Download Lyme Disease Update

7/14/2015
Objectives
At the end of this session you should be able to:
(1) Understand epidemiology and transmission
of Lyme disease
(2) Identify the most common tests used to
diagnose Lyme disease
(3) Compare treatment options for Lyme disease
including prophylaxis and for positive
serologic results
Lyme Disease Update
Ashley Blake, MSN, APRN, FNP-BC
Family Nurse Practitioner
Allegheny Clinic
Wexford Health + Wellness Pavilion Primary Care
Wexford, PA
Formerly Wright & Associates Family Healthcare,
PLLC
Amherst, NH
No Disclosures
Figure 1. Lyme disease cases 2012 (CDC, 2015)
Lyme Disease concentrated in
Northeast and Upper Midwest
• In 2013 95% of confirmed Lyme Disease cases
were from 14 states:
– Connecticut
– Delaware
– Maine
– Maryland
– Massachusetts
– Minnesota
– New Hampshire
- New Jersey
- New York
- Pennsylvania
- Rhode Island
- Vermont
- Virginia
- Wisconsin
(CDC, 2015)
Figure 2. Lyme disease cases 2013 (CDC, 2015)
Confirmed cases of Lyme disease
New England 2013
State
Number of
Confirmed Cases
Cases/100,000
people
Vermont
674
107.6
New Hampshire
1324
100
Maine
1127
84.8
Connecticut
2111
58.7
Massachusetts
3816
57
Rhode Island
444
42.2
(CDC, 2015)
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Deer Tick Lifecycle
Transmission of Lyme Disease
• Borrelia burgdorferi spread to humans by
infected blacklegged ticks called Ixodes
Scapularis in this region
• Usually have to be attached for >24 hours to
infect host
• Mostly spread by nymphs which are smaller
than a poppy seed (2 mm in size)
(CDC, 2015)
Figure 3. Deer ticks (CDC, 2015)
Dog Ticks significantly
larger and not Lyme carriers
Deer Tick
This is NOT a Lyme Bearing Tick
Dog Tick
Figure 4. Ticks (CDC, 2015)
The “Great Imitator”
Lyme Bearing Tick
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•
•
•
•
•
•
•
•
•
•
Alzheimer’s Disease
Arthritis
ADD
Chronic fatigue syndrome
Fibromyalgia
Lupus
Guillain-Barre
Mononucleosis
ALS
MS
Parkinson’s (Lyme Research Alliance, 2015)
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Common Symptoms of Early
Lyme Disease
(3-30 days after tick bite)
Avril Lavigne
"They would pull up their computer
and be like, 'Chronic fatigue
syndrome.' Or, 'Why don't you try
to get out of bed, Avril, and just
go play the piano?' It's like, 'Are
you depressed?’ ”
“This is what they do to a lot of
people who have Lyme disease.
They don't have an answer for
them so they tell them, like,
'You're crazy.'” (“Huffington
Post”, 2015)
Figure 7. (Getnetworth.net, 2015)
•
•
•
•
•
•
•
Fatigue
Chills
Fever
Joint pain
Headaches
Muscle Aches
Swollen lymph nodes
(CDC, 2015)
Symptoms of Early Disseminated
Lyme Disease
(days to weeks after tick bite)
• Bell’s Palsy
• Spreading EM rash or development in other
locations
• Joint pain
• Neck pain
• Worsening headaches
• Dizziness
Bell’s Palsy
• Trauma to the peripheral part of the facial nerve
• Presents with unilateral facial paralysis (eye brow
sagging, inability to close eye, no visible
nasolabial fold, corner of the mouth drooping on
affected side, decrease in tearing, loss of taste on
2/3rds of tongue, hyperacusis)
• Occurs over a course of approx 1-2 days
• Usually recovery occurs in <2 months if due to
lyme
(CDC, 2015)
Symptoms of Late Disseminated
Lyme Disease
(months to years after tick bite)
Frequency of Reported Symptoms
Symptom
• Short-term memory loss
• Arthritis
• Numbness, tingling in extremities
Erythema Migrans rash
Arthritis
Bell’s Palsy
Radiculoneuropathy
Meningitis/encephalitis
Cardiac signs
Percentage of cases with
reported symptom
70%
30%
8%
4%
2%
1%
(Nelson & Drexler, 2014)
(CDC, 2015)
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The Workup/Diagnosis
•
•
•
•
Erythema Migrans
Erythema migrans rash
ELISA Titer
Western Blot
IGenex
Figure 8. (CDC, 2015)
Erythema Migrans
Erythema Migrans
Erythema Migrans
Follow-up Testing
with Tick Bite, EM Rash
• Seroconversion occurs within 6-8 weeks
