Lyme disease
Download
1 / 44

LYME DISEASE - PowerPoint PPT Presentation


  • 148 Views
  • Uploaded on

LYME DISEASE. Lyme Disease. Controversial Suboptimal diagnostic testing Transmitted by Ixodes ticks May also transmit Babesia and Anaplasma Variable disease presentation Cutaneous Cardiac Rheumatologic Neurologic Treatment is longer than for other spirochetal illnesses.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' LYME DISEASE' - fritz


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Lyme disease1
Lyme Disease

  • Controversial

  • Suboptimal diagnostic testing

  • Transmitted by Ixodes ticks

    • May also transmit Babesia and Anaplasma

  • Variable disease presentation

    • Cutaneous

    • Cardiac

    • Rheumatologic

    • Neurologic

  • Treatment is longer than for other spirochetal illnesses


Historical context
Historical Context

  • 1883 – Buchwald, degenerative skin d/o

  • 1902 – Herxheimer, ACA

  • 1909 – Afzelius, EM rash post tick bite described

  • 1913 – Lipschutz, ECM rash described

  • 1921 – Afzelius case reports, associates Ixodes ticks

  • 1930 Hellerstrom, links EM and lymphocytic meningitis

  • 1941 – Bannwarth, lymphocytic meningoradiculitis

  • 1946 – Svartz, PCN for ACA


More historical context
More Historical Context

  • 1948 – Lenhoff, spirochetes on EM

  • 1950 – Hellerstrom, ECM with meningitis treated with PCN

  • 1955 – Binder, 355 cases of ECM treated with PCN

  • 1968 – Scrimenti, first case of EM in US reported

  • 1975 – Murray (Lyme resident) reports cases in relatives and friends in area

  • 1975 – Steere identifies cases as “Lyme arthritis”


Even more historical context
Even More Historical Context (?)

  • 1997 – Steere, defines more complete case description (cardiac, rheum, neuro)

  • 1980 – Steere, rx with PCN or tetracycline

  • 1982 – Burgdorfer, discovers spirochetes in blood, CSF, skin lesions of Lyme patients

  • 1997 – genome sequenced

  • 1999 – vaccine marketed


Meet the pathogen
Meet the Pathogen

  • Borrelia burgdorferi has has at least 132 functional genes (c/w about 22 for T pallidum)

  • Most plasmids of any bacteria identified to date

  • Antigenic variation/quorum sensing to evade immune response

  • Dormancy? Cyst structures form in vitro



Lyme disease vectors
Lyme Disease Vectors

  • Ixodes scapularis (east and midwest)

  • Ixodes pacificus (west)

Deer / blacklegged tick,

Ixodes scapularis

Western blacklegged tick         (Ixodes pacificus)


From left to right: The deer tick (Ixodes scapularis) adult female, adult male, nymph, and larva on a centimeter scale.


I scapularis larvae and nymphs feed on the white footed mouse peromyscus leucopus
I. scapularis larvae and nymphs feed on the white-footed mouse (Peromyscus leucopus)


I scapularis adult ticks feed on white tailed deer odocoileus virginianus
I. scapularis adult ticks feed on white-tailed deer (Odocoileus virginianus)


I. pacificus is infected by the dusky-footed woodrat (Neotoma fuscipes), but prefers to feed on lizards, which are not infected


Lyme disease2
Lyme Disease

  • Most common tick-borne disease in US and Europe.

  • Affects 50 nations worldwide

  • Nymphal ticks are primarily responsible for Lyme transmission to humans.

  • Tick must feed for ~ 48 hours and become engorged before risk of transmission becomes substantial.

  • Risk of infection after a deer tick bite in a highly endemic area is ~1.4%.


Lyme disease exposure
Lyme Disease Exposure

  • Obtaining Lyme serology at the time of tick bite is not recommended.

  • Prophylactic one time use of 200 mg doxy can be considered if:

    • 20% or more of local ticks are Bb+ (this is generally true in East only)

    • The patient presents within 72 hours of Ixodes bite

    • The tick was attached for 36 hours or more.

    • No contraindication to doxy

  • Analysis of ticks to determine whether they are infected is not recommended.


Lyme disease stages
Lyme Disease Stages

  • Early local infection

    • Skin - EM

    • CNS

  • Early disseminated infection

    • Skin

      • Multifocal EM

      • Lymphocytoma cutis (Europe)

    • Heart

      • Heart block

    • Musculoskeletal

    • Nervous System

    • Ocular

      • Conjunctivitis

  • Late stage infection

    • Skin

    • Musculoskeletal

      • Oligoarticular arthritis

    • Nervous system

    • Eye

      • uveitis


Lyme disease early
Lyme Disease - Early

  • EM:

    • Erythema migrans appears 3-30 (usually 7-10) days after tick bite, commonly on thigh, groin, axilla.

    • EM recognized in 70% of patients with objective evidence of B. burgdorferi infection.

    • Early symptoms may include fever, malaise, headache, myalgias, arthralgias, meningismus.


