10% of untreated patients after several weeks to months. They can present as cranial nerve palsies, most commonly facial nerve palsy that may be bilateral. Meningitis with a lymphocytic pleocytosis and elevated protein level in the cerebrospinal tluid or a mild encephalitis are possible. There may also be a sensory radiculoneuropathy. In Asia and Europe, the first characteristic neurologic sign is radicular pain, followed by the development of cerebrospinal fluid (CSF) pleocytosis, which is known as Bannwarth syndrome.
The third stage of the disease represents late or persistent infection. This occurs months to years after initial infection, usually when the initial presentation of the disease was not recognized or was not treated with medications. The common presentation is that of generalized musculoskeletal pain and a migratory polyarthritis that may mimic juvenile rheumatoid arthritis in 50% of the cases. There are also intermittent attacks of oligoarthritis most often involving the knees: the episodes can last from weeks to months within the involved joint. Aspiration of joint fluid shows white blood cells approximately 25,000/mm3 with a predominance of polymorphonuclear leukocytes. This may develop into a chronic inflammatory joint disease lasting 5-8 years, especially if no treatment is given. Late neurologic manifestations or tertiary borreliosis in the form of subtle encephalitis, neurocognitive dysfunction, or peripheral neuropathy occurs in this stage.
Treatment of Lyme disease consists of antibiotics. It is important to recognize the illness in the early phase to prevent progression to the later and more chronic stages. Most patients with Lyme disease, including those with skin or joint manifestations, can be treated with oral antibiotics, preferably doxycy-cline 100 mg twice daily. Other choices include amoxicillin 500 mg three times daily, cefuroxime 500 mg twice daily, or erythromycin 250 mg four times daily. The treatment period usually is 1 month. In more severe manifestations of the disease, such as third-degree heart block or neurologic manifestations, intravenous delivery of antibiotics is preferred, usually ceftriaxone 2 g daily, cefotaxime 2 g every 8 hours, or penicillin G 5 million units every 6 hours. Again, the treatment is to be given for 1 month.
Match the Lyme disease stage (A-D) to the clinical manifestations described in Questions [23.1| to 123.3].
A. First stage (localized infection)
B. Second stage (disseminated infection)
C. Third stage (persistent infection)
D. Not consistent with Lyme disease
[23.11 A 35-year-old woman with heart rate of 54 bpm, slightly irregular, with second-degree atrioventricular block on ECG
[23.2] A 22-year-old man who has facial weakness on the right, headache, and fever
[23.3] A 28-year-old man who complains of 2 weeks of headache, fatigue, myalgias, and a rash along the belt line
(23.4) A 45-year-old woman complains of near syncope. Her heart rate is 50 bpm. On ECG, third-degree heart block is noted. She had been in good health, but she spent time camping in the woods of New Hampshire and had numerous tick bites 6 months previously. Which of the following is the best treatment for this condition?
A. Oral doxycycline
B. Intravenous lidocaine
C. Oral amoxicillin
D. Intravenous ceftriaxone
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