The presentation is an update on Lyme Disease, that was part of my duties as a Pediatrics Acting Intern at Ruby Memorial Hospital, West Virginia University School of medicine and supervised by Dr. Patra Kamakshya.

1. LYME DISEASE
Prepared by
Maha Elsebaie
Pediatric Sub-I, West Virginia University
School of Medicine, USA
Final year medical student, Ain Shams
University, Egypt
Supervised by
Patra Kamaksya, MD
Assistant professor, Department of
Pediatrics, West Virginia University

2. Lyme Disease
• Organism: Borrelia burgdorferi
• Mode of transmission: Tickborne, bite of infected blacklegged ticks
• How Ticks find their host? They wait for a host in a position known as "questing"
https://www.cdc.gov/lyme/

4. Endemic areas with Lyme disease

5. CLINICAL PICTURE
Classic presentation
• First presentation in 70-80% of
infected persons
• Any area of the body
• Expanding >> “bull’s-eye”
appearance or “Target like”
Late infection
• Lyme arthritis
• Mainly knees and other
large joints.
• Can be migratory.
Early disseminated infection
• First presentation in 2-3%
• Dissemination to central or
peripheral NS (mainly
cranial neuropathy)
• Myopericarditis

6. ~60% of patients with erythema
migrans who were not treated
With antibiotics in the
northeastern United States
developed arthritis an average of
6 months (range: 4 days to
2 years) later.
Steere, A. C., Schoen, R. T. & Taylor, E. The
clinical evolution of Lyme arthritis. Ann. Intern.
Med. 107, 725–731 (1987).
Steere AC, Strle F, Wormser GP, Hu LT, Branda JA, Hovius JWR, et al. Lyme borreliosis. Nature Reviews Disease Primers. 2016;2:16090.

7. DIAGNOSIS
Manifestations Diagnostic approach Additional considerations
Erythema migrans Visual inspection ONLY Serologic testing is Not recommended
because it is very insensitive in the acute
phase (the first 2 weeks of infection)
Extracutaneous mainfestations
including but not limited to facial
nerve palsy, meningitis,
radiculopathy, myopericarditis,
arthritis
Serological testing according to
the 2-tier testing algorithm.
Lyme arthritis > Consider testing synovial
fluid for borrelia DNA.
Lyme meningitis > Consider testing CSF
for borrelia AB production and DNA
Sanchez E, Vannier E, Wormser GP, Hu LT. Diagnosis, Treatment, and Prevention of Lyme Disease, Human Granulocytic
Anaplasmosis, and Babesiosis: A Review. Jama. 2016;315(16):1767-77.
What if you are uncertain that this is erythema migrans?
Test serum during convalescent-phase (i.e., 2 weeks after the acute-phase) using the 2-tier testing algorithm.

9. Wrong answers would be ?
• Culture of Borrelia spp.
Positive cultures have been obtained only during the first weeks of infection, primarily from skin biopsy samples of erythema migrans lesion >>>
Only experimental use.
• PCR for B. burgdorferi DNA
1- Borrelia DNA can persist after spirochaetal killing, therefore PCR is not an accurate test for active infection.
2- In patients with Lyme neuroborreliosis, PCR was found to be only positive in the CSF of a small number of patients.
• IgM or IgG tests without a previous ELISA/EIA/IFA
• Using an IgM western blot to support a diagnosis of late Lyme borreliosis.
Thus, in both the United States and Europe, serological testing is the ONLY practical and readily
available method to support a diagnosis of Lyme disease
(1) Li, X. et al. Burden and viability of Borrelia burgdorferi in skin and joints of patients with erythema migrans or Lyme arthritis. Arthritis Rheum. 63, 2238–2247 (2011).
(2) Steere AC, Strle F, Wormser GP, Hu LT, Branda JA, Hovius JWR, et al. Lyme borreliosis. Nature Reviews Disease Primers. 2016;2:16090.

10. TREATMENT
The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the
Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2006;43(9):1089-134.

11. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the
Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2006;43(9):1089-134.

12. PREVENTION
• If being in tick-infested areas is unavoidable:
- Frequent visual inspection of skin and clothes.
- Attached ticks should be removed promptly, preferably with the aid of
fine-tip forceps.
- Wear light-colored clothing (increase contrast)
- Use Tick and insect repellents that contain N,N-diethyl3 methylbenzamide
(DEET) for both skin and clothes.
- Avoid applying DEET the face or hands.
- Avoid excessive application of DEET-containing repellents to children >>>
Serious neurologic complications in children after excessive application of
have been reported.

13. TAKE HOME MESSAGES
• Most common manifestation of early neurologic Lyme disease is Facial nerve
palsy.
• Most common cardiac manifestation of Lyme Carditis is atrioventricular heart
block (3rd degree Heart block)
• Erythema migrans is diagnosed based on visual inspection rather than
laboratory testing
• Two-step serologic testing that consists of an enzyme immunoassay followed
by supplemental Western blot testing is a sensitive and specific approach to
diagnose extra-cutaneous manifestations of Lyme disease
• Most manifestations of Lyme disease can be successfully treated with oral
doxycycline (100 mg twice daily for 10-14 days, except for arthritis, which has
been traditionally treated for 28 days)
• For hospitalized patients with early central neurological or cardiac disease >> a
parenteral antibiotic, such as ceftriaxone is recommended as initial treatment