment. Specifically, the divergent therapeutic standards for Lyme disease are addressed, and the difficult process of creating treatment guidelines for this complex infection is explored. Consideration by healthcare providers of the medicolegal issues outlined in this review will support a more rational approach to the diagnosis and treatment of Lyme disease and related tick-borne illnesses.     

Ocular Lyme disease

Lyme disease is reported from all over the United States. Transmitted by deer ticks, mosquitoes, and deer flies, it affects numerous organ systems. All age groups are vulnerable to this disease and must be educated about early signs and symptoms to speed diagnosis and appropriate treatment.     

Lyme disease: neurologic manifestations

Lyme disease is a multisystem infectious, inflammatory, and immune-related disorder that follows the bit of an Ixodes dammini tick infected with Borrelia burgdorferi. Subsequent manifestations are protean. This is particularly true concerning the nervous system. It is estimated that 15% of patients with Lyme disease have neurologic complications. It is very possible that nervous system manifestations of Lyme disease are even more common, and these can occur from weeks to many years following the primary infection and can be quite devastating. A high index of suspicion is necessary in diagnosing Lyme-related disorders, because the majority of patients will not recall a tick bite or characteristic rash, and because the subsequent neurologic manifestations are not unlike those seen with many other diseases. With this awareness and appropriate laboratory testing, a presumptive diagnosis can usually be made without significant difficulty. When the nervous system has been affected by Lyme disease, aggressive antibiotic treatment is usually necessary, often using IV preparations. Usually, there will be significant improvement following the use of antibiotics, but there are some patients who will continue to have persistent, probably irreversible, nervous system abnormalities. This is often the case in patients who have had symptoms for long periods of time or who have had multiple recurrences.     

Clinical association: Lyme disease and Guillain-Barre syndrome

Guillain-Barre Syndrome (GBS) is a life-threatening condition in which patients may present to the Emergency Department in respiratory distress leading to death. The early identification and treatment of such a condition is paramount in preventing mortality. While there are many infections associated with GBS, the association with Lyme disease is uncommon. Through our case we aim to highlight Borrelia burgdorferi as an important antecedent infection associated with the development of GBS. In this case we report a 31-year-old male who was diagnosed with Lyme disease and GBS with relevant clinical presentation including progressive numbness and weakness in bilateral hands and feet for the past 1 week along with areflexia. Initiation of medical therapy with intravenous immunoglobulin and parenteral ceftriaxone resulted in resolution of his symptoms. The treatment of both diseases early can help prevent further central nervous complications leading to high morbidity and mortality.