Lyme disease3
Lyme disease

  • Erythema migrans

    • Clinical diagnosis – testing not indicated

    • Annular or macular

    • History of tick bite in only 25% of cases

    • Location: Skin/folds and creases

    • By definition at least 5 cm in size (controversial)

    • Lesions may grow 2-3 cm/day

    • Multiple EM reflective of disseminated disease (hematogenous)



Early disseminated lyme disease
Early Disseminated Lyme Disease

  • Multiple EM 3-5 weeks after tick bite.

  • Cranial nerve palsies (especially facial nerve—can be bilateral).

  • Aseptic meningitis.

  • Carditis 5% (AV block).

  • Myalgias, arthralgias, headache, fatigue.


Lyme disease4
Lyme Disease

  • Lyme Lymphocytoma

    • May be associated with

      EM lesion


Late lyme disease
Late Lyme Disease

  • 80% of untreated patients will develop some manifestation of late disease

  • Arthritis (mono- or oligoarticular, affecting large joints, especially the knee).

  • Encephalitis/encephalopathy.

  • Polyradiculopathy.


Lyme neurologic
Lyme: Neurologic

  • Early local infection (<30 days)

    • EM with CNS seeding (HA, stiff neck, cognitive difficulties)

    • Flu like syndrome with CNS seeding

  • Early disseminated infection (<3 mo)

    • Aseptic meningitis

    • Meningoencephalitis (acute cerebellar ataxia, acute myelitis)

    • Cranial nerve palsy (facial)

    • Acute painful radiculoneuritis


Lyme neurologic1
Lyme: Neurologic

  • Late persistent infection (>3 mo)

    • Encephalopathy

    • Chronic axonal polyradiculoneuropathy

    • Chronic encephalomyelitis


Lyme cardiac
Lyme: Cardiac

  • 4-10% of Lyme Disease patients develop carditis

  • AV block

    • 40% Wenkebach

    • 50% complete

  • Myocardial involvement


Lyme arthritis
Lyme: Arthritis

  • Emerges in 60% of untreated EM within 6 months average

  • Intermittent attacks

  • Asymmetrical

  • Usually large joints especially the knees

  • May involve the TMJ


Chronic lyme disease
Chronic Lyme Disease

  • No formal definition: persistent (predominantly neurologic) subjective symptoms that date to initial Lyme disease illness

  • Most likely heterogeneous and multifactorial causes involved

    • Persistent infection

    • Post infectious immune/inflammatory syndrome

    • Co infection

    • Reinfection

    • Fixed deficits

    • Alternative diagnosis

    • Hypochondriasis

  • Most patients do not respond to antibiotics

  • Medical Clinics of NA 2002;86(2)


Lyme disease diagnosis
Lyme Disease: Diagnosis

  • Erythema migrans is the only manifestation of Lyme sufficiently diagnostic to be clinically diagnosed without lab testing

  • Serology (ELISA)

    • Only 30-40% of patients with EM have a positive serology.

    • IgM antibodies appear in 3-4 weeks, may persist despite treatment.

    • IgG antibodies appear in 6-8 weeks, usually remain detectable for many years.

    • 2-4 weeks after acute reaction 70-80% are positive

  • Western blot

    • Indicated for positive or equivocal ELISA.

    • IgM is only diagnostic within the first month of illness.


Western blot
Western Blot

Up-To-Date 2004


Lyme elisa
Lyme ELISA

  • False positive

    • Other spirochete (syphilis)

    • Cross reaction with other bacterial heat shock protein (RMSF, Ehrlichia)

    • RA

    • SLE

    • Mononucleosis


Lyme diagnosis
Lyme: Diagnosis

  • IFA: At least as sensitive and specific as the ELISA

  • Immune assays of CSF

    • ELISA



Lyme diagnosis1
Lyme: Diagnosis

  • Cultivation

    • Barbour-Stoenner-Kelly (BSK) broth medium

    • Sensitive for detection of early-phase infection (EM)

    • Limited value for detection of infection during late stages

    • Very few places can do this

    • Skin biopsy or blood taken within first 2-3 weeks of infection


Lyme diagnosis2
Lyme: Diagnosis

  • Histology

    • Numbers of B. burgdorferi in tissues is low

    • Very hard to find on specimens

    • Silver stain

  • PCR

    • Limited places are able to do this

    • Urine PCR is available but there is insufficient evidence of its accuracy, predictive value, or its significance

    • Unclear of benefit of this test


Lyme disease treatment
Lyme Disease: Treatment

  • Early localized

    • Doxycycline 100 bid or amoxicillin 500 tid or Cefuroxime 500 mg po bid x 14-21 days.

  • Early disseminated

    • Isolated facial nerve palsy/mild carditis: doxy/amoxicillin.

    • Meningitis/severe carditis: ceftriaxone 2gm qd x 14-28 days.

  • Late disease

    • Arthritis: doxycycline or amoxicillin or ceftrixaone or IV PCN x 28 days.

    • Recurrent arthritis: ceftriaxone.

    • CNS disease: ceftriaxone or IV PCN.

    • Facial palsy alone: oral meds may be enough


Lyme disease treatment1
Lyme Disease: Treatment

  • Cardiac

    • 1st degree AV block: oral meds

    • High degree AV block: Ceftriaxone for 14-21 days or IV PCN for 28 days



ad