Lyme Disease

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Bryan N. -

There were some mentions inthis piece of arthralgias as a symptom of lyme but I frequently see patient's present with large joint effusions that subsequently test positive for lyme. In a lyme endemic area I treat patient's with atraumatic effusions presumptively as lyme disease.

Anand S., M.D. -

Bryan - some thoughts from Justin Hensley on the matter:

Pretty legit. From attached article. Their reference is "British Infection Association. The epidemiology, prevention, investigation and treatment of Lyme borreliosis in United Kingdom patients: a position statement by the British Infection Association. J Infect 2011;62:329–38."

The palindromic form affects approximately 60% of patients,8 typically with an asymmetric oligoarthritis or monoarthritis
of large joints, commonly the knees and or ankles.82 83 Joint effusion is a common presentation and may be out of proportion to the pain experienced.31 Ankles and wrists are the next most commonly affected sites.83 Examination reveals warm swollen joints with mild discomfort on movement. The arthritis lasts several weeks or months and tends to be self-limiting.84 If untreated with antibiotics, frequent recurrence is characteristic, especially in the first few years of the disease.83 85 Between recurrences, patients are often well with no joint symptoms.

Katherine S. -

Hi - do you have any references from your Cochrane review supporting your statement that dental staining is not significant in single-dose doxy for the pediatric population? I'm in a HIGHLY Lyme endemic area and would love to be able to prophylax kids with high-risk bites guilt-free. On the occasions that I've done it (after going over risks/benefits and numbers with mom & dad) I've gotten um... feedback... from some of the pediatricians in my area.

Justin H., MD -

Sadly, I named the wrong "C" group. It was the CDC (with the IHS). And yes, you're using it "off-label", as the FDA still has the warning against kids under 8 simply due to the dental staining. The original data for staining was from papers published in 1958, 1962, and 1967, and they all tested tetracyclines that bind calcium. Doxycycline wasn't on the market until 1967 and doesn't bind calcium as well. Unfortunately, they haven't gone back and looked at the warning in almost 50 years.

However, here's the May 2015 paper from the Journal of Pediatrics: http://www.jpeds.com/article/S0022-3476(15)00135-3/pdf?ext=.pdf
"This study failed to demonstrate dental staining, enamel hypoplasia, or tooth color differences among children who received short-term courses of doxycycline at <8 years of age. Healthcare provider confidence in use of doxycycline for suspected RMSF in children may be improved by modifying the drug’s label."
Dental staining isn't significant with doxycycline even with multiple courses of 7-10 days (kids had an average of 1.8 courses in the paper).

Another source is the March 2007 Clinical Pediatrics: http://cpj.sagepub.com/content/46/2/121
"The aim of the study was to determine if doxycycline causes tooth staining in young children. A dentist examined 31 randomized children who had been treated with doxycycline and 30 children who had not received doxycycline. Mean age of the children was 10.4 ∓ 2.1 years. Mean age at receipt of the first doxycycline treatment was 4.1 ∓ 1.6 years, and mean number of doxycycline courses was 2.0 ∓ 1.3. No tooth staining was detected by the dentist in any of the children in either group. These findings indicate that treatment with doxycycline in children aged 2 to 8 years is not associated with tooth staining."

And then, most recently (Aug 2016), in Archives of Diseases in Childhood, they reviewed doxycycline in children. http://adc.bmj.com/content/101/8/772.1.extract
"Clinical bottom line: The risk of dental staining with short courses of up to 10 days doxycycline in children <8 years of age (outside the neonatal period) is negligible (<1%) (Grade B).
Side effects of longer courses or doses exceeding 2.9 mg/kg twice daily require further study (Grade B).
There are insufficient data on dental adverse effects with exposure in the neonatal period (Grade D)."
Since the Lyme dosage is 4mg/kg/day, or 2mg/kg twice daily, and most neonates aren't hiking in the woods, I would argue that there's enough evidence for expanding the age range of doxycycline.

James C. -

The written summary states that bilateral bell's is lyme until proven otherwise, but in the next line, you recommend a tap for any neurologic finding. Are you tapping everyone with bilateral bell's or were you referring to more meningitis type neuro findings?

Justin H., MD -

This one is tough. If you have bilateral bells, you run the risk of a lot of other diseases being present. However, if everything else about the presentation screams bells (rash, hiking in endemic area, etc) I might not do an LP. But they would have to be followed very closely to make sure you aren't missing something else. Of note, meningitis can also present as bilateral facial palsy, as can GBS, and many other diseases I don't want to have personally or miss in my patient.
It's exceedingly rare, which is why it's a board question, but certainly something to think about in any patient. If they've got neuro findings, as Swami said, it's probably worth considering it as a CNS infection and admitting for IV ABx (or at least consulting ID), and doing an LP.

James C. -

Thanks! (Anand as well)

Anand S., M.D. -

James - great question. If it's unilateral Bell's with no meningitis symptoms, I wouldn't tap. If it's bilateral with no meningitis symptoms, I probably wouldn't tap either but I'd consider it. My concern, even though Bell's is peripheral, is that I'm missing a CNS infection and the oral doxy isn't gonna cut it. I've never seen a bilateral Bell's so I'll send this over to Justin as well to see his thoughts.
For sure if the patient has headache, neck pain, fever they're getting tapped or if they have neuro findings concerning for CNS infection.

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