​Kembara Xtra - Medicine - Lyme Disease

​Kembara Xtra - Medicine - Lyme Disease
The bacterium Borrelia burgdorferi is the cause of Lyme disease, which is spread primarily by ixodid ticks, specifically Ixodes pacificus (black-legged ticks and Western black-legged ticks) in the West and Ixodes scapularis (deer ticks) in the Northeast and Great Lakes regions.

Epidemiology 

34,945 confirmed and probable cases of Lyme disease were reported to the CDC in 2019. Each year, 300,000 people in the US are at risk of contracting Lyme disease.
Incidence
high frequency Wisconsin, West Virginia, Virginia, Vermont, Rhode Island, Pennsylvania, New York, New Jersey, New Hampshire, Massachusetts, Maryland, Maine, District of Columbia, Delaware, and Connecticut are among the states in the United States.
Prevalence
Age group most affected: people between the ages of 55 and 70, as well as children between the ages of 5 and 14.

Pathophysiology and Etiology 

Most transmissions take place in May to September, when nymphal tick activity is at its peak. The average incubation time is 7 to 10 days after a tick bite.
Infected ticks have a higher risk of transmitting the disease the longer they are attached: 12% at 48 hours, 79% at 72 hours, and 94% at 96 hours.
The white-footed mouse is the main animal reservoir for spirochetes, which multiply and spread within the dermis to cause the recognizable (erythema multiforme [EM]) rash.
Involvement of the central nervous system (CNS), cardiovascular system, or other organ stems is the result of hematogenous dispersion.
Genetics
Prolonged arthritis is more likely to affect those with the human leukocyte antigen haplotypes DR4 or DR2.
RISK ELEMENTS
endemic region for Lyme disease. Deer frequently carry Ixodid ticks, putting hunters at higher risk.


Basic Prevention 
When outdoors in endemic areas during peak tick activity, dress appropriately. Pretreat clothing, footwear, and tents with 0.5% permethrin and wear clothing that covers your ankles.
"Tick checks": After being outside, check your skin for ticks.
Ticks should be removed as soon as possible to reduce transmission.
N,N-diethyl-meta-toluamide (DEET), picaridin ethyl-3-(N-n-butyl-N-acetyl) aminopropionate (IR3535), oil of eucalyptus (OLE), pmenthane- 3,8-diol (PMD), and 2-undecanone are some products that can be used to prevent tick bites.
In endemic locations, prophylactic treatment with 1 dosage of 200 mg of doxycycline is advised within 72 hours of a tick that has been attached for at least 36 hours. Treatment required: 50 to 53

Accompanying Conditions 
Human granulocytic anaplasmosis and/or babesiosis in endemic people; coinfection with other tick-borne diseases (such as babesiosis, ehrlichiosis, or anaplasmosis);

A sensitive enzyme immunoassay (EIA) or immunofluorescence assay is used for the diagnosis, and for specimens that produce positive or ambiguous results, a Western immunoblot assay is performed.

A tick bite's history, followed by EM and/or illness (fever, lethargy, headache, myalgias), is presented.
EM is a round, flat, or elevated, erythematous bull's-eye lesion with a center clearing region that grows in diameter over days to weeks.
- Axilla, back, abdomen, groin, or popliteal fossa are common sites; - 75-80% of patients who come for EM have just one lesion
Early Lyme disease might present with no symptoms at all and has an incubation period of 3 to 30 days. Regional lymphadenopathy, myalgias, arthralgias, fever, and headache
Early-stage widespread Lyme disease:
Carditis symptoms include pleuritic chest pain, palpitations, mild headaches, dizziness, and shortness of breath. Other cranial neuropathies include facial palsies.
- Joint discomfort (arthritis/arthralgia polyarthritis)
Months after exposure, late Lyme disease manifests as monoarthritis, iritis, conjunctivitis, and migrating musculoskeletal discomfort.
- Recurrent bursitis, tendonitis, and synovitis
- Peripheral nerve involvement causes radiculoneuropathy, which causes numbness, tingling, shooting pain, or weakness in the arms or legs. - Encephalopathic symptoms include severe headaches, neck stiffness, confusion, and facial palsy on one or both sides of the face.
- Mimicking signs of other CNS conditions Symptoms resembling those of multiple sclerosis, stroke, and transverse myelitis

