Lyme disease

Heba Al-thuwaini – jumana Al-Qahtani

Group : 4

Learning objectives

• Definition

• Causes and risk factors

• Sighs and symptoms

• Pathophysiology

• Diagnosis

• Treatment

• Complication

• prevention

Case summary

For several weeks a 41 year old male has felt as if he is slightly drunk all the time. He

can’t walk properly anymore and feels as if he is in daze. At first he thought it might be

exhaustion but as it is not improving he wants to know what is wrong and what the

prognosis is .

Lyme disease

• Is an infectious disease

• Caused by spiral- shaped bacteria called Borrelia burgdorferi that carried by

infected Ixodes tick.

• A tick become infected by feeding on animals that carries the borrelia.

( white footed mouse, white tailed deer or black birds)

Epidemiology

Europe (In central Europe, particularly in Slovenia and Austria. Incidence in southern Europe, such as Italy and

Portugal, is much lower.)

• North America

• Canada

• Mexico ( A 2007 study suggests Borrelia infections are endemic to Mexico)

• United States (Lyme disease has been reported in all states except Montana)

• South America (Reported widely in Brazil, Colombia and Bolivia)

Epidemiology

Asia ( in Japan, northwest China, Nepal, Thailand and far eastern Russia)

Risk factors

• Travelling to a city where the Lyme disease is common

• Having exposed skin.

• Spending time in wooded or grassy areas.

• Not removing ticks promptly or properly.

Signs And Symptoms

The clinical manifestation depends on the stage of disease:

1- Early Localized :

• Onset: within one month after bite

• Presentation:

Erythema Migraines:

• The redness of the rash expand forming a rash in a bull’s

eye pattern.

• Rash usually feels warm to the touch but is not itchy or

painful.

• The size of the rash can range from between 2cm-30cm.

Flu-like symptoms : Fever, chills, fatigue, body aches and a

headache .

Signs And Symptoms

2- Early disseminated stage :

• Onset : Within one to 4 months after the onset of local infection.

• Presentation:

1- Neurological symptoms:• Meningitis: ( severe headeches and neck stiffness)

• Radiculoneuritis: Infection of the nerve roots (shooting pains ,

numbness or tingling).

• Bell’s palsy.

2- Joint Problems:• Arthritis.

Signs And Symptoms

2- Early disseminated stage :

Heart problems:• In rare cases, untreated Lyme disease may lead to

inflammation of the heart (myocarditis).

• That causes :

• Light-headedness.

• fainting.

• shortness of breath.

• palpitations.

• chest pain.

Signs And Symptoms

3- late persistent stage:

• Onset: More Than 4 Months.

• Presentation:

Chronic neurologic symptoms occur in up to 5% of untreated

patients.

cognitive problems, such as difficulties with concentration and

short-term memory.

chronic arthritis

Stages of Lyme

disease

1- Early Localized

Within One Month

2- Early Disseminated

From One To 4 Months

3- Late Chronic

More Than 4 Months

Quiz

• 47 years old woman presented to hospital with rash that has

bull’s eye pattern, headache, fatigue and fever.

• Doctors diagnosed her with Lyme Disease.

• Q: in which stage of disease her symptoms is in ?

First stage ( early localized stage)

Pathophysiology

A tick becomes infected by

feeding on an animal that

carries the bacteria

Infected ticks then inject B. burgdorferi into the

human’s skin by attached to the skin for

approximately 24-48 hours

Tick saliva, which accompanies the spirochete into

the skin during the feeding process, contains

substances that disrupt the immune response at the

site of the bite

The spirochetes multiply and migrate outward within the

dermisDays to weeks following the tick bite, the spirochetes

spread via the bloodstream to different organs

Erythema Migraines in different

part of the body

Borrelia burgdorferi may

induce astrocytes to

undergo astrogliosis

(proliferation followed by

apoptosis), which may

contribute to

neurodysfunction.

Lyme cordites: cause

impairment of the

conduction

( atrioventricular block )

Lyme arthritis:

inflammation of the tissue

that lines the joints.

The spirochetes may also

induce host cells to

secrete products toxic to

nerve cells, including

quinolinic acid and the

cytokines IL-6 and TNF-

alpha, which can produce

fatigue and malaise.

Diagnosis History taking :

History of tick bite.

Epidemiologic context is extremely important. The clinician

should determine where the patient lives, works, and

vacations, and should ask about specific activities in which the

patient participates.

The season is important, especially with early disease. Most

cases of erythema migrans occur from late spring through

early fall.

Previous manifestations of Lyme disease from many years in

Physical Examination

Erythema migrans (EM) is thecharacteristic rash of Lyme disease.

