Differential diagnosis
- co-infection
- babesiosis
- human granulocytic anaplasmosis (“ehrlichiosis”)
- other Borrelial infection
- southern tick-associated rash illness (STARI) (Borrelia lonestari )
- Borrelia miyamotoi
Treatment
- hospitalization advised for symptomatic Lyme carditis
- usual antibiotic treatment for adults (IDSA guidelines)
- early Lyme disease
- for EM without complications, any of
- doxycycline 100 mg orally twice daily for non-pregnant patients ≥ 8 years old for 14 days
- amoxicillin 500 mg orally 3 times daily for 14 days
- cefuroxime axetil 500 mg orally twice daily for 14 days
- for EM without complications, any of
- for early neurologic Lyme disease
- ceftriaxone 2 g IV once daily for 14 days
- alternatives if normal renal function
- cefotaxime 2 g IV every 8 hours
- penicillin G 18-24 million units/day in 6 divided doses
- doxycycline 200-400 mg/day orally in 2 divided doses if unable to tolerate beta-lactam antibiotics
- for seventh cranial nerve palsy
- if both clinical and laboratory evidence of CNS involvement, use same for early neurologic Lyme disease
- if CSF exam normal/unnecessary, use 14-day regimen for EM
- for Lyme carditis, treat for 14-21 days with
- ceftriaxone 2 g IV once daily (inpatients)
- oral regimen as for EM (outpatients or to complete therapy after hospitalization)
- late Lyme disease
- for Lyme arthritis without neurologic involvement, treat for 28 days using EM dosing with doxycycline or amoxicillin or cefuroxime
- for late neurologic Lyme disease, treat for 2 to 4 weeks with antibiotics used for early neurologic Lyme disease
- for Lyme arthritis with neurologic involvement, treat with antibiotics and duration as for late neurologic Lyme disease
- for acrodermatitis chronic atrophicans, treat for 21 days with antibiotics used for EM
- avoid doxycycline if pregnant or lactating
- early Lyme disease
- other treatments
- temporary pacemaker (if advanced heart block)
- arthroscopic synovectomy (if persistent synovitis)
- alternative therapies
- Bismacine (Chromacine) NOT recommended
- no evidence to support alternative therapies
Follow-up
- test of cure should not be performed (seroreactivity can persist for years)
Complications
- arthritis
- carditis
- neurologic
- facial nerve paly
- meningitis
- encephalomyelitis
- radiculoneuropathies
Prognosis
- untreated EM typically resolves in 3-4 weeks
- excellent long-term prognosis with early antibiotic treatment
- repeat episodes of EM more likely to be re-infection than relapse
- post-Lyme disease syndromes
- no evidence for existence of symptomatic chronic B. burgdorferi infection after recommended treatment regimen
- antibiotic therapy not proven to be useful and not recommended for patients with chronic (≥ 6 months) subjective symptoms after recommended treatment
Prevention
- tick avoidance measures include
- decreased time in tick-infested habitats
- light-colored clothing with long pants tucked into socks and long-sleeve shirts
- tick repellents and use of permethrin-treated clothing
- bite care
- preferred method of tick removal is using forceps or tweezers grasping tick as close to skin surface as possible and pulling upward with steady pressure
- disinfect bite site and save tick for identification
- avoid use of physical substances (such as petroleum jelly) or heat (ineffective for tick removal)
- antibiotic prophylaxis following tick-bite (IDSA guidelines)
- routine prophylaxis not recommended
- consider single-dose doxycycline (200 mg for adults, 4 mg/kg (maximum 200 mg) for children ≥ 8 years old) if
- tick adherent for ≥ 36 hours
- area endemic for B. burgdorferi
- < 72 hours after bite
- single-dose doxycycline 200 mg within 72 hours of Ixodes scapularis tick bite may be effective
Alan Drabkin, MD, is a senior clinical writer for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics, and assistant clinical professor of population medicine at Harvard Medical School.
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