Case1 - Lyme disease

[pbruss]

A few things.

1. Big thanks to dr levit for setting this up
2. Will try for one case a week but depends on how many good cases I get
3. Everyone feel free to post cool cases you have
4. Spoke to a lot of first years for the first time today, don't be afraid to add comments, this is for education no one is going to think you are stupid.

Now for the case:

22 yo male in Lima comes in by ambulance for "stroke alert". He has left facial drooping that does involve the forehead. He states he had same thing 6 months ago on right side of his face and was told it was Bell's palsy. The rest of his exam is all normal.

What is the underlying cause of his symptoms?

[kemple]

My guess would be Lyme's Disease. Tumor or CNS event wouldn't usually be one side than the other. I guess checking for herpes might be useful as well.

[pbruss]

correct. on further history he recently moved to lima from south eastern pennsylvania and he is an avid hunter- always in the woods and does remember "pulling a tick out of his hair". he does not remeber a rash but it could of been hiding under his hair. the lab testing for lyme disease is tricky. the chance of you ordering a lab test and accuratley knowing that the patient has lyme disease is not the greatest. due to the patients history, risk factors, and lack of reliable follow up i ordered a lyme titer but treated him emperically with doxy. for more detailed information read the following which i got from uptodate:

"Approximately 20 to 40 percent of patients with early localized Lyme disease (EM) are seropositive at the time of presentation using the two-tier serologic method"

"Even among B. burgdorferi sensu stricto strains in the US the sensitivity of the Western blot for detection may vary significantly. Borrelial strains may be classified by ribosomal spacer type (RST). In culture-proven cases of infection, two-tier testing was less sensitive than VlsE C6 ELISA testing in detecting antibodies in RST types 2 (37 percent positive versus 66.7 percent positive, respectively) and 3 (25 percent positive versus 75 percent positive) [25]. Detection of RST type 1 strains were equivalent. The loss of sensitivity in the two-tier approach was mainly due to decreased sensitivity of the Western blot."

"Serologic testing should be performed in patients who meet all of the following criteria:


•A recent history of having resided in or traveled to an area endemic for Lyme disease and

•A risk factor for exposure to ticks and

•Symptoms consistent with early disseminated disease or late Lyme disease (eg, meningitis, radiculopathy, mononeuritis, cranial nerve palsy, arthritis, carditis) (see 'Indications for serologic testing' above)




●Serologic testing for Lyme disease should not be performed in the following settings:


•In patients with an EM rash. Patients with skin rashes consistent with EM who reside in or have recently traveled to an endemic area should be treated for Lyme disease. (See "Clinical manifestations of Lyme disease in adults", section on 'Erythema migrans' and "Lyme disease: Clinical manifestations in children", section on 'Erythema migrans' and "Treatment of Lyme disease", section on 'Early disease (erythema migrans)'.)


•For screening of asymptomatic patients living in endemic areas


•For patients with non-specific symptoms only (eg, fatigue, myalgias/arthralgias). The use of serologic testing in populations with a low pre-test probability of Lyme disease results in a greater likelihood of false positive test results than true positive test results. (See 'Indications for serologic testing' above"


"Recommended antibiotics — Intravenous antibiotic therapy is indicated for acute neurologic manifestations of Lyme disease with the exception of isolated facial palsy, which can usually be treated with oral antibiotics.

●Acute neurologic disease — Recommended antibiotic regimens for acute neurologic disease include (table 1):


•Ceftriaxone (in adults: 2 g intravenously once daily; in children: 50 to 75 mg/kg intravenously once daily, maximum dose 2 g) OR


•Cefotaxime (in adults: 2 g intravenously every eight hours; in children: 150 to 200 mg/kg intravenously per day divided in three doses, maximum dose 6 g per day) OR


•Penicillin G (in adults: 18 to 24 million units per day intravenously divided into 6 daily doses; in children: 200,000 to 400,000 units/kg per day divided into 6 daily doses, maximum 18 to 24 million units per day)

Adults and children ≥8 years who are intolerant of beta-lactam antibiotics should receive oral doxycycline (in adults: 200 to 400 mg per day in two divided doses; in children: 4 to 8 mg/kg per day in two divided doses, maximum, 100 to 200 mg per dose). The higher dose of doxycycline may not be well tolerated. In addition, some patients with neuroborreliosis in the United States require intravenous antibiotic therapy for successful treatment of the infection. Desensitization to a cephalosporin or penicillin may be considered in patients with a history of an IgE-mediated (anaphylactic) reaction to these agents. (See "Allergy to penicillins", section on 'Desensitization' and "Rapid drug desensitization for immediate hypersensitivity reactions".)


●Isolated facial nerve palsy — For isolated facial nerve palsy, the preferred agent is oral doxycycline 100 mg orally twice daily for adults; 2 mg/kg twice daily (maximum 100 mg per dose) for children ≥8 years of age. However, doxycycline is not recommended for children under the age of eight years or for pregnant or lactating women. A single treatment course of doxycycline may be given to children younger than eight years in whom the alternate agents are contraindicated. Amoxicillin and cefuroxime may be effective alternatives to doxycycline, but this has not been demonstrated in clinical trials"