• Western Blot 6-8 weeks following tick bite
(Meyerhoff, 2008)
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ELISA Titer
• Sensitive enzyme linked immunosorbent assay
• Two-tier approach
• Tests for antibodies only (Lyme Research
Alliance, 2015)
• Check WB if equivacol or + result
• Cross-sensitivity: EBV, gingivitis, lupus, RA,
bacterial, or viral infections
Western Blot
• IgM – 1st few weeks
• IgG – after first few weeks
• IgM – 2 of the following bands:
– 24, 39, 41
• IgG – 5 of the following bands:
– 18, 23, 28, 30, 39, 41, 45, 58, 66, 93 (Dressler,
1993)
Sensitivity of Two-Tier Testing
Symptom
Sensitivity
Erythema Migrans rash (acute)
38%
Erythema Migrans rash
(convalescent)
67%
Early neurologic symptoms
87%
Arthritis
97%
Late neurologic symptoms
100%
(Bacon et al, 2003)
Lyme Disease Vaccination
• GlaxoSmithKline – LYMERix
• 3 dose series to stimulate antibodies that attack
lyme in the tick’s gut while feeding on human
host
• Indicated for 15-70 year olds living in endemic
regions
• Licensed in 1998; provided 1998-2002;
withdrawn from the market in 2002 (Carr,
2014)
IGenex
• Western blot test
• IgM & IgG criteria- 2 or more of the double
starred bands are present
• Bands: 18, **23-25, 28, 30, **31, **34, **39,
**41, 45, 58, 66, **83-93 (IGenex, 2015)
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Other Testing Techniques
• PCR
• Antigen Capture
• Spinal taps
Management of Positive Result
• Reportable disease
• EKG
• Additional labs – tick co-infections, CD57
EKG
CD57
Heart block
potentially
result of Lyme
Carditis
• Changes in this lab value can be useful in
evaluating response to treatment course
• Normal range: 60-360
• Decrease in CD57 lymphocyte may be a
significant marker in the treatment of chronic
Lyme disease (Stricker, Winger, 2001;
Burrascano 2008)
Figure 11. (Children’s Heart Specialists PSC, 2015)
CD57 Test Result Example
Tick Co-Infections
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•
•
•
•
•
•
Babesia*
Bartonella*
Ehrlichia*
Mycoplasma
Powassan Encephalitis
Rocky Mountain Spotted Fever
Tularemia
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Tick Co-infection Distribution
Babesia
• Protozoa
• Symptoms: fatigue, malaise, weakness,
headaches, fever, chills, sweats, arthralgia,
anorexia
• Testing: PCR, blood test, microscopy
• Treatment: Based on a positive result with
atovaquonone and zithromax* OR clindamycin
and quinine x7-10 days
Figure 12. (CDC, 2015)
Bartonella
Ehrlichia
• Symptoms: Agitation, anxiety, insomnia,
gastritis, sore soles (especially in the AM),
tender nodules along the extremities, enlarged
lymph nodes, sore throats, and red streaking
rashes
• Testing: Serology, PCR available but very
insensitive
• Treatment: Levofloxacin in adults,
azithromycin in children (Burrascano, 2008)
• Symptoms: fever, malaise, myalgia, headache,
chills (>2/3rds of patients); n/v, arthralgias,
cough (25-50% patients); rash, clonus, stiff
neck
• Testing: labs (CBC, CMP, PCR)
• Treatment: doxycycline 100mg po BID x10
days; chloramphenicol; rifampin 300mg po
BID x7-10 days
Controversy
CDC
“Although Lyme disease is not rare, the
treatment of Lyme disease has not attracted
pharmaceutical interest and the evidence base
for treating Lyme disease is best described as
sparse, conflicting and emerging” (“Cameron,
Johnson & Maloney”, 2014)
• Testing – two-tier testing; red flag with tests that
are not regulated by the FDA (Nelson & Drexler,
2014)
• Most patients who are treated, recover completely
• “Post-Treatment Lyme Disease Syndrome”
(PTLDS) – lingering symptoms due to damage to
tissues and the immune system (CDC, 2015)
• Studies do not support the long-term use of
antibiotics (Nelson & Drexler, 2014)
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ILADS
Infectious Disease
• Adoption of the Grading of Recommendations
Assessment, Development and Evaluation (GRADE)
system as its basis for guidelines
• Clinicians should continue antibiotic therapy for