Classic EM is a flat to slightly raisederythematous lesion that appears at thesite of the tick bite after 1-33 days bite(average, 7-10 days).

Without therapy, erythema migranstypically fades within 3-4 weeks.

1- Dermatological Finding

Less than 1% of patients with stage 2 Lyme

disease, develop Borrelia lymphocytoma

Described as a small, bluish-red nodule or

plaque.

The earlobe and scrotum are the typical

location in children,

whereas the nipple is the more common

location in adults.

2-Borrelial lymphocytoma

Muscle tenderness can result from myositis.

Tenderness of tendons and periarticular

structures may be present.

Frank arthritis can occur after weeks,

months, or years and may lead to erythema,

edema and tenderness of the affected joints.

Usually, this is a monoarthritis or

oligoarthritis involving large joints, especially

the knee.

3- Musculoskeletal findings

5-10% of untreated patients with Lyme

disease have signs of cranial

neuropathies.

Up to 60% of patients with early

neuroborreliosis develop cranial neuritis.

7th nerve palsy is by far the most

common.

4- Neurologic

involvement

Stretch reflex is a muscle contraction in

response to stretching within the muscle.

Absent ( lower motor neuron lesion)

Muscle stretch reflexes

Elicited when the sole of the foot is

stimulated with a blunt instrument.

Positive babinski sign (upper motor

neuron lesion)

Plantar reflex

Gait test ( unsteady )

Speech changes

Finger to nose test (intention tremor and

hypermetria)

Cerebellum dysfunction tests:

Sign of a disturbance of proprioception,

either from neuropathy or posterior

column disease.

In the dark or with eyes closed they have

problems. (positive)

Romberg’s test

Sensation of pain and

temperature (Disturbed)

Sensibility

Ophthalmic manifestations vary by disease

stage.

In stage 1 Lyme disease, the ocular

manifestations are conjunctivitis and

photophobia.

In stage 2 Lyme disease,

Fundoscopy : papilledema, optic atrophy

might occur.

Eye movement: Cranial nerve palsies

might occur.

6- Ophthalmic involvement

Laboratory Tests

To identify antibodies to help confirm the diagnosis.

These tests are most reliable a few weeks after an infection, after your body has time to develop

antibodies.

Investigation

Serological Laboratory tests

Has been demonstrated to be useful in detecting the antibody response to B. burgdorferi.

A Western blot (WB) assay is detects antibodies to several proteins

of B. burgdorferi and used to confirm positive Lyme ELISA results

due to the presence of IgG- or IgM-class antibodies.

ELISA

(enzyme-

linked

immunosorbe

nt assay )

Western

immunoblot

(WB)

Cont.

Positive results Negative results

Should be supplemented by re-

testing the corresponding serum

samples on a standardized

Western Blot test to confirm

the result .

No antibody to B.

burgdorferi detected.

This result does not

exclude the possibility of B.

burgdorferi infection

A second sample should

be drawn 2 – 4 weeks later

and re-tested.

If the sensitive screening test results

were :

PCR test PCR (Polymerase Chain Reaction) test amplifies

the DNA of the spirochete and will usually

indicate its presence.

It is used for people who may have chronic Lyme

arthritis or used to detect persistent infection in

CSF of people with nervous system symptoms.

This test does produce many false negatives

This is because Lyme bacteria are sparse and

may not be in the sample tested.

Blood test Blood tests measure antibodies made in response to the infection.

These tests may be falsely negative in patients with early disease,

but they are quite reliable for diagnosing later stages of disease.

Culture

Culture of the organism is the gold standard for the evaluation of all infections.

Borrelia burgdorferi is a slow growing organism, so culture may take weeks.

More problematic is that culture is rarely positive once the infection has disseminated beyond the stage of erythema migrans.

Because of the low yield of this test in cases of late stage or disseminated Lyme disease, culture is rarely used

What are other lab tests that may be

done when the infection has spread

???

Spinal Fluid analysis

Patients with neurologic symptoms suggestive of central nervous system involvement should have a lumbar puncture.

When the CSF is examined, the fluid is sent for routine studies such as cell count, and proteinand glucose levels.

In addition, the CSF should be sent for Borreliaburgdorferi (Bb) PCR assay and intrathecalindex (The index refers to the ratio of Bb antibodies in the CSF )

When the index is positive, that indicates that there is a production of antibodies against Bb in the CSF – a finding strongly suggestive of central nervous system invasion by the agent of Lyme disease.

Imaging

MRI.

Imaging test that uses powerful

magnets and radio waves to create

pictures of the brain and

surrounding nerve tissues.

