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Wiener klinische Wochenschrift

, Volume 130, Issue 15–16, pp 463–467 | Cite as

Management approaches for suspected and established Lyme disease used at the Lyme disease diagnostic center

  • Gary P. Wormser
  • Donna McKenna
  • John Nowakowski
Lyme Borreliosis

Summary

2015 marks the 27th year that the Lyme Disease Diagnostic Center, located in New York State in the United States, has provided care for patients with suspected or established deer tick-transmitted infections. There are five deer tick-transmitted infectious in this geographic area of which Lyme disease is the most common.

For patients with erythema migrans, we do not obtain any laboratory testing. However, if the patient is febrile at the time of the visit or reports rigors and high-grade fevers, we consider the possibility of a co-infection and order pertinent laboratory tests.

Our preferred management for Lyme disease-related facial palsy and/or radiculopathy is a 2-week course of doxycycline. Patients who are hospitalized for Lyme meningitis are usually treated at least initially with ceftriaxone. We have not seen convincing cases of encephalitis or myelitis solely due to Borrelia burgdorferi infection in the absence of laboratory evidence of concomitant deer tick virus infection (Powassan virus). We have also never seen Lyme encephalopathy or a diffuse axonal peripheral neuropathy and suggest that these entities are either very rare or nonexistent.

We have found that Lyme disease rarely presents with fever without other objective clinical manifestations. Prior cases attributed to Lyme disease may have overlooked an asymptomatic erythema migrans skin lesion or the diagnosis may have been based on nonspecific IgM seroreactivity. More research is needed on the appropriate management and significance of IgG seropositivity in asymptomatic patients who have no history of Lyme disease.

Keywords

Lyme disease Borrelia Lyme borreliosis 

Notes

Acknowledgments

The authors thank Lisa Giarratano for assistance. The authors also thank the many physicians, nurses, and medical students who have participated in the care of patients seen at the Lyme Disease Diagnostic Center.

Compliance with ethical standards

An approval by an ethics committee is not applicable to this manuscript.

The manuscript does not contain any patient data thus a statement regarding informed consent is not applicable.

Conflict of interest

Dr. Wormser reports receiving research grants from Immunetics, Inc., Institute for Systems Biology, Rarecyte, Inc., and bioMérieux SA. He owns equity in Abbott; has been an expert witness in malpractice cases involving Lyme disease and babesiosis; and is an unpaid board member of the American Lyme Disease Foundation. Donna McKenna and John Nowakowski—none.

