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.
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References
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.
Tibbles CD, Edlow JA. Does this patient have erythema migrans? JAMA. 2007;297:2617–27.
Wormser GP, McKenna D, Carlin J, et al. Brief communication: hematogenous dissemination in early Lyme disease. Ann Intern Med. 2005;142:751–5.
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.
Goldberg WS, Forseter G, Nadelman RB, et al. Vesicular erythema migrans. Arch Dermatol. 1992;128:1495–8.
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.
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.
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.
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.
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.
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.
Vannier E, Krause PJ. Human babesiosis. N Engl J Med. 2012;366:2397–407.
Wormser GP, Villafuerte P, Nolan SM, et al. Neutropenia in congenital and adult babesiosis. Am J Clin Pathol. 2015;144:94–6.
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.
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.
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.
Steere AC, Hutchinson GJ, Rahn DW, et al. Treatment of early manifestations of Lyme disease. Ann Intern Med. 1983;99:22–6.
Clark JR, Carlson RD, Sasaki CT, Pachies AR, Steere AC. Facial paralysis in Lyme disease. Laryngoscope. 1985;95:1341–5.
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.
Wormser GP, Halperin JJ. Oral doxycycline for neuroborreliosis. Lancet Neurol. 2008;7:665–6.
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.
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.
Personal communication from Dr. Franc Strle, 08/2015.
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.
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.
Nimmrich S, Becker I, Horneff G. Intra-articular corticosteroids in refractory childhood Lyme arthritis. Rheumatol Int. 2014;34:987–94.
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.
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.
Wormser GP, Nadelman RB, Nowakowski J, Schwartz I. Asymptomatic Borrelia burgdorferi infection. Med Hypotheses. 2001;57:435–8.
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.
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Wormser, G.P., McKenna, D. & Nowakowski, J. Management approaches for suspected and established Lyme disease used at the Lyme disease diagnostic center. Wien Klin Wochenschr 130, 463–467 (2018). https://doi.org/10.1007/s00508-015-0936-y
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DOI: https://doi.org/10.1007/s00508-015-0936-y