Madison Zuis FNP student Nursing 652: Fall 2014. Multisystem infectious disease caused by bacterium Borrela burgdorferi Most common tick-borne illness.

LYME DISEASE

Madison Zuis FNP student

Nursing 652: Fall 2014

DEFINITION Multisystem infectious disease

caused by bacterium Borrela burgdorferi

Most common tick-borne illness in North America and Europe

PATHOPHYSIOLOGY Contracted from a deer tick ( Ixodes) bite containing the Borrelia species of

bacteria. Ticks act as disease vectors Borrelia bacteria is abundant in wild animals in which ticks feed Species has evolved to survive in other warm blooded vertebrate hosts (ie deer,

mice , chipmunks) ( Pearson, 2014)

Ticks attach via barbed mouthpiece called hypostome Inject anti-inflammatory and anti-clotting agents that assist in feeding and

transmission of Borrelia, thus furthering the bacterium’s survival ( Berende, et al 2010)

EPIDEMIOLOGY Approximately 30,000 confirmed cases in US In 2012 ( CDC, 2013)

Incidence has been increasing Climate changes Changes in land management Changes in biodiversity Changes in human interaction with nature Increasing awareness of Lyme disease

(Medlock, et al 2013)

INCIDENCE Most cases occur May- September

Ixodes tick is in the nymph stage Increased outdoor leisure activities

In 2011, 96% of Lyme disease cases Connecticut, Massachusetts, Maine, Vermont, new Hampshire, Minnesota, New

Jersey, New York, Pennsylvania, Rhode island, and Wisconsin. Connecticut, Maine, new Hampshire and Vermont have highest incidence = 0.5

cases/1,000 persons

Has been reported in all 50 states

Can effect any group, ethnicity

(Schub & Lawrence, 2013)

RISK FACTORS Spending time in wooded or grassy areas

Exposed skin

Tick bite If the tick is infected, the chances of transmission increases with time, from 0% at 24

hours, 12% at 48 hours, 79% at 72 hours and 94% at 96 hours. ( CDC, 2013)

Not removing ticks properly

(Duncan, 2014)

CLINICAL FINDINGS

Annular erythematous plaque with central clearing ( bulls-eye lesion) Classic lesion in 80% of cases Usually 5-68cm in diameter Appear 3-30 days after tick bite

(Owoloabi, 2014)

BULLS –EYE LESION(CDC LYME DISEASE GUIDE, 2014)

CLINICAL FINDINGS Three stages

Early localized = influenza like symptoms- primary erythema migrans, fever, fatigue, general or regional lymphadenopathy, arthralgia, and myalgia. Occurs 3-30 days after tick bite

Early disseminated stage= multiple lesions, arthralgia, stiff neck, photophobia, sensory loss, asymmetric back pain, poor memory, difficulty concentrating, myocarditis, cardiac conduction blocks, syncope, Belle’s palsy, encephalitis, peripheral neuropathy, anorexia, nausea Occurs few days to 10 months after tick bite

Late stage = chronic arthritis ( especially knee joints)arthritis, severe fatigue, subacute encephalopathy, cognitive disturbances, sleep disturbances, headaches, paresthesia Occurs months to years after tick bite

(Schub & Lawrence, 2013)

DIFFERENTIAL DIAGNOSIS Bell’s palsy

Stroke

Polio-like syndrome

Parkinsons disease

Dementia

Motor neuron disease

Guillain-Barre syndrome

Systematic Lupus

Erthematousous

Sarcoidosis

( Mylgland, et al 2010)

SOCIAL/ENVIRONMENTAL Geographic location

Outdoor leisure activities

Pets

( CDC, 2012)

LAB/DIAGNOSTIC TESTING

- Two tiered test- Enzyme linked immunosorbent assay ( ELISA) or indirect fluroscnet antibody ( IFA)

If positive or equivocal, Western blot test performed. If both positive- Lyme diagnosed If ELISA/IFA negative, no further testing needed

- Polymerase chain reaction ( PCR) Highly specific, but insensitive as a result of low numbers of bacteria present in bodily fluids

and tissues CSF may be examined in patient with neurologic symptoms- CRP may be slightly elevated- EKG and/or ECHO if cardiac involvement suspected- CT, MRI, spinal tap if CNS involvement suspected

(Aberer & Schwanzter, 2012)

MANAGEMENT/TREATMENT

Non-Pharmacological

- Education- Treatment options, referrals,

completing abx therapy

- Assessment for late disease manifestations

- Referrals

- Pain assessment- analgesics

Pharmacological

Children under 12: Amoxicillin 25-50mg/kg or cefuroxime 30-40mg/kg x 14 days

Adults/children over 12: Doxycycline 100mg po 2 x day for 14 days

Pregnant women: Amoxicillin 500mg po 3 x day or cefuroxime 500mg po 2 x day for 14 days

( Pearson, 2014)

COMPLICATIONS Fluctuating global muscle weakness, muscle/joint pain, muscle twitching

Aseptic meningitis

Encephalitis

Lyme carditis related to heart blocks or CHF; three deaths reported from 2012-2013 ( CDC, 2013)

Bell’s palsy slurred speech, facial numbness, swallowing problems

(Schub & Lawrence, 2013)

FOLLOW UP Close monitoring for disease

progression Improvement often gradual Consider other diagnosis Consider need for referral

Referrals Neurologist Infectious Disease Rheumatology Orthopedist Physical therapy Social worker Mental health Pain management

EDUCATION:PREVENTION Reducing risk of tick bites

Bug spray ( DEET) long pants/sleeves ( tucked into socks), closed toed shoes Clearing environmental brush Avoiding contact with animals that carry ticks Performing tick checks on persons/dogs after outdoor activity

Correct tick removal Remove promptly ( <48 hours after attachment)

Grip as close as possible to skin, using tweezers ( or tick removal tool) without squeezing ticks body pull out Clean skin with disinfectant and wash hands

Prompt medical attention If symptoms appear

( CDC, 2013)

LYME DISEASE QUESTIONS #1 True or false

Lyme Disease is primarily seen from October – March

False- Lyme disease is most commonly seen in May-September when ticks carrying Borrelia are more common

LYME DISEASE QUESTIONS #2 If a patient with suspected

Lyme disease has a positive ELISA test, what is the second test ordered confirm a Lyme diagnosis? A. CRP B. Western blot C. PCR D. CBC

B. Western Blot If positive or equivocal, Western

blot test performed. If both positive- Lyme diagnosed

LYME DISEASE QUESTIONS # 3 True or false- Lyme disease is the most common tick-borne disease in

north America?

- True Lyme disease is the most common tick-borne disease in north America and Europe

LYME DISEASE QUESTIONS # 4 Prevention of Lyme Disease includes:

A. DEET bug spray B. Long sleeve shirt C. Long pants tucked into socks D. all of the above

D. ALL of the above

LYME DISEASE QUESTIONS # 5 Lyme Disease classic lesion is

described as a

A. red blistered rash

B. superficial petechial

C. Annular erythematous plaque with central clearing

D. Open pustules

C. Annular erythematous plaque with central clearing or a bull’s eye

LYME DISEASE QUESTIONS #6 In early stage Lyme disease,

or early localized, common symptoms include:

A. fatigue

B. Fever

C. myalgia

D. primary erythema

E. all of the above

E - Early localized = influenza like symptoms- primary erythema migrans, fever, fatigue, general or regional lymphadenopathy, arthralgia, and myalgia.

LYME DISEASE QUESTIONS #7 How soon after a tick bite is

late Lyme disease symptoms seen?

A. a few days

B. days to weeks

C. months to years

Late stage = chronic arthritis ( especially knee joints)arthritis, severe fatigue, subacute encephalopathy, cognitive disturbances, sleep disturbances, headaches, paresthesia Occurs months to years after tick

bite

LYME DISEASE QUESTIONS

#8 A pregnant patient is recently diagnosised with Lyme disease, what is the appropriate medication and dosage?

A. Amoxicillin 500mg po 3 x day or cefuroxime 500mg po 2 x day for 14 days

B. Doxycycline 100mg po 2 x day for 14 days

C. Either

A- Pregnant women: Amoxicillin 500mg po 3 x day or cefuroxime 500mg po 2 x day for 14 days

LYME DISEASE QUESTIONS # 9 True or false- The longer a

tick remains on your skin, the greater the risk of transmission?

T- If the tick is infected, the chances of transmission increases with time, from 0% at 24 hours, 12% at 48 hours, 79% at 72 hours and 94% at 96 hours. ( CDC, 2013)

LYME DISEASE QUESTIONS #10 True or false- A rare but

serious complication of Lyme Disease includes cardiac complications such as CHF and heart blocks?

True- Complications from Lyme include heart blocks or CHF; three deaths reported from 2012-2013 ( CDC, 2013)

REFERENCES Aberer, E. & Schwantzer G. ( 2012). Course of antibody response in Lyme borreliosis patients before and after

therapy, ISRN Immunology, 14 ( 5) 11-13

Berende, A., Oosting, M., Kullberg, BJ., Netea, MH, & Joosten, L. ( 2010). Activation of innate host defense mechanisms by Borrelia, European Cytokine Network, 21 (1) 7-18

Center for Disease Control ( 2013). Lyme Disease, retrieved November 5th, 2014 from http://www.cdc.gov/lyme/sign_symtoms

Center for Disease Control (2013). Three sudden cardiac deaths associated with Lyme Carditis , Morbidity and Mortality Weekly Report, 62(49) 994-996

CMAJ, (2014). Advice varies for suspected Lyme disease, Canadian Medical Association Journal, 2 ( 12) 186-187

Medlock, J., Hansford, K., & Bormane, A. (2013). Driving forces for changes in georgraphic distribution of Ixodes ticks in Europe, Parasites &Vectors,6 (1) 1-11

Mygland, A. (2010). EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. European Journal of Neurology, 17 (1) 8-16

Owolabi, T. ( 2014). An Annular Rash, American Academy of Family Physicians, 89 ( 7) 581-583

Pearson, S. ( 2014) Recognizing and understanding Lyme disease. Nursing Standard, 29 (1) 37-43

Schub ,T. & Lawrence, P. ( 2013). Lyme Disease, Nursing, 43 ( 5) 28-34