References

  1. 1.
    Molloy PJ, Telford SR 3rd, Chowdri HR, et al. Borrelia miyamotoi disease in the Northeastern United States: a case series. Ann Intern Med. 2015;163:91–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Tibbles CD, Edlow JA. Does this patient have erythema migrans? JAMA. 2007;297:2617–27.CrossRefPubMedGoogle Scholar
  3. 3.
    Wormser GP, McKenna D, Carlin J, et al. Brief communication: hematogenous dissemination in early Lyme disease. Ann Intern Med. 2005;142:751–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43:1089–134.CrossRefPubMedGoogle Scholar
  5. 5.
    Goldberg WS, Forseter G, Nadelman RB, et al. Vesicular erythema migrans. Arch Dermatol. 1992;128:1495–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Wormser GP, Ramanathan R, Nowakowski J, et al. Duration of antibiotic therapy for early Lyme disease. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2003;138:697–704.CrossRefPubMedGoogle Scholar
  7. 7.
    Kowalski TJ, Tata S, Berth W, Mathiason MA, Agger WA. Antibiotic treatment duration and long-term outcomes of patients with early Lyme disease from a Lyme disease-hyperendemic area. Clin Infect Dis. 2010;50:512–20.CrossRefPubMedGoogle Scholar
  8. 8.
    Chapman AS, Bakken JS, Folk SM, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky mountain spotted fever, ehrlichioses, and anaplasmosis–United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep 2006;55 (RR-4):1–27.Google Scholar
  9. 9.
    Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10–52.CrossRefPubMedGoogle Scholar
  10. 10.
    Bakken JS, Aguero-Rosenfeld ME, Tilden RL, et al. Serial measurements of hematologic counts during the active phase of human granulocytic ehrlichiosis. Clin Infect Dis. 2001;32:862–70.CrossRefPubMedGoogle Scholar
  11. 11.
    Wormser GP, Aguero-Rosenfeld ME, Cox ME, et al. Differences and similarities between culture-confirmed human granulocytic anaplasmosis and early Lyme disease. J Clin Microbiol. 2013;51:954–8.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Vannier E, Krause PJ. Human babesiosis. N Engl J Med. 2012;366:2397–407.CrossRefPubMedGoogle Scholar
  13. 13.
    Wormser GP, Villafuerte P, Nolan SM, et al. Neutropenia in congenital and adult babesiosis. Am J Clin Pathol. 2015;144:94–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Wang G, Wormser GP, Zhuge J, et al. Utilization of a real-time PCR assay for diagnosis of Babesia microti infection in clinical practice. Ticks Tick Borne Dis. 2015;6:376–82.CrossRefPubMedGoogle Scholar
  15. 15.
    Wang G, Villafuerte P, Zhuge J, Visintainer P, Wormser GP. Comparison of a quantitative PCR assay with peripheral blood smear examination for detection and quantitation of Babesia microti infection in humans. Diagn Microbiol Infect Dis. 2015;82:109–13.CrossRefPubMedGoogle Scholar
  16. 16.
    Aguero-Rosenfeld ME, Kalantarpour F, Baluch M, et al. Serology of culture-confirmed cases of human granulocytic anaplasmosis. J Clin Microbiol. 2000;38:635–8.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Steere AC, Hutchinson GJ, Rahn DW, et al. Treatment of early manifestations of Lyme disease. Ann Intern Med. 1983;99:22–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Clark JR, Carlson RD, Sasaki CT, Pachies AR, Steere AC. Facial paralysis in Lyme disease. Laryngoscope. 1985;95:1341–5.PubMedGoogle Scholar
  19. 19.
    Ljostad U, Skogvoll E, Eikeland R, et al. Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trial. Lancet Neurol. 2008;7:690–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Wormser GP, Halperin JJ. Oral doxycycline for neuroborreliosis. Lancet Neurol. 2008;7:665–6.CrossRefPubMedGoogle Scholar
  21. 21.
    van Dam AP, Kuiper H, Vos K, et al. Different genospecies of Borrelia burgdorferi are associated with distinct clinical manifestations of Lyme borreliosis. Clin Infect Dis. 1993;17:708–17.CrossRefPubMedGoogle Scholar
  22. 22.
    Weitzner E, McKenna D, Nowakowski J, et al. Long-term assessment of post-treatment symptoms in patients with culture-confirmed early Lyme disease. Clin Infect Dis. 2015;61:1800–6.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Personal communication from Dr. Franc Strle, 08/2015.Google Scholar
  24. 24.
    Kindstrand E, Nilsson BY, Hovmark A, Pirskanen R, Asbrink E. Peripheral neuropathy in acrodermatitis chronica atrophicans—a late manifestation. Acta Neurol Scand. 1997;95:338–45.CrossRefPubMedGoogle Scholar
  25. 25.
    Brisson D, Baxamusa N, Schwartz I, Wormser GP. Biodiversity of Borrelia burgdorferi strains in tissues of Lyme disease patients. PLoS One. 2011;6(8):e22926. doi: 10.1371/journal.pone.0022926.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Nimmrich S, Becker I, Horneff G. Intra-articular corticosteroids in refractory childhood Lyme arthritis. Rheumatol Int. 2014;34:987–94.CrossRefPubMedGoogle Scholar
  27. 27.
    Wormser GP, Horowitz HW, Nowakowski J, et al. Positive Lyme disease serology in patients with clinical and laboratory evidence of human granulocytic ehrlichiosis. Am J Clin Pathol. 1997;107:142–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Steere AC, Dhar A, Hernandez J, et al. Systemic symptoms without erythema migrans as the presenting picture of early Lyme disease. Am J Med. 2003;114:58–62.CrossRefPubMedGoogle Scholar
  29. 29.
    Wormser GP, Nadelman RB, Nowakowski J, Schwartz I. Asymptomatic Borrelia burgdorferi infection. Med Hypotheses. 2001;57:435–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Wien 2015

Authors and Affiliations

  • Gary P. Wormser
    • 1
  • Donna McKenna
    • 1
  • John Nowakowski
    • 1
  1. 1.Division of Infectious DiseasesNew York Medical CollegeValhallaUSA

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