Lyme Disease

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Lyme disease was first described as a clinical entity in 1977 as a consequence of a clustering of children in Lyme, Connecticut, who were thought to be infected with juvenile arthritis (7). It became apparent that the disease was a multisystem illness that affected skin, CNS, lymphatics, joints, and heart.

Definition. The etiologic agent isolated from patients with Lyme disease is the spirochete, Borrelia burgdorferi, found in the tick Ixodes dammini. Clinically, the infection is similar to syphilis in its multisystem involvement, stages and clinical course, and masquerade of other disorders.

Epidemiology. Lyme disease is the most common vector-borne infection in the United States. The deer tick I. dammini serves as the intermediate host vector for the Borrelia organism. Nymphal ticks both acquire and pass the organism by horizontal transmission to the white-footed mouse. Adult ticks carrying the organism then occupy their preferred host, the white tail deer, which is not involved in the life cycle of the spirochete. Human infection generally occurs when nymphal ticks feed, between the months of May and July. Adult ticks will transmit the spirochete when they feed, in the autumn season. People of all ages and both genders may be affected. The Northeast United States demonstrates rates of disease higher than that of the western part of the country and Europe.

Pathogenesis. Following inoculation by the tick, the spirochete spreads locally in the skin in the majority of patients, resulting in erythema migrans. It is at this point that the spirochete may be recovered and cultured from the skin lesion more readily than at any subsequent stage. During the second stage of the illness, the spirochete will spread to the lymph and blood, resulting in widespread systemic dissemination and the subsequent constellation of multiorgan symptoms characterizing the disorder.

Clinical Manifestations. Lyme disease occurs in stages, manifesting different clinical signs/symptoms at each stage. The typical patient experiencing the untreated course of illness develops erythema migrans (stage I); followed by meningitis or facial palsy (stage II); followed months and perhaps years later by arthritis (stage III) (8). It is now known that specific symptoms do not always occur in a specific stage and that both symptoms and stage of infection may vary significantly from patient to patient.

The cervical lymphadenitis resulting from the spirochete generally occurs in stage I of early infection, generally regional in distribution relative to the inoculation site. It may be accompanied by fever and malaise. Disseminated infection during stage II is characterized most commonly by skin, CNS, and musculoskeletal symptoms. Annular rash, headache, and migratory arthralgias characterize this stage of infection. Patients are generally quite ill with severe weakness, fatigue, and discomfort. Late dissemination results in organ system sequestration of the spirochete with periods of quiescence and relapsing symptoms. It is at this point in stage II that differing proportions of patients will experience meningitis, cranial and/or peripheral neuropathies, and cardiac rhythm disturbances. Late stage II of the disease is characterized by relapsing arthralgias leading to frank intermittent episodes of arthritis in early stage III of the process.

Diagnosis. Because of the difficulty in securing reliable culture material, serology represents the most effective modality for diagnosis.

Treatment. Oral antimicrobials directed against the spirochete, generally doxycy-cline, are the treatment of choice for early or localized infection. Intravenous antibiotics (Ceftriaxone) are generally reserved for patients with neurologic abnormalities, excluding facial palsy.

Complications and Prognosis. Timely treatment with appropriate antibiotics is usually curative, but longer courses of therapy are often required later in the illness. Some patients may not respond to treatment completely, resulting in recrudescent symptoms, or in the event of facial palsy, incomplete return of function.

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