patients who: have not fully recovered by initial
therapy; were successfully treated but have relapse of
symptoms or disease progression
• Always reassess if diagnosis is accurate (Cameron,
Johnson, & Maloney, 2014)
• Need for better testing as disease is not always
identified and treated
• Similar opinions as CDC- PTLDS
• Do not believe in “chronic” form of lyme
• “Most cases of Lyme disease are successfully
treated with 10-28 days of antibiotics” (“IDSA”,
2012)
• Risk of prolonged use of antibiotics versus
benefit (IDSA, 2012)
Adults Early Lyme Disease Treatment
Treatment with Facial Nerve Palsy
• Doxycycline 100mg po BID x21 days
• Amoxicillin 500mg po TID x21 days
• Cefuroxime acetil 500mg po BID x21 days
Pediatrics Early Lyme Disease
Treatment
• Doxycycline 2mg/kg BID (max 100mg/dose) –
kids > 8 years of age x21 days
• Amoxicillin 50mg/kg in 3 divided doses (max
500mg/dose) x21 days
• Cefuroxime acetil 30mg/kg in 2 divided doses
(max 500mg/dose) x21 days
• Acute neurologic disease: IV therapy with
ceftriaxone, Pen G, or cefotaxime
• Adults: oral doxycycline 200-400mg total
daily
• Children >/=8 years old: doxycycline 48mg/kg in 2 divided doses
Chronic Treatment
• Treatment only supported by ILADS
• Must fit the following criteria:
– Illness present for at least 1 year
– Have persistent neurologic involvement
– Still have active infection with B. burgdorferi
(Burrascano, 2008)
• Treat x 4-6 weeks at a time
• Always re-evaluate diagnosis if not responding to
treatment (Cameron, Johnson & Maloney, 2014)
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How to Remove a Tick
• Use fine-tipped tweezers to grasp the area of the
tick closest to the skin
• Pull upward with a steady, firm pressure; do not
twist or jerk as this can result in mouth parts
breaking off
• Clean the bite area with rubbing alcohol, soap &
water, or iodine scrub
• Submerse the tick in rubbing alcohol, place in a
sealed container, ziplock bag, wrap in tape, or
flush down the toilet (CDC, 2015)
Lyme Disease and other Tick Borne
Disease Prevention
•
•
•
•
•
Avoid wooded areas and tick habitats
Use DEET or wear permethrin-treated clothing
Shower after being outdoors
Perform daily tick checks
Treat household pets for ticks (Nelson &
Drexler, 2014)
Case Study #1
Case Study #1 Continued
First visit with patient:
50 y/o female presenting with no history of
chronic conditions complaining of “sharp
pains in front of [her] ears”, neck pain, scalp
sensitivity, fever, myalgias, fatigue x2 days.
Denies nausea, vomiting, vision changes, rash,
exposure to sick contacts. Normal physical
exam including no neuro deficits, negative
meningeal signs.
Visit #2 with patient (6 days later):
Patient presents with worsening fatigue, leg and
backache, headache, spreading rash described
as “red blotches”. On exam, she has scattered
annular, erythematous rashes, some with
central clearing- all approximately 10cm in
diameter (located on L cheek, L anterior wrist,
R forearm, bilateral thighs, L knee, back, and
abdomen). They are warm to the touch.
Case Study #2
Patient is an 8 year old patient presenting with
complaints of bilateral knee pain, fevers,
fatigue, and a non-itching or painful red rash
behind his knee.
On exam, patient is well-appearing, conversant.
Exam WNL except for circular rash L posterior
knee 9 cm in diameter.
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7/14/2015
References
Bacon et al. (2003). Serodiagnosis of Lyme Disease by Kinetic Enzyme-Linked
Immunosorbent Assay Using Recombinant VlsE1 or Peptide Antigens of Borrelia burgdorferi Compared with 2-Tiered Testing
Using Whole-Cell Lysates. JID, 187. Retrieved from http://archive.poughkeepsiejournal.com/assets/pdf/BK1961331021.pdf
Burrascano, J. J., (2008). Diagnostic hints and treatment guidelines for lyme and other
tick borne illnesses. Retrieved from http://www.ilads.org/lyme/B_guidelines_12_17_08.pdf
Questions?
