Objectives. Lyme Disease Update. Lyme Disease concentrated in Northeast and Upper Midwest. Confirmed cases of Lyme disease New England /14/2015

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1 Objectives 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 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 Figure 1. Lyme disease cases 2012 (CDC, 2015) Figure 2. Lyme disease cases 2013 (CDC, 2015) Lyme Disease concentrated in Northeast and Upper Midwest In % of confirmed Lyme Disease cases were from 14 states: Connecticut - New Jersey Delaware - New York Maine - Pennsylvania Maryland - Rhode Island Massachusetts - Vermont Minnesota - Virginia New Hampshire - Wisconsin (CDC, 2015) Confirmed cases of Lyme disease New England 2013 State Number of Confirmed Cases Vermont New Hampshire Maine Connecticut Massachusetts Rhode Island Cases/100,000 people (CDC, 2015) 1

2 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) Deer Tick Lifecycle (CDC, 2015) Figure 3. Deer ticks (CDC, 2015) Dog Ticks significantly larger and not Lyme carriers This is NOT a Lyme Bearing Tick Deer Tick Dog Tick Figure 4. Ticks (CDC, 2015) Lyme Bearing Tick The Great Imitator Alzheimer s Disease Arthritis ADD Chronic fatigue syndrome Fibromyalgia Lupus Guillain-Barre Mononucleosis ALS MS Parkinson s (Lyme Research Alliance, 2015) 2

3 "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) Avril Lavigne Figure 7. (Getnetworth.net, 2015) Common Symptoms of Early Lyme Disease (3-30 days after tick bite) 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) Short-term memory loss Arthritis Numbness, tingling in extremities Frequency of Reported Symptoms Symptom Percentage of cases with reported symptom Erythema Migrans rash 70% Arthritis 30% Bell s Palsy 8% Radiculoneuropathy 4% Meningitis/encephalitis 2% Cardiac signs 1% (Nelson & Drexler, 2014) (CDC, 2015) 3

4 The Workup/Diagnosis Erythema migrans rash ELISA Titer Western Blot IGenex Erythema Migrans 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) 4

5 ELISA Titer Sensitivity of Two-Tier Testing 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 Symptom Erythema Migrans rash (acute) 38% Erythema Migrans rash (convalescent) Sensitivity 67% Early neurologic symptoms 87% Arthritis 97% Late neurologic symptoms 100% (Bacon et al, 2003) Western Blot IgM 1 st 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) 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 year olds living in endemic regions Licensed in 1998; provided ; 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) 5

6 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: 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 Babesia* Bartonella* Ehrlichia* Mycoplasma Powassan Encephalitis Rocky Mountain Spotted Fever Tularemia 6

7 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 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) Ehrlichia 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 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) CDC 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) 7

8 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 days of antibiotics ( IDSA, 2012) Risk of prolonged use of antibiotics versus benefit (IDSA, 2012) Adults Early Lyme Disease Treatment Doxycycline 100mg po BID x21 days Amoxicillin 500mg po TID x21 days Cefuroxime acetil 500mg po BID x21 days Treatment with Facial Nerve Palsy Acute neurologic disease: IV therapy with ceftriaxone, Pen G, or cefotaxime Adults: oral doxycycline mg total daily Children >/=8 years old: doxycycline 4-8mg/kg in 2 divided doses 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 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) 8

9 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 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. Case Study #1 Continued 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. 9

10 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 Burrascano, J. J., (2008). Diagnostic hints and treatment guidelines for lyme and other Questions? Thank you! tick borne illnesses. Retrieved from 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), Retrieved from Carr, J. (2014). The History of the Lyme Disease Vaccine. Retrieved from CDC. (2015). Lyme Disease. Retrieved from Children s Heart Specialists PSC. (2009). AV Block. Retrieved from 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), Retrieved from References Continued References Continued Gelfand, J.A., Vannier, E.G. (2014). Clinical manifestations, diagnosis, treatment, and prevention of babesiosis. Up-To-Date. Retrieved from Get Net Worth. (2015). Avril Lavigne net worth. Retrieved from Hu, L. (2015). Diagnosis of Lyme disease. Up-To-Date. Retrieved from 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 estimony-global%20health%20subcommittee.pdf IGenex. (2015). IGenex, Inc. Retrieved from Lyme Research Alliance. (2015). About Lyme Disease. Retrieved from Marcus, S. (2015, June 29). Avril Lavigne Breaks Down During Interview About Lyme Disease. Huffington Post. Retrieved from Meyerhoff, J. O. (2015, Jan 22). Lyme disease treatment and management. Retrieved from Moore, K.S. (2015). Lyme Disease: Diagnosis, Treatment Guidelines, and Controversy. The Journal for Nurse Practitioners, 11(1), Nelson, C & Drexler, N. (2014). Tickborne Diseases: A Springtime Review of Diagnosis, Treatment and Prevention [PDF Document]. Retrieved from Ronthal, M. (2015). Bell s palsy: Prognosis and treatment in adults. Up-To-Date. Retrieved from Sexton, D.J. (2014). Human erhlichiosis and anaplasmosis. Up-To-Date. Retrieved from 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), Retrieved from 10

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