clinical assessment 

Early Lyme disease: 70–80% of patients have EM. Developing 7 to 14 days after the tick detaches is an expanding erythema. Lesions are frequently larger than 5 cm, may be flat or elevated, uniform, or feature a central clearing region (typical target session).
 Widespread Lyme disease:
- Multiple EM lesions on the skin
- Neurology: unilateral or bilateral facial palsies or other cranial neuropathies
Cardiovascular: dysrhythmia (heart block), friction rub (pericarditis), and irregular pulse


Differential Diagnosis Other tick-borne diseases include ehrlichiosis, babesiosis, and Rocky Mountain spotted fever (RMSF). Autoimmune diseases include juvenile rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and RA.
Viral syndromes, cellulitis, contact dermatitis, granuloma annulare (which mimics EM), and syphilis


Laboratory Results 
A tick bite is only deemed high risk if it came from a known Ixodes spp. vector species, it happened in an area with a high endemicity, and the tick was attached for at least 36 hours.
Patients with a characteristic EM lesion who reside in or have gone to an area where Lyme disease is endemic may be given an acute Lyme disease diagnosis without the need for laboratory testing.
Because serologic assays are insensitive during the acute stage of infection, serologic testing is not advised for individuals who report with EM lesions.
Only when a diagnosis is supported by clinical and epidemiologic data should healthcare professionals seek Lyme testing.
Initial examinations (lab, imaging)
 Clinical diagnosis rather than laboratory testing is advised for those with one or more skin lesions compatible with EM who may have been exposed to ticks in an area where Lyme disease is endemic.
Due to an increased risk of false-positive results, testing for IgM or IgG-class antibodies to B. burgdorferi only by immunoblot without a preceding positive or ambiguous first-tier immunoassay is strongly discouraged.
The CDC advises two-tier testing: an immunoblot for Tier 2 and an antibody screening assay for Tier 1.
If the immunoassay(s) are unfavorable, no more testing is required.
Reflex immunoblot testing is required if the immunoassays are positive or ambiguous.
IgM and IgG specific anti-B. burgdorferi immunoblots should be carried out on patients with symptoms lasting less than 30 days.
Only anti-B. burgdorferi Ig immunoblot should be carried out for patients who have had symptoms for more than 30 days.
Modified two-tiered Lyme disease serologic testing - Concurrent or sequential immunoassays are used in both tiers. Results are quicker and easier to understand.
Tests in the Future & Special Considerations
Arthritis: Synovial fluid PCR and serology are sensitive and specific.
Neuroborreliosis: serology in conjunction with CSF pleocytosis (extremely low sensitivity for PCR in CSF).
Lumbar puncture when there are neurologic symptoms. Diagnostic procedures.
TREATMENT
Doxycycline 200 mg PO for adults and 4.4 mg/kg up to 200 mg for children should be administered as prophylactic antibiotic therapy only to adults and children within 72 hours of removal of a diagnosed high-risk tick bite—not for bites that are equivocal risk or low risk.

Medication 

Amoxicillin, doxycycline, and cefuroxime intolerance sufferers may benefit from taking macrolides (azithromycin, clarithromycin, or erythromycin). Since macrolides have a reduced efficacy, patients receiving them need to be watched to make sure their symptoms go away.