Cameron, D. J., Johnson, L. B., Maloney, E. L. (2014). Evidence assessments and
guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and
persistent disease. Anti Infect. Ther., 12(9), 1103-1135. Retrieved from
http://informahealthcare.com/doi/full/10.1586/14787210.2014.940900
Carr, J. (2014). The History of the Lyme Disease Vaccine. Retrieved from
Thank you!
http://www.historyofvaccines.org/content/articles/history-lyme-disease-vaccine
CDC. (2015). Lyme Disease. Retrieved from http://www.cdc.gov/lyme/
Children’s Heart Specialists PSC. (2009). AV Block. Retrieved from
http://mykentuckyheart.com/information/First-degreeAVblock.htm
Dressler, F., Whalen, J.A, Reinhardt, B.N., & Steere, A.C. (1993). Western blotting in
the serodiagnosis of Lyme Disease. Journal of Infectious Disease, 167(2), 392-400. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/8380611
References Continued
Gelfand, J.A., Vannier, E.G. (2014). Clinical manifestations, diagnosis, treatment, and
prevention of babesiosis. Up-To-Date. Retrieved from http://www.uptodate.com/contents/clinical-manifestations-diagnosistreatment-and-prevention-of-babesiosis?source=search_result&search=babesia&selectedTitle=1%7E31
Get Net Worth. (2015). Avril Lavigne net worth. Retrieved from
http://getnetworth.net/avril-lavigne-net-worth/
Hu, L. (2015). Diagnosis of Lyme disease. Up-To-Date. Retrieved from
http://www.uptodate.com/contents/diagnosis-of-lymedisease?source=search_result&search=elisa+test+lyme&selectedTitle=1%7E150
IDSA (2012, July 17). Statement for the House Foreign Affairs Committee
Africa, Global Health and Human Rights Subcommittee’s Hearing on Global Challenges in Diagnosing and Managing Lyme
Disease — Closing Knowledge Gaps. Retrieved from
http://www.idsociety.org/uploadedFiles/IDSA/Topics_of_Interest/Lyme_Disease/Policy_Documents/Lyme%20Disease%20T
estimony-Global%20Health%20Subcommittee.pdf
References Continued
Lyme Research Alliance. (2015). About Lyme Disease. Retrieved from
http://www.lymeresearchalliance.org/index.html
Marcus, S. (2015, June 29). Avril Lavigne Breaks Down During Interview About Lyme Disease. Huffington Post. Retrieved from
http://www.huffingtonpost.com/2015/06/29/avril-lavigne-lyme-disease_n_7689642.html
Meyerhoff, J. O. (2015, Jan 22). Lyme disease treatment and management. Retrieved
from http://emedicine.medscape.com/article/330178-treatment
Moore, K.S. (2015). Lyme Disease: Diagnosis, Treatment Guidelines, and Controversy.
The Journal for Nurse Practitioners, 11(1), 64-69.
Nelson, C & Drexler, N. (2014). Tickborne Diseases: A Springtime Review of
Diagnosis, Treatment and Prevention [PDF Document]. Retrieved from
http://emergency.cdc.gov/coca/ppt/2014/04_10_14_tickborne_ppt2.pdf
Ronthal, M. (2015). Bell’s palsy: Prognosis and treatment in adults. Up-To-Date.
Retrieved from http://www.uptodate.com/contents/bells-palsy-prognosis-and-treatment-in-
IGenex. (2015). IGenex, Inc. Retrieved from http://www.igenex.com/Website/#
adults?source=search_result&search=bell%27s+palsy&selectedTitle=1%7E50
Sexton, D.J. (2014). Human erhlichiosis and anaplasmosis. Up-To-Date. Retrieved from
http://www.uptodate.com/contents/human-ehrlichiosis-and-anaplasmosis?source=search_
result&search=ehrlichia&selectedTitle=1%7E46
Stricker, R.B., Winger, E. E. (2001, Feb 1). Decreased CD57 lymphocyte subset in
patients with chronic Lyme disease. Immunol Lett, 76(1), 43-48. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11222912
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