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Lyme disease class copy

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  • 1. Nichole C. Martin RN, BSN, CEN, CPEN Family Health II - July 2011 Lyme Disease “The Great Imitator”Background:· First identified near Old Lyme, CT in 1975 after a cluster of childern experienced arthritis-like symptoms· Linked to the black-legged tick in 1977· Borrelia burgdorferi was discovered in 1982, and identified as the causitive agent of Lyme disease· In 2010, 734 confirmed and probable cases of Lyme disease were reported among Maine residents, which is a rate of 55.7 cases of Lyme disease per 100,000 persons in Maine. Almost half of the cases were reported among residents from York County (24%) and Cumberland County (24%)· Lyme disease is still listed as a reportable diseaseTransmission definitionsHost: an organism that harbors or nourishes another organism mice, deer, dogs, cats, humans – all hosts to the tickVector: a carrier, transfers the infective agent from one host to another ticks transfer B. burgdorferi from mice to other mice and humansReservoir: has the infective agent but is not sickened by it mice, chipmunks, and shrews are reservoirs for the spirochete B. burgdorferiLife cycle of a tick:Black-legged tick a.k.a. Deer tick (Ixodes scapularis)· Arthropod (related to spiders, mites and scorpions)· Four developmental stages: egg, larva, nymphs and adult· Female ticks deposit from 3,000 to 6,000 eggs onto the ground, which hatch into larvae or "seed ticks"· Larvae climb nearby vegetation where they collect in large numbers while waiting for small rodents (mice, chipmunks, squirrels, etc.) or other vertebrates to pass within reach· After a blood meal on the host, the engorged larvae drop to the ground, shed their skins (molt), and emerge as nymphs· Nymphs await the passage of a host, engorge themselves with blood, drop to the ground, molt, and become adults· Adult ticks seek host animals and after engorgement, mate. Females die soon after depositing their eggs in protected habitats on the ground. The life cycle requires from as little as 2 months to more than 2 years, depending on the species.Transmission of Lyme:· Lyme is most commonly transmitted by the nymphal ticks (nymphal ticks are about the size of a poppy seed, adults ticks are larger and therefore more noticable, about the size of a sesame seed) – nymphal ticks are most active in the late spring / early summer
  • 2. Nichole C. Martin RN, BSN, CEN, CPEN Family Health II - July 2011· Lyme disease more often results from an unknown bite, rather than a recognized bite (the people that show up on your door step with a tick on them are not likely to develop Lyme, however, the person who presents with EM without recalling a tick bite is more likely)· It typically takes ticks 3 or more days to fully feed, at which time they become engorged and fall off· Risk of transmission of B. burgdorferi from an infected tick increases with the amount of time the tick is embedded 24 hours - 0% 48 hours - 12% 72 hours - 79% 96 hours - 94%· General rule of thumb is that a tick must be attached for 36 – 48 hours for transmissionRemoval:· Best method is to use fine tweezers (hold parallel to skin) or curved forceps with thin tips· Grab tick at the base of it’s head· Be careful not to squeeze or crush the tick body because you could inadvertanly squirt body contents into the skin· Similiarly, using items such as hot matches, cigarettes, vaseline or gasolene may cause the tick to squirt body contents into the skin· Pull straight back with slow steady force, being careful not to rock, twist, or yank quickly· If mouth parts are retained, leave them alone, digging at them will irritate the skin and risk infection· Wash area with soap and water or rub with alchol· May use ice packs or hydrocortisone cream to bite to help with pain/itchingSymptoms of Lyme:Early / localized stage:· Flu-like symptoms (fatigue, mylagias, headaches)· Localized lymphadenopathy· Erythema migrans (EM) a.k.a. bull’s eye rash · forms at bite site, usually 7 – 14 days after bite, measures greater than 5cm diameter · 80% of patients will develop this rash · some bites develop redness due to the tick saliva that extends as much as 4-5 cm around bite · recent studies show that in highly endemic areas, early EM presents as central redness rather than peripheral erythema with central clearingEarly disseminated stage:· Secondary annular lesions· General malaise and fatigue· Localized and/or regional lymphadenopathy
  • 3. Nichole C. Martin RN, BSN, CEN, CPEN Family Health II - July 2011· Migratory pains in bones, joints, and muscles· Brief arthritis attacks· Bell’s palsy, cranial neuritis, meningitis· Acute onset high-grade AV blocks (2 or 3), myopericarditis, pancarditisLate / chronic stage: ***if symptoms persist after appropriate course of antibiotics, this is known as Post-Treatment Lyme Disease Syndrome (PTLDS)· Chronic fatigue· Chronic and prolonged arthritis attacks· Encephalopathy, leukoencephalitis· Neuropathy· Lymphocytoma, acrodermatitis, chronica atrophicansDiagnostic Testing:· If EM present – no testing required, just treat with antibiotics (EM should start to improve within a couple of days· In patients with characterisitic symptoms and liklihood of exposure (time of year, activities, location), do serologic testing and then start treatment· CBC and ESR will often be normal, Lyme titer will likely be negative in the first few weeks, so testing is more helpful after 4 – 6 weeks· Post-treatment testing isn’t helpful to determine irradication of disease, as serology will continue to be positive for months to years post-exposure· It is not recommended to do serologic testing for Lyme on patients who report a tick bite in the absence of symptoms1. EIA Test (enzyme-linked immunoassay test) a.k.a. Lyme titer · very “sensitive” (almost everyone with Lyme disease will test positive) · not “specific” (you might test positive if you have other illnesses such as H.pylori, Epstien Barr virus, a dental infection, certain autoimmune disorders like lupus, other tick-borne illnesses such as anaplasmosis or tick-borne relapsing fever, or syphilis [those bacteria often resemble the spirochete, flagella, etc OR if you happened to have had the Lyme vaccine)*if it’s negative, don’t worry, no Lyme (unless you ran the test too early)*if it’s positive or equivocal you need to look further with an immunoblot test to help determine if it is truly Lyme or something else*the immunoblot can be done on that same specimen, the pt doesn’t need to be stuck again2. Immunoblot testing (Western blot most common used for Lyme) · an ‘indirect test’ (not looking for the disease itself, but the body’s response to it) · looks specifically for antibodies against an antigen (in this case the B. burgdorferi bacteria) · looks at IgM and IgG antibodies