Unlike SPECT and PET images

which assess brain function, MRI

captures the physical structure

of the brain.

Inflammatory abnormalities in the

brain are also assessed with MRI

scans.

Complications

Stage 3 or late disseminated Lyme disease can cause:

long-term joint inflammation (Lyme arthritis) and heart rhythm

problems.

Brain and nervous system problems might include:

Decreased

concentration

Memory

disorders

Numbness

Sleep

disorders

Vision

problems

Treatment :

Antibiotics are the primary treatment for Lyme disease, and

almost all patients recover after antibiotic treatment.

The recommended treatment for Lyme disease varies

depending upon the stage of disease and the types of

symptoms.

The rate of recovery may also vary depending upon the

specific symptoms and recovery may take weeks to months

after finishing antibiotic treatment.

Stages of Treatment

Prophylaxis after tick

bite

Early Lyme disease

Late Lyme disease

Prophylactic after Tick bite

Routine use of antimicrobial prophylaxis or serologic testing is not

recommended.

A single dose of doxycycline may be offered to adult patients

(200 mg dose) and to children ⩾8 years of age (4 mg/kg up to a

maximum dose of 200 mg) only considered if:

Identifiable tick

Treatment can be started 72 hours after tick removal

Doxycycline is not contraindicated

Early treatment is a 14 to 21 day

course of oral antibiotics.

Medications:

doxycycline.

cefuroxime

amoxicillin.

Early Stage:

+ Side Effects Pediatric dose Adult dose MedicationStage

nausea,

vomiting,

diarrhoea and

rashes

50 mg/kg per day

in three divided

doses

500 mg three

times daily

amoxicillinEarly Stage

anorexia, dry

mouth, flushing,

anxiety and

tinnitus.

2 mg/kg twice

daily for children

≥8 years of age.

100 mg twice

daily

doxycycline

Diarrhoea,

nausea,

vomiting,

abdominal

discomfort,

headache, fever,

rashes

30 mg/kg per day. 500 mg twice

daily

Cefuroxime

Intravenous antibiotics for a period

of 10 to 28 days.

Late Stage:

Side EffectsPediatric dose Adult dose MedicationStage

Same as

Cefuroxime

50 to

75 mg/kg intraven

ously once daily

2 g intravenously

once daily

Ceftriaxonelate

stage

Same as

Cefuroxime

150 to

200 mg/kg intrave

nously per day

divided in three

doses,

2 g intravenously

every eight hours

Cefotaxime

fever, chills,

malaise,

headache,

tachycardia, hy

perventilation

200,000 to

400,000 units/kg p

er day divided into

6 daily doses.

18 to 24 million

units per day

intravenously

divided into 6

daily doses

Penicillin G

Prognosis

If diagnosed in the early stages

Lyme disease usually recover rapidly and completely with antibiotics.

If diagnosed in the late stages

Approximately 10-20% of who were diagnosed later, may have

persistent or recurrent symptoms and are considered to have Post-

treatment Lyme disease syndrome (PTLDS). The cause of this

syndrome is unknown.

Prevention

Avoid areas where deer

ticks live, especially

wooded, bushy areas with

long grass

Use insect

repellents

Wear long pants

,long sleeves and

enclosed shoes

Prevention

Bathe as soon as possible after

going indoors to wash off and

more easily find ticks that may be

on you.

Do a final, full-body tick

check at the end of the

day

Summary

Definition

Causes and risk factors

Signs and symptoms

Pathophysiology

Diagnosis

Treatment

Complication

prevention

Referencehttp://www.nlm.nih.gov/medlineplus/ency/article/001319.htmhttp://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/definition/con-20019701http://www.lymedisease.org/lyme101/lyme_disease/lyme_disease.htmlhttp://www.medicinenet.com/lyme_disease/article.htm

http://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/risk-factors/con-20019701http://ldnr.us/lyme_disease_pathophysiology.htmlhttp://www.merckmanuals.com/professional/infectious_diseases/spirochetes/lyme_disease.html

http://emedicine.medscape.com/article/330178-clinicalhttp://www.uptodate.com/contents/treatment-of-lyme-diseasehttp://www.uptodate.com/contents/evaluation-of-a-tick-bite-for-possible-lyme-disease?source=see_link&anchor=H7#H7http://www.uptodate.com/contents/lyme-disease-treatment-beyond-the-basicshttp://www.lymedisease.org/lyme101/lyme_disease/lyme_treatment.htmlhttp://cid.oxfordjournals.org/content/43/9/1089.fullhttp://ldnr.us/lyme_disease_pathophysiology.html

Any QUISTIONS !!