Tick Talk: What s new in Lyme Disease. May 5 th, 2017 Cristina Baker, M.D., M.P.H.

Transcription

1 Tick Talk: What s new in Lyme Disease May 5 th, 2017 Cristina Baker, M.D., M.P.H. Dr. Baker indicated no potential conflict of interest to this presentation. She does not intend to discuss any unapproved/investigative use of a commercial product/device. Disclosures None

2 Objectives 1. Outline approaches early vs late-stage disease 2. Discuss prophylaxis following tick bites 3. Review how to monitor after treatment Distribution of the Blacklegged tick, Ixodes scapularis that transmits Lyme Disease

3 cdc.gov Tick Identification Nymphs and females are most likely to bite. Most exposures occurs from May through the fall. cdc.gov

4 Clinical Infectious Diseases 2006; 43:

5 Case study 14 yo girl presents with dizziness and arthralgias during high school fall soccer pre-season Traveled to Long Island, NY and northern MN over the summer Developed a rash on upper back and fever/flu-like symptoms for several days in July Seen by pediatrician diagnosed with mono in late August 2 weeks later develops Bell s palsy thought to be related to mono Develops headaches and photosensitivity LP shows lymphocytic pleocytosis 2-3 weeks later develops acute onset of chest pain with 2-3 degree heart block and carditis Develops radiculopathy, migrating monoarthritis of the hips and knees Sent to several specialists without diagnosis Case study Ultimately sees an Infectious Disease specialist at Park Nicollet Lyme Disease testing Western blot IgG positive and CSF testing positive for Lyme Disease Treated with Ceftriaxone x 4 weeks Lingering symptoms of fatigue, neurologic symptoms (headaches, neuropathy) and migratory arthralgias for 1 year following treatment but then made a full recovery

6 Lyme Disease Spread via Ixodes scapularis tick Caused by spirochete, Borrelia burgdorferi Symptoms Localized: Rash (erythema migrans) with or without constitutional symptoms Disseminated: multiple annular rashes, flu-like symptoms, lymphadenopathy Rheumatologic : arthralgias, mono or polyarthritis Cardiac: progressive heart block Neurologic: meningitis, radiculitis, Bells palsy Lyme Disease Skin Manifestations Erythema migrans

7 Manifestations - Early vs Late Stage Early days after bite Testing usually negative Erythema migrans/rash Fever Headache Flu-like symptoms Myalgia/Polyarthalgia *Rash as only symptom occurs in 30% Early Disseminated -Weeks to months after bite Testing usually positive Multiple erythema migrans Carditis (rare 1-5%) AV block (1>2>3) Myocarditis Neurologic Cranial nerve palsy: CN VII most common Lymphocytic meningitis Radiculitis, paresthesia and rarely weakness Manifestations - Early vs Late Stage Late months to > 1 yr Testing nearly always positive Late neurologic (rare) Encephalitis Encephalopathy Peripheral neuropathy (sensory) Late Lyme arthritis Joint swelling and pain usually knee Universally seropositive Usually monoarthritis but then may recur in same or different joint Late cutaneous (seen more in Europe) Lymphocytoma Usually ear lobe Mistaken for cutaneous lymphoma Acrodermatitis chronica atrophicans Bluish to red discoloration affecting distal extremities (fingers/toes) with swelling developing over months to years

8 Lyme disease testing Labs: elevated CRP and ESR, mildly elevated LFTS Diagnosis: Testing on blood: Lyme ELISA and Western Blot (if ELISA positive or equivocal) Testing can be negative in the first few weeks of illness. Can do acute (may be negative 30-70%) then convalescent serology (4-6 weeks later) Testing on CSF Lyme IgM and IgG antibodies Borrelia burgdorferi PCR Cell count with lymphocytic pleocytosis Testing on joint fluid Borrelia burgdorferi PCR

9 Advice on testing Avoid serologic testing without objective symptoms Subjective symptoms alone are not an indication for Lyme testing Fatigue Neurocognitive symptoms Fibromyalgia-like pain KEY POINT: Lyme IgM Western blot should not be used to diagnosis any condition > 1 month duration due to high rate of false positives IgM Western blot is the most common reason for misdiagnosis and unnecessary treatment New testing VlsE C6 ELISA May be positive earlier in acute infection (sensitivity 66% vs 35% for 2tier testing) Comparable sensitivity to IgM ELISA tests with improved specificity Not yet endorsed by the United States Centers for Disease Control and Prevention or guidelines from major organizations, and they have not gained widespread acceptance Not widely available

10 Question #1 A 20-year-old female is evaluated for a skin eruption on her thigh. She lives in Wisconsin and is active outdoors. One week ago, she removed a tick on her thigh. Now she has developed diffuse myalgia, neck stiffness, and fatigue. She also noticed a red ring-like rash at the site of the previously attached tick. On physical examination, temperature is F; other vital signs are normal. Exam is normal aside from a macular skin lesion with central clearing. Question #2 A 42-year-old man is evaluated in the emergency department for a 3-day history of dizziness and shortness of breath. He is training for a marathon. Despite rest and hydration, his symptoms have persisted. On physical examination, he appears well. Temp is normal, bp is 100/60 mm Hg, and pulse is 35/min. Labs: normal CBC, BMP and cardiac enzymes. EKG shows a second degree heart block Serologic testing for Borrelia burgdorferi is performed. Both the initial ELISA and a confirmatory Western blot assay are positive.