  • 4. Nichole C. Martin RN, BSN, CEN, CPEN Family Health II - July 2011 · IgM made sooner (first few weeks of infection) but more likely to give false positive results · IgG made later (4-6 weeks to produce in quantities large enough to detect) · Because of this: if it is during the first 4 weeks of disease onset, do both IgM and IgG! · can do western blot on blood or CSF (if meningitis is suspected) · be familiar with how your lab interprets Western blots (or doesn’t!), some labs will give the results and interpret, others will simply give the results In case you need to interpret them: *first of all, there is no “mildly” or “somewhat” positive, it either is or it isn’t *people with Lyme diease have at least 5 antigens, so there must be at least 5IgG bands detected on the western blot (the CDC does break it down further,identifying particular bands of the IgM and IgG blots) *you can do a PCR test (looks for DNA of B. burgdorferi) in synovial fluid, butnot done much (if you think it’s Lyme so much that you are going to tap a joint andtest the fluid… treat it) In general: wait 4 – 6 weeks, then order a ‘Lyme titer with reflex testing’ toensure that a Western blot is done on a positive EIA testTreatment:· B. burgdorferi  is a bacteria, so we treat with an antibiotic· Goals of treatment: · cure B. burgdorferi infection · symptom resolution · prevention of complicationsProphylaxis:· Only treat prophylacticly if: · attached tick is a deer tick · tick has been attached for greater than or equal to 36 hours *likelihood of transmission is increased if the tick is engorged and or has been attached for at least 72 hours · prophylactic treatment is begun within 72 hours of tick removal · local infection rate of ticks is greater than or equal to 20% (yup, Maine counts as one of those locations)· In pt’s who don’t meet criteria for prophylactic treatment, it is recommended to observe them and treat only if s/s of Lyme develop (EM, arthralgias)Recommended therapy:· Doxycyline 200mg PO x 1 dose for adults· Doxycycline 4mg/kg (max of 200mg) PO x 1 dose for children age 8 or greater ***Doxycyline is the only medication recommended for prophylaxis***
  • 5. Nichole C. Martin RN, BSN, CEN, CPEN Family Health II - July 2011· Since Doxycycline is contraindicated in pregnant or lactating women, children under age 8, and those who are allergic, no prophylaxis is recommended, but rather watchful waiting· Amoxicillin, though safe in those populations, has not been shown to be an effective method of prophylaxisTreatment of infection· Doxcycline is first-choice· Doxycycline has the best penetration into the central nervous system (this is important when you think about the risk of Lyme menengitis)Recommended therapy:· Doxycycline 100mg PO bid x 14 – 21 days, 28 days for Lyme arthritis· Amoxicillin is alternative for those who can’t take DoxycyclineSpecial considerations: Pregnancy: · No prophylaxis · CDC says: Untreated Lyme disease can lead to placental infection which can then lead to miscarriage · UpToDate says: no evidence that Lyme disease during pregnancy causes harm, however women should be treated according to their disease manifestations · Bottom line – get OB and ID consult! · Lyme disease is not transmitted through breastmilk Recommended therapy: · Amoxicillin 500mg PO tid x 14 – 21 days Children under 8 years of age: · No prophylaxis · Amoxicillin 50mg/kg/day in divided doses every 8 hours (max 500mg/dose) PO x 14 – 21 days Acute neurologic manifestations (except Bell’s Palsy) · IV antibiotics are indicated Recommended therapy: · Rocephin (Ceftriaxone) 2gm IV daily for adults · Rocephin (Ceftriaxone) 50-75 mg/kg IV daily for children OR · Claforan (Cefotaxime) 2gm IV every 8 hours for adults · Claforan (Cefotaxime) 150-200mg/kg for children Carditits · IV antibiotics are indicated until symptoms such as heart-block resolve, then may be switched to oral therapy to complete a 21 day course
  • 6. Nichole C. Martin RN, BSN, CEN, CPEN Family Health II - July 2011 Prolonged treatment for Lyme disease · Research does not support the use of long-term use (10 weeks or greater) of IV antibioticsComplications & Sequelia: Chronic arthritis · Treat with NSAIDS and / or Plaquenil (an antimalirial used in treatment of Lupus and RA) Lyme carditis (a-fib, AV blocks) · Often need hospitalization for management of cardiac symptoms, but rarely need pacemaker, symptoms often resolve with prompt initiation of antibiotics Post-treatment Lyme disease syndrome (PTLDS) · Thought to be auto-immune in natureMany people wonder about testing the tick that bit them… · This really isn’t helpful · Tick may carry the bacteria, but not have been on you long enough · Tick test results take a long time to get back which may delay treatment · Tick may not carry the disease but you may have been unknowingly been bit by anotherMany people wonder about a vaccine for humans… · Currently no vaccine for humans · There was one in 1998 called LYMErix intended for those who work in the woods (foresters, biologists), but was pulled off the market in 2002 for too many adverse effectsMany people think testing for Lyme is inaccurate… · This is a myth, however, the tests are only as good as the provider ordering and interpreting them. · If testing is done too early, may get a false-negative