Initial Line

Early Lyme disease treatment options include amoxicillin 500 mg PO TID for 14 days (pediatric dose: 50 mg/kg/day), cefuroxime axetil 500 mg PO BID for 14 days, or doxycycline 100 mg PO BID for 10 to 14 days (do not use in children under 8 years old or in pregnant women). A substitute would be to take clarithromycin 500 mg BID for 14 to 21 days or azithromycin 500 mg QD for 7 to 10 days.
Early disseminated Lyme - Neurologic disease: Corticosteroid treatment should be given within 72 hours to patients under the age of 16 who have acute facial nerve palsy but no other signs of Lyme disease. Apply the proper Lyme therapy to your case.
 Doxycycline 100 mg PO for 14 to 21 days in adults
Children should take doxycycline for 14 to 21 days at a dose of 4.4 mg/kg/day.
Adults should take either ceftriaxone 2 g IV once daily for 14 to 21 days or doxycycline 200 mg PO divided into 1 or 2 doses for 14 to 21 days if they have radiculoneuritis or Lyme meningitis.
Cardiac disease: mild (1st-degree AV block, PR 300 ms): adults: 100 mg of doxycycline PO BID or 500 mg of amoxicillin PO TID for 14 to 21 days; children: 4.4 mg of doxycycline PO divided into BID and TID doses for 14 to 21 days; 50 mg of amoxicillin PO divided into TID and BID doses for 14 to 21 days; or 30 mg of cefuroxime
Adults should take ceftriaxone 2 g IV QD for 14 to 21 days if they have severe (symptomatic, first-degree AV block with PR interval 300 ms, second- or third-degree AV block), while children should take ceftriaxone 50 to 75 mg/kg IV QD for 14 to 21 days.
– Arthritis
Adults should take either doxycycline 100 mg BID PO for 28 days, 500 mg TID PO for 28 days, or 500 mg BID PO for 28 days of cefuroxime.
Children under the age of eight should take cefuroxime 30 mg/kg/day PO, divided BID for 28 days, or doxycycline 4.4 mg/kg/day PO, divided BID for 28 days.
 Children 8 years old: Cefuroxime 30 mg/kg/day PO, divided into 2 doses for 28 days, or amoxicillin 50 mg/kg/day PO for 28 days
Adults should get ceftriaxone 2 g IV QD for 14 to 28 days, while children should receive ceftriaxone 50 to 75 mg/kg IV QD for the same period of time.
Doxycycline is contraindicated in youngsters and in women who are pregnant or nursing. - Allergies to particular drugs.
 Safety measures:
- Within 24 hours, a Jarisch-Herxheimer-type reaction appears in 15% of patients receiving IV treatment.
- Oral anticoagulants and oral contraceptives have significant interactions.
pregnant women's issues
Parenteral antibiotics should be administered to pregnant individuals with active illness because B. burgdorferi can pass the placenta.

Surgical Techniques 

High-grade heart block and carditis accompany the temporary pacemaker.

Admission 

Accept patients with Lyme carditis, chest discomfort, syncope, dyspnea, a first-degree heart block of less than 300 ms, a second- or third-degree block, or meningitis symptoms.

Take Action 

Because seroreactivity frequently lasts for months after treatment of an early illness and years after treatment of a late infection, do not retest the patient to see if antibody titers have decreased after treatment.

Patient Education Avoid exposure to ticks in regions where they are endemic. When removing ticks off skin, avoid "painting" them with petroleum jelly or nail polish or using heat.
To prevent: Use insect repellents with 20–30% DEET.
After returning indoors, take a bath as soon as possible (within two hours), and check for ticks frequently.


Prognosis Early use of antibiotics can reduce the length of time that symptoms last and stop later disease. Treatment for diseases in their late stages varies. Weeks may pass before symptoms disappear.
Rashes left untreated typically go away in 3 to 4 weeks. With early antibiotics, the prognosis is excellent. 15% of Lyme disease patients who are not being treated develop neurologic symptoms.

Complications 
Following therapy PTLDS: 10-20% residual symptoms of fatigue, pain, or joint and muscle aches; can continue for 6 months; Lyme carditis >40% syncopal presentation; Lyme disease syndrome (PTLDS): discomfort, exhaustion, or difficulties thinking that last for >6 months after they end therapy; no confirmed treatment for PTLDS