11 Lyme Disease Treatment Early infection (erythema migrans) Duration days Doxycycline 100mg po bid Advantage of also covering Anaplasma, Ehrlichia, Rocky Mountain Spotted Fever Cefuroxime 500mg po bid Amoxicillin 500mg po tid Bell s palsy Oral therapy as above Some use parenteral therapy if abnormal CSF Lyme Disease Treatment Carditis/heart block Oral regimen 14 days for those with asymptomatic 1 degree heart block Ceftriaxone 2gm IV daily generally recommended along with hospitalization for those with symptomatic 2 nd or 3 rd degree until heart block resolves Meningitis/radiculitis: Ceftriaxone 2 grams IV q day for 28 days European data suggests oral doxycycline is equivalent to IV ceftriaxone Arthritis Doxycycline for 28 days Recurrent Arthritis Repeat doxycycline for 28 days Or consider Ceftriaxone days 10-15% will develop persistent arthritis despite multiple rounds of antibiotics due to auto-immune, non-infectious inflammatory synovial process that is treated similarly to rheumatoid arthritis

12 Clinical Infectious Diseases 2006; 43: NEJM 2001: 345: 79-84

13 Lyme Disease Prophylaxis Consider prophylaxis if: Ixodes tick engorged and on for over 36 hours Prophylaxis given within 72 hours of tick bite Ecological information states that percentage of ticks with B. burgdoferi is over 20% (New England, parts of mid Atlantic, parts of MN, Wisconsin) Doxycycline 200mg po once This RCT showed 87% efficacy in preventing Lyme disease Lyme vaccine no longer available Tick Bite Prevention - Wear long sleeve clothing - Socks - Insect repellant -DEET - Shower after being outdoors - Tick checks

14 Question #3 A 72-year-old man is evaluated for fatigue and memory loss of 9 months' duration. The patient is a retired executive who is an avid outdoorsman and recalls many tick bites over the past several years. He lives in Florida now but has traveled extensively throughout the United States. The patient was seen in a walk-in clinic 1 week ago and had laboratory testing for Lyme disease. An enzyme-linked immunosorbent assay for Borrelia burgdorferi was positive. A Western blot assay was negative for IgG antibodies and positive for IgM antibodies. On physical examination today, vital signs are normal. Remaining physical examination findings are unremarkable. An electrocardiogram is normal. What to watch for after treatment Persistent symptoms of musculoskeletal pain, fatigue, headache, sleep disturbance, anxiety or depression Occurs within 6 month of Lyme diagnosis More common in adults than children 3 months: up to 25% 6 months: 10% 15 years: similar symptoms to general US population Clinical Infectious Diseases 2006; 43: Infectious Dis Clin NA June 2008:

15 What to watch for after treatment If symptoms persist for > 6 months termed post-treatment Lyme Disease Syndrome (PTLDS) Post-infectious disease fatigue syndrome Rule out alternative explanations (sleep disorders, thyroid problems, anemia) Can try strategies that are used for patient with fibromyalgia and chronic fatigue syndrome (CDC chronic fatigue toolkit) Low impact, gradual increase exercise program Cognitive behavioral therapy Sleep hygiene Pacing protocols Pharmacologic therapy Antidepressants for pain or fatigue Pain modifiers Gabapentin, Pregabalin

16 Post-treatment Lyme Disease Syndrome No role for prolonged antibiotics Most symptoms slowly resolve with time No proven benefit Hyperbaric oxygen IVIG Vitamins Nutritional management Chelation therapy Cholestyramine Avoid empiric treatment of babesiosis or bartonella without supportive lab testing

17 Controversy Different viewpoints on Lyme Disease Primary care providers need to be aware of the differing viewpoints on testing and management of Lyme Disease If patients use the internet as a primary source of medical knowledge, they are likely to be overwhelmed by the information that is out there are varying viewpoints It is helpful when referring patients for Lyme Disease management to be clear on the different practice patterns of providers Providers that follow Infectious Disease Society of American Guidelines (IDSA) on testing and treatment Providers that are associated with International Lyme and Associated Disease Society (ILADS)

18